Every finding on record at Crosbyton Nursing and Rehabilitation Center

Based on observation, interview, 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 dietary services, in that: The facility failed on 09/23/25 to seal food stored in pantry. These failures could place residents at risk for food contamination and foodborne illness.The findings included: The following observation was made on 09/23/25 at 09:40 AM during the initial tour of the kitchen:Bag of brownie mix in plastic bag not sealed.Bag of Pasta in original bag with large hole in bag in a plastic container not covered or sealed. The container lid was under plastic container to the right.Plastic container of sugar with lid not sealed.Bag of brown gravy mix in plastic bag not sealed. During an interview on 09/23/25 at 03:15 PM with DM she stated all food items in plastic bags should be sealed when stored on the shelf in pantry. She stated it was everyone's responsibility to seal items when storing them in the pantry. She stated all plastic container lids should be sealed when stored. She stated the flour bin should not have a hole in the lid. She stated the potential negative outcome could be bugs get in the food and could cause harm to the residents. She stated if bugs get in the food, it could cause residents to get an infection. She stated all kitchen staff have been trained in proper food storage and have safe serve certificates. During an interview on 09/25/25 at 09:30 am with [NAME] A, she stated all staff were responsible for making sure food put in the pantry was sealed. She stated she had been trained on how to properly store food in the pantry. She stated the potential negative outcome could be bugs or other stuff getting in the food and making the residents sick.During an interview on 9/25/25 at 11:19 am with the ADM, he stated all food stored in the pantry should be dated and sealed. He stated he was not aware food was being stored open. He stated kitchen staff have been trained to properly store food. He stated his expectations were for staff to follow policy and procedure. He stated the potential negative outcome could be cross contamination and environmental stuff getting in food making residents sick. He stated kitchen staff and ADM were responsible for making sure all food is sealed. He stated he makes weekly rounds. Record review of the facility's policy, titled Food Receiving and Storage dated revised November 2022, reflected the following: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation: .3. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use.

Based on observations, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 1 facility roof. The facility failed to ensure the roof of the facility was in good repair. This failure could cause leaking and water damage and cause the facility to have an unsightly appearance. The findings included: On 09/23/25 at 9:30 AM, upon entrance to the facility, an observation was made of the roof of the facility. A large blue tarp was noted to cover a large portion of the roof. The areas of the roof that were uncovered by the blue tarp were noted to have shingles missing in places. On 09/23/25 at 9:55 AM, during entrance conference, the ADM stated several rooms on the front hall and the North hall were leaking water during the last storm. The ADM stated the residents were moved out of those rooms at that time and trash cans were used to collect the leaking water. The ADM stated he put up blue tarps with the MS after the last storm about 3 weeks ago and the roof has not leaked water since then. The ADM stated he was unsure exactly when the roof would get fixed as it was out of his hands and the owners were responsible for writing the check. During an observation on the front hall on 09/23/25 at 10:10 AM, it was noted that rooms [ROOM NUMBER] were closed and did not have any residents. room [ROOM NUMBER] was noted to have a large brown ring noted on the ceiling with some of the ceiling hanging down. A medium sized trash can was noted on the floor under the air vent half full of brown water. During an interview on 09/25/25 at 9:36 AM, the MS stated the roof has been having problems at the facility for as long as he had worked there, which was around 3 years. The MS stated the facility had gone through several administrators and he told all of them about the roof problems. The MS stated every time a storm went through the town, the roof shingles would come off in spots and he would go up there and patch up the spots. The MS stated over time, it was a battle after battle with the roof and he could not keep up. The MS stated the big storm that affected the town a few weeks ago was when the roof started leaking. The MS stated the ADM got tarps and they put tarps on the roof to prevent any leaking until the roof can get fixed. The MS stated insurance adjustors had gone out to the facility and approved the roof to be fixed, but that was all he knew. The MS stated it was out of his hands at that point and the ADM and the owners were responsible. The MS stated the residents had a risk of too much water getting in and the sheet rock collapsing on them. During an interview on 09/25/25 at 10:38 AM, the MS stated he could not find a policy related to the facility roof conditions or environment that included the roof. During a phone interview on 09/25/25 at 11:26 AM, the Previous ADM stated he had worked at the facility for about 1 year before leaving in August 2025. The Previous ADM stated the roof had issues with shingles coming off during his time working at the facility. The Previous ADM stated a big windstorm occurred in March or April of 2025 and the roof began having leaking issues at that time. The Previous ADM stated the leaking was not bad, but he did reach out to Facility Owner A and notify him of the roof damages from that storm. The Previous ADM stated another big storm occurred in June 2025 and he again reached out to Facility Owner A to notify him of the roof damages from the storm. The Previous ADM stated that was when insurance became involved. The Previous ADM stated the roof required constant attention at that time and some emails he sent to Facility Owner A and Facility Owner B went unanswered. The Previous ADM stated he did not have record of the emails due to them being deleted when he stopped working at the facility. The Previous ADM stated when he stopped working at the facility, the insurance check had not been provided to the facility. During an interview on 09/25/25 at 12:22 PM, the ADM stated he had worked at the facility for less than a month and the first week he was at the facility a storm went through the town and the roof of the facility started leaking heavily in some areas. The ADM stated Facility Owner A provided payment to him so he could purchase the tarps to put on the roof. The ADM stated it was his understanding that the insurance adjustor had already been out to the facility and had approved the roof to be fixed. The ADM stated Facility Owner A told him he was waiting for the insurance check for the roof. The ADM stated that was several weeks ago and the facility was still waiting for the roof to be fixed. The ADM stated the residents had a risk of mold or pest problems. During a phone interview on 09/25/25 at 12:40 PM, Facility Owner A stated he had filed a claim with insurance for the roof damage that occurred from the storm back in June 2025. Facility Owner A stated the facility had a mold air quality test done that revealed no mold in the facility, so the roof was not an immediate concern with the tarps being in place at this time. Facility Owner A stated the insurance company sent an engineer to the facility about 3 weeks ago to approve the claim and he has been waiting for the approval check. Facility Owner A stated he was not aware that the facility had been in bad condition for 3 years. Facility Owner A stated he did not know why he did not submit an insurance claim to fix the roof back from the storm in March or April 2025. Facility Owner A stated he did not think the roof needed replacement at that time. Facility Owner A stated he does not get the roof replaced with every storm. Facility Owner A stated a blue tarp was placed on the roof when it began leaking and to hold it over for the next couple of weeks. Facility Owner A stated it may be inconvenient for the residents who had to change rooms because their room was leaking and stated no rooms were leaking at that time.

Based on observation, interview, and record review, the facility failed to provide a resident or family group with private space for the residents' monthly council meetings and the confidential resident group meeting during survey (09/24/2025) for eight of eight confidential residents reviewed for resident council. The facility did not provide private space for resident council meetings. This failure could place residents at risk of not being able to exercise their rights of being able to voice their grievances in private, without uninvited staff being present.Findings Included:Observation and interviews on 09/24/2025 at 2:00 PM in a Resident Council meeting, conducted during survey, revealed the following: The Resident Council meeting was held in the activities room. The area contained two open doorways that did not have a door closure. The activities room was outside of the DON's and ADON's offices. There were numerous staff members observed walking past the open room during the Resident Council meeting. The noise from the hallway was heard in the activities room, causing distraction to residents. A staff member entered the room during the Resident Council meeting, speaking to residents, which caused a disruption to the meeting. Staff were observed sitting in the hallway, within hearing distance, during the Resident Council meeting. Six of Eight Residents attending the meeting stated they had Resident Council meetings in the activities room every month, and there was not another, more private, area utilized for residents to meet. Six of Eight Residents attending the meeting stated the area was distracting and difficult to hear at times, during meetings. Six of Eight Residents attendign the meeting stated they did not feel the area was private, as staff could overhear their conversations.During an interview on 09/25/2025 at 10:15 AM the AD stated she was responsible for scheduling and organizing Resident Council meetings monthly. The AD stated Resident Council meetings were held in the activities room monthly. The AD stated the activities room does not have doors to ensure the meetings are private. The AD stated she usually ensures staff stay out of the area when Resident Council meetings are being held, but she was not present on the day of the Resident Council meeting held during survey (09/24/2025). The AD stated the Resident Council meetings could be held in the therapy room if they needed to be private. The AD stated she would ensure that future Resident Council meetings were held in a private space to ensure residents felt comfortable to voice their opinions more openly. The AD stated if the resident council meetings were not held in a private space, it could have caused the residents to be fearful of speaking openly or fearful of retaliation. During an interview on 09/25/2025 at 11:00 AM the ADON stated Resident Council meetings were usually held in the activities room, but the therapy room could be utilized if the residents wanted a private space to meet. The ADON stated the AD was responsible for organizing resident council meetings monthly. The ADON stated she was aware staff members were within hearing distance of the resident council meeting held during survey (09/24/2025). The ADON stated staff members should have been aware the Resident Council meeting was confidential, and they should not have been present and should not have interrupted the meeting. The ADON stated, if residents cannot meet in a private area, it could cause residents to be afraid to speak their concerns openly for fear of retaliation. During an interview on 09/25/2025 at 12:30 PM the ADM stated he was aware the Resident Council meeting held during survey (09/24/2025) would be a concern, as it was not held in a private location. The ADM stated the AD was responsible for organizing Resident Council meetings monthly. The ADM stated the AD was on leave on 09/24/2025. The ADM stated there was not a back up plan in place for the AD on 09/24/2025 and stated he should have had someone covering for the AD on that day. The ADM stated the Resident Council meetings should have been held in a private location, and staff should not interrupt those meetings. The ADM stated it was important for residents to be able to voice their concerns openly without fear of retaliation. The ADM stated residents cannot speak freely if the meetings were not held in a private location. The ADM stated he would look for a more private location for Resident Council meetings in the future. Record Review of the facility's document titled, Resident Council revised February 2021, revealed the following:Policy StatementThe facility supports residents' rights to organize and participate in the resident council.Policy Interpretation and Implementation3. The resident council group is provided with space, privacy, and support to conduct meetings.

Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 2 of 16 residents (Residents #4, and #8) reviewed for advanced directives. Residents #4, and #8 were listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were missing required information. This failure could place residents at risk of not having their end of life wishes honored and incomplete records.Findings included: Record Review of Resident #4's face sheet, dated [DATE] , revealed a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses that included: muscle weakness, Major Depressive Disorder (a mental disorder characterized by pervasive low mood, low self-esteem, and loss of interest or pleasure in activities), and problem related to life management difficulty. Record Review of Resident #4's Care Plan dated [DATE], revealed: The resident request code status of: DNR. Record Review of Resident #4's physician orders dated [DATE] revealed: verbal orders placed for DNR. Record Review of Resident #4's OOH-DNR records dated [DATE] revealed: Under the section labeled, Physician's Statement,, next to the Physician's signature/name, a physician's license number was not listed. Record Review of Resident #8's face sheet, dated [DATE] , revealed a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses that included: vascular dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain), muscle weakness, and problem related to life management difficulty. Record Review of Resident #8's Care Plan dated [DATE], revealed: The resident request code status of: DNR. Record Review of Resident #8's physician orders dated [DATE] revealed: verbal orders placed for DNR. Record Review of Resident #8's OOH-DNR records dated [DATE] revealed: Under Section B, labeled, Declaration by legal guardian, agent or proxy on behalf of the adult person who is incompetent or otherwise incapable of communication, was not dated next to the Legal Guardian. Under the Physician Statement, next to the Physician signature was not dated. During an interview on [DATE] at 11:10 AM the ADON stated Advance Directives were reviewed by the admitting nurse and administrator to ensure accuracy. The ADON stated Advance Directives should be completed thoroughly. The ADON verified there were no additional advance directives for Resident #4 or Resident #8. The ADON verified the current Advance Directives for Resident #4 and Resident #8 were not completed, as they were both missing dates. The ADON stated it was important for Advance Directives to be completed thoroughly to ensure the documents were legally binding. The ADON stated if an advance directive was not completed, the resident's wishes may not be honored. The ADON stated she would ensure the advance directives were updated as soon as possible. During an interview on [DATE] at 12:35 PM the ADM stated the admitting nurse was responsible for ensuring the resident's advance directive was completed thoroughly. The ADM stated this should have been completed within 24 hours of admission. The ADM stated all nursing staff were responsible for ensuring advance directives were complete and accurate. The ADM stated he did not know how often advance directives should be checked, but he stated they should be checked regularly to ensure they were accurate. The ADM stated it was his expectation that advance directives would be completed properly and reviewed regularly. The ADM stated a resident could have been assaulted if the advance directive was not completed properly. The ADM stated a resident's wishes may not have been followed if their advance directive was not completed. Record review of the facility's policy, Advance Directives, Revised [DATE], revealed the following documentation: Policy Statement:The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Policy Interpretation and Implementation: Definitionsb. Advance Directive - a written instruction, such as a living will or durable power of attorney for health care, recognized by state law (whether statutory or as recognized by the courts of the state), relating to the provisions of health care when the individual is incapacitated (per 5489.100).(3) Do Not Resuscitate (DNR) - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used.

Based on observations, interviews, and record review, the facility failed to ensure a resident has a right to a safe, clean, comfortable, and homelike environment for 1 of 16 residents (Resident #13) reviewed for physical environment. The facility failed to ensure Resident #13 had a safe and secure toilet in the bathroom. This failure could place residents at risk for injuries and falls.Findings included: Record review of Resident #13's face sheet dated 9/25/2025 revealed a [AGE] year-old female, admitted to the facility on [DATE]. The face sheet indicated, under Diagnosis Information, diagnoses that included the following: Unspecified sequelae of nontraumatic intracerebral hemorrhage (bleeding in the brain which could result in motor and sensory deficits such as weakness or paralysis in the limbs and cognitive impairments), unsteadiness on feet, muscle weakness, other abnormalities of gait and mobility, and unspecified lack of coordination. Record review of Resident #13's Annual MDS assessment, dated 08/13/2025, revealed under Section C, Cognitive Patterns, a BIMS score of 15 indicating the resident was cognitively intact. The MDS assessment indicated under Section H, H0300, Resident #13 was occasionally urinary incontinent and always continent of bowel. Record review of Resident #13's most recent care plan, dated 09/26/2025, reflected a focus area ADL Self Care Performance Deficit t CVA with left hemiparesis. The goals for the focus area included, The resident will improve current level of function in transfers, dressing through the review date. The Interventions/Tasks for the focus area included, TOILET USE: The resident is able to use toilet with assist. During an interview with Resident #13 on 09/24/2025 at 02:45 PM Resident #13 stated her toilet was wobbly and moved back and forth, from side to side and front to back. Resident #13 stated she had not reported the loose toilet yet. Resident #13 stated she had not had an accident because of the loose toilet. Resident #13 stated she received assistance, by facility staff, when transferring to the toilet. An observation on 9/24/2025 at 3:15 PM revealed the toilet in Resident #13's room was not secure and could be moved from side to side and front to back, by several inches, with only a gentle nudge. During an interview on 09/24/2025 at 03:30 PM the ADM stated he was not aware of Resident #13's concern of her toilet being loose. The ADM stated he would have the toilet fixed as soon as possible. During an interview on 09/25/2025 at 11:30 AM the MS stated he was not aware Resident #13's toilet was loose. The MS stated Resident #13's toilet had become loose previously, and it was tightened as soon as it was observed or when Resident #13 reported it. The MS stated he had already secured the toilet on 09/24/2025, and he stated it was no longer loose. The MS stated he planned to replace the seal on the toilet to ensure it did not become loose again. The MS stated he did regular checks weekly to ensure Resident #13's toilet was secured, since it had become loose previously. The MS stated the toilet was still bolted down, but the bolts became loose and allowed for the toilet to move some. The MS stated he did not feel there was a risk to the resident because the toilet was still bolted down, and it would not tip from side to side. The MS stated he did not feel the resident was at risk of falling or obtaining an injury due to the loose toilet. An observation on 9/25/2025 at 11:35 AM revealed the toilet in Resident #13's room was secure and could no longer be moved from side to side or front to back. During an interview on 09/25/2025 at 1:05 PM the ADM stated the MS and nursing staff were responsible for ensuring Resident #13's toilet was safe and secure. The ADM stated he was ultimately responsible for ensuring this was followed up on. The ADM stated he was not aware Resident #13's toilet was loose prior to 09/24/2025. The ADM stated the MS does regular checks of each resident's bathroom to ensure everything is functioning properly. The ADM did not know how often the MS completed maintenance checks of the residents' bathrooms. The ADM stated he would make sure the maintenance checks were completed regularly. The ADM stated the resident was at risk of falling and incurring an injury if her toilet was loose. Record review of the facility's policy, Bathrooms, Revised February 2020, revealed the following documentation: Policy Statement:Resident rooms are equipped with (or located near) toilet and bathing facilities. Policy Interpretation and Implementation:l . Residents who can independently use the toilet (including chair-bound residents) are ensured timely access to a safe, clean, sanitary, and accessible toileting facility. (Note: if certified after November 28, 2016, resident rooms come equipped with a minimum of one toilet/commode and sink.)

Based on observation, interview, and record review, the facility failed to ensure resident had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 15 residents (Resident #2) observed for physical restraints in that; The facility failed to ensure Resident #2 had a consent and an evaluation for scoop mattress for fall prevention. This failure could place residents at risk of injuries or entrapment.Findings include:Resident #2Review of Resident #2's Face Sheet, dated 09/24/25, revealed she was an 83 -year-old female admitted on [DATE] and readmitted on [DATE] with the following diagnoses: dementia (loss of brain function), major depression, diabetes (high blood sugar), epilepsy (seizure disorder), muscle weakness and hypertension (high blood pressure).Review of Resident #2's Comprehensive MDS, dated [DATE] stated she was not cognitively intact with a BIMS score of 00. She required extensive assistance and total dependence on one person for bed mobility, toilet use, dressing, and personal hygiene. She requires substantial/maximal assistance with roll left and right, sit to lying, lying to sitting, and transfers. Further review of the MDS revealed resident had one fall since admission with no injury and did not address restraint. Record review of Resident #2's Care Plan dated 03/25/25 revealed the resident had an actual fall (fell from bed) with injury (wound to left side of the forehead). The interventions included bed in low position, fall matt beside bed, and scoop mattress to bed.Record review of Resident #2's orders dated 09/24/25 revealed a Physician Order dated 03/03/25 for a scoop mattress on bed to prevent unintentionally rolling off the bed. Record review Resident #2's medical record revealed no consent for scoop mattress.Observation on 09/23/25 at 10:30 AM revealed Resident #2's bed with a scoop mattress.During an interview on 09/24/25 at 03:45 pm the ADON stated restraint consents were scanned into resident electronic medical records. She stated, I bet she don't have a consent for scoop mattress, because I did not think about it.During an interview on 09/25/25 at 10:15 am the ADON stated Resident #2 had a scoop mattress to keep her from rolling over and accidentally falling out of bed. She stated consent for restraints should be obtained at the time the restraint is applied. She stated the scoop mattress could be a restraint for certain residents. She stated Resident #2 does not try to get up out of bed, she just rolls. She stated ADON and DON were responsible for obtaining consent. She stated the potential negative outcome could be residents and families not getting notified of the restraint and making them mad.During an interview on 09/25/25 at 11:19 AM, the ADM stated a scoop mattress could be a restraint. The ADM stated nursing staff were responsible for making sure consent was obtained before applying the scoop mattress to the bed. The ADM stated the potential negative outcome could be lowering the resident's quality of life.Record review of the facility policy titled, Bed Safety and Bed Rails, with a revised date of August 2022 reflected the following: Policy Statement: Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met.Policy Interpretation and Implementation:1. The resident's sleeping environment is evaluated by the interdisciplinary team.2. Physical restraints are any manual method, or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.a. The definition of restraints is based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting movement or normal access to one's body could be considered a restraint.

Based on observations, interviews, 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 1 of 16 residents reviewed for activities, in that: The facility failed to ensure there were organized activities available to residents on 09/23/2025 and 09/24/2025. This failure placed residents at risk for a diminished quality of life, isolation, and lack of stimulation. Findings included: During observation of the facility's activities area on 09/23/2025 at 10:30 AM, the wall-sized, centrally located group activities board was observed to have a large print calendar posted. There was not a month identified on the activities calendar. During observation of the facility's activities area on 09/23/2025 from 10:00 AM to 04:00 PM, there were no observed group activities conducted. During observation of the facility's activities area on 09/24/2025 from 06:30 AM to 03:30 PM, there were no observed group activities conducted. During a confidential interview held on 09/24/2025 at 1:00 PM an anonymous resident stated the facility's activities director was on leave and the residents had not had any scheduled activities while she was out. The residents stated the facility did not have a full time activities director to facilitate activities daily and residents were organizing their own activities at times, due to this. The resident stated the activities director was also working as the facility's business office manager which took away time from organizing activities. During confidential interviews held on 09/24/2025 at 02:00 PM 1 of 6 confidential residents stated they did not have any activities on 09/23/2025 or 09/24/2025. The Residents stated the activities director was out and that was why they did not have activities on these days. 5 of 6 confidential residents stated they were not bothered by not having activities on 09/23/2025 or 09/24/2025. One resident stated she was frustrated that the facility did not coordinate any activities on these dates. During an interview on 09/24/2025 at 03:30 PM the housekeeping supervisor stated she was hired as the housekeeping supervisor, but she was also a certified activities director. The housekeeping supervisor stated she recently started working at the facility on 09/24/2025, and she planned to help organize activities for the residents going forward. During an interview on 09/25/2025 at 10:00 AM the AD stated her job title was business office manager, but she also worked as the AD. The AD stated she has worked at the facility as the AD for the past 5 years. The AD stated she ensured the residents had ongoing activities daily, but she was on leave on 09/23/2025 and 09/24/2025. The AD stated the housekeeping supervisor was also a certified AD and was supposed to cover activities on the days she was out, but the housekeeping supervisor was out, unexpectantly, as well. The AD stated she tried to complete her business office management tasks during the mornings, around scheduled activities with the residents. The AD stated residents should not have to organize their own activities, and the ADM should have ensured activities were conducted while she was on leave. The AD stated it was important for residents to have ongoing activities to keep their minds busy and for enjoyment. During an interview on 09/25/2025 at 12:25 PM the ADM stated the facility did not have any activities on 09/23/2025 or 09/24/2025 due to the AD being out on leave. The ADM stated he did not have a back up plan for activities during this time, and this was his responsibility. The ADM stated he should have had someone organizing activities while the AD was out. The ADM stated the facility did not have a full time AD due to budgeting constraints. The ADM stated the business office manager was the part-time AD and she tried to balance both job duties. The ADM stated he recently hired a housekeeping supervisor who was also a certified AD, so she will coordinate with the business office manager/AD to fill in the gaps when the business office manager was unavailable to conduct activities, but the housekeeping supervisor was out on the same days, so he did not have anyone to help conduct activities for the residents. The ADM stated it was not the responsibility of the residents to organize their own activities. The ADM stated if the residents did not have organized activities it could lead to boredom, lower quality of life, increased behaviors, and residents not feeling important. Record review of the facility's policy, Activity Programs, Revised June 2018, revealed the following documentation: Policy Statement:Activity programs are designed to meet the interests of and support the physical, mental, and psychosocial wellbeing of each resident. Policy Interpretation and Implementation:3. The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities.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.

Based on observation, interview, and record review, the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail and ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements: Assess the resident for risk of entrapment from bed rails prior to installation and/or Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 1 of 15 residents (Resident #17) observed for physical restraints in that; The facility failed to ensure Resident #17 had a physician order, consent and evaluation for side rails used for positioning and mobility. This failure could place residents at risk of injuries or entrapment. Findings include: Resident #17 Review of Resident #17's admission record, dated 09/23/25, revealed he was an 89 -year-old female admitted on [DATE] with the following diagnoses: essential hypertension (high blood pressure), radiculopathy (pinched nerve), and nutritional anemia (body lacks enough healthy blood red cells to transport oxygen due to lacking diet). Review of Resident #17's Comprehensive MDS assessment, dated 03/23/25 stated she required partial assistance of one person for bed mobility. Further review of the MDS revealed bed rails were not addressed as a restraint. Record review of Resident #17's order summary report dated 09/23/25 revealed no physician order for side rails. Record review Resident #17's medical record revealed no consent or evaluation of need for side rails on her bed. Observation on 09/23/25 at 3:16 PM revealed Resident #17 lying in bed with 1/4 side rails to both sides of the head of bed. Both of the side rails were observed to be raised at this time. During an interview on 09/25/25 at 11:06 AM, LVN B stated nursing staff were responsible for ensuring a resident had an order for side rails. LVN B stated the admitting nurse usually put the orders in, or the nurse who determined the resident required the side rails. LVN B stated Resident #17 has had side rails on her bed for as long as she could remember, at least a few years. LVN B stated Resident #17 used the side rails for mobility and positioning before she had a decline in health and went on hospice services. LVN B stated the resident had an increased risk of falling with the bed rail, if she tried to climb over it or it could impede the resident from getting out of bed. During an interview on 09/25/25 at 12:00 PM, the ADON stated she did not know why Resident #17 did not have a physician order, consent or evaluation for side rails. The ADON stated the DON and her recently did an audit on side rails in the facility and it must have been missed. The ADON stated the DON and herself were ultimately responsible for ensuring residents had orders and consents for side rails. The ADON stated the residents had a risk for entrapment and the doctor not being aware of a need for side rails. During an interview on 09/25/25 at 12:16 PM the DON stated the nursing staff were responsible for ensuring side rail orders were initiated by calling the physician. The DON stated it was the ADON's and her responsibility to ensure all side rails used in the facility had a physician order, consent and evaluation done. The DON stated side rails were considered a restraint and residents had a risk of falling over it and injuring themselves. During an interview on 09/25/25 at 12:22 PM, the ADM stated a physician order was required if a resident needed to use side rails. The ADM stated a side rail was considered a restraint if it did not have a physician order for use. The ADM stated the DON and himself were responsible for ensuring side rails had orders, consents and evaluations in place. The ADM stated the resident was at an increased risk for restraint. Record review of the facility policy titled, Bed Safety and Bed Rails, with a revised date of August 2022 reflected the following: Policy Statement: Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met.Policy Interpretation and Implementation:1. The resident's sleeping environment is evaluated by the interdisciplinary team.Use of Bed Rails1. Bed rails are adjustable metal or rigid plastic bars that attach to the bed .For the purpose of this policy bed rails include:a. side rails;b. safety rails; andc. grab/assist bars.2. Physical restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.a. The definition of restraints is based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting movement or normal access to one's body could be considered a restraint.3. The use of bed rails or side rails.is prohibited unless the criteria for use of bed rails have been met, including attempts to alternatives, interdisciplinary evaluation, resident assessment, and informed consent.

Based on observations, interviews, and record reviews, the facility failed to ensure menus were followed for 2 of 2 meals observed. (Lunch meal 9/23/25 and 9/24/25) The facility failed to follow the week 1 menu for two lunch services served at the facility on Tuesday 09/23/25 and Wednesday 09/24/25. These failures could place residents that eat food from the kitchen at risk of poor intake, and/or weight loss.The findings included: Observation on 09/23/25 at 11:45 AM of dining room puree lunch meal trays being served consisting of spaghetti with white gravy and green beans. No puree bread on plate. Observation on 09/24/25 at 11:45 AM of dining room puree lunch meal trays being served consisting of roasted thyme chicken with gravy, mashed potatoes with gravy, and mixed vegetable florets. No puree bread on plate. Record review of the Tuesday Week 1 menu dated 05/07/25 revealed the noon menu was changed to the meal of the month spaghetti with meatballs, green beans and garlic bread. Record review of the Wednesday Week 2 menu dated 05/07/25 revealed the noon menu was roasted thyme chicken, mushroom rice, broccoli florets, wheat dinner roll, margarine, confetti cake, 2 percent milk, coffee. During an interview on 09/25/25 at 09:30 a.m., [NAME] A stated she should have served puree bread with the noon meals on 09/23/25 and 09/24/25. She stated she got nervous and forgot to puree the bread. She stated she was training on following the menu and substitutions. She stated the negative outcome could be decrease in calories and weight loss. During an interview on 09/25/25 at 09:45 a.m., the DM stated the cooks were responsible for properly preparing the puree diets. She stated the cook forgot to puree the bread on 09/23/25 and 09/24/25 and the cook had been trained to follow the menu. She stated she was responsible for monitoring staff, and the cook was responsible for following the menu when preparing the meal. She stated the potential negative outcome could be weight loss and residents feeling left out. During an interview on 9/25/25 at 11:19 a.m., the ADM stated dietary staff should follow the menu and make appropriate substitutions. He stated he was not aware the menus were not being followed. He stated he expected the dietary staff to follow the menus correctly and substitute foods correctly. He stated the potential negative outcome could be calorie and nutritional deficiencies.Record review of Menus policy revised 10/2017 revealed the following: Policy statement - menus are developed and prepared to meet resident choices including religious, cultural, and ethnic needs while following established national guidelines for nutritional adequacy. Policy interpretation and implementation: .6. Deviations from posted menus are recorded (including the reason for the substitution and/or deviation) and archived.

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 2 residents (Resident #11) reviewed for meals. The facility failed to ensure that Resident #11 was served pureed spaghetti meat, chicken and vegetables that were the proper texture. This deficient practice could affect residents by placing them at risk for choking and weight loss.The findings include:Record review of Resident #11s face sheet dated 09/25/25 revealed a [AGE] year-old female with an admission date of 07/06/2023 with the following diagnoses: gastro-esophageal reflux disease (stomach disease), problem related to life management and weakness. Record review of Resident #11s physician orders dated 09/24/25 revealed an order dated 10/19/24 for regular diet, pureed texture and regular thin liquid consistency. During an observation on 09/23/25 at 11:45 AM, 1 puree plate was served to Resident #11. Resident #11 was observed picking large chunks out of puree spaghetti out of her mouth and placing them on the edge of the plate. During an observation on 09/23/25 at 12:00 PM a test tray with puree spaghetti had large chunks of noodles and meat that had to be chewed. During an observation on 09/24/25 at 09:45 AM [NAME] A prepared puree chicken that had chunks that had to be chewed. Prepared puree vegetables had chunks that had to be chewed. During an observation on 09/24/25 at 11:45 AM observed Resident #11 picking chunks out of puree chicken and vegetable out of her mouth with her fingers and placing them on the edge of the plate. During an interview on 09/25/25 at 09:20 AM with Resident #11 she stated she was on a puree diet because she cannot chew food. She stated if it was not smooth, she cannot swallow the food. She stated she had to pick out the chucks of food in the puree to swallow it. She stated It looks bad; it (the food) gets your fingers messy. She stated the texture of the food depends on the cook. She stated some cooks puree the food good and some do not.During an interview on 09/25/25 at 09:30 am with [NAME] A, she stated puree should be smooth with no chunks. She stated she looks at the puree to make sure it does not have chunks. She stated she has been trained in how to puree food. She stated the purpose of puree diet was the resident cannot chew or swallow food. She stated she was responsible for making sure food was properly pureed. She stated the potential negative outcome could be a resident choking. During an interview on 09/25/25 at 09:45 am with DM she stated puree should be pudding like consistency with no chunks. She stated all staff have been trained in how to prepare puree diets. She stated staff should taste puree for texture not just look at it. She stated puree diets were ordered for residents who had a hard time chewing or swallowing food. She stated the potential negative outcome could be resident choking.During an interview on 9/25/25 at 11:19 AM with the ADM, he stated puree food should be pudding like consistency and should not have chunks. He stated he was not aware the puree meals had chunks. He stated all staff have been trained in how to prepare puree diets. He stated his expectations were for food to be prepared properly. He stated the ADM was responsible for monitoring puree diets. He stated he gets a test tray weekly but has not tested the puree meal. He stated the potential negative outcome could be resident choking or aspirating on chunks. Record review of the facility policy titled Nutrition Policies and Procedures, dated 9/25, revealed the following: Subject: Diet Definitions.2. Puree recipes that do not specify portions for combined foods such as casseroles that include the starch with the meat will serve a 6-ounce portion (#6 scoop).a. Place the number of portions you need in the food processor.b. You may need to add liquid such as broth, juice or milk as appropriate to make a fluffy, mashed potato-like consistency.c. You may need to add thickener to produce a fluffy, mashed potato like consistency.e. Blenderize until there are no small pieces of lumps in food.f. Final product should hold its shape (not runny) and have a fluffy, moist consistency with no lumps.

Based on observation, interview and record review, the facility failed to ensure residents were provided with the therapeutic diets as prescribed by the attending physician for 1 of 2 residents (Resident #11) reviewed for therapeutic diets and food and nutrition services. The facility failed to ensure Resident #11 received ice cream with noon meals on 09/23/25 and 09/24/25 as ordered by the physician. This failure could place residents with diet needs at risk for weight loss and potential decline in health.The findings included:Record review of Resident #11's admission record dated 09/25/25 revealed she was [AGE] years old and admitted on [DATE] with muscle weakness, gastro esophageal reflux disease (stomach acid flows back into the esophagus), and problem related to life management difficulty.Record review of the physician's orders dated 09/24/25 revealed Resident #11's diet was Regular, puree texture, regular/thin consistency, ice cream with noon meal for unplanned weight loss with a start date of 10/20/24.Record review of the MDS comprehensive assessment dated [DATE], revealed Resident #11's BIMS score was 10 indicating moderate impairment with cognition. No weight loss or gain of 5% or more in the last month or loss of 10% or more in the last 6 months was noted. Therapeutic diet was noted.Record review of the care plan dated 05/27/25 revealed Resident #11 had a potential nutritional risk (such as weight loss) related to requesting to be on a pureed diet at every meal.Record review nutrition data collection dated 08/06/25 revealed Diet Order/Consistency: puree diet, ice cream with noon meal and supplements at all meals. It further revealed annual evaluation - weight remains stable and she is on supplements and ice cream to compliment her meal intake to promote stable weight.Record review of the diet card dated 09/23/25 and 09/24/25 revealed puree diet with supplement handwritten below diet order.During an interview on 09/25/25 at 09:20 am with Resident 11 she stated she was on a puree diet because she cannot chew food. She stated she does like ice cream but does not always get it with her noon meal.During an observation on 09/23/25 at 11:45 am Resident #11's meal provided was puree spaghetti, puree veggie and puree dessert. No ice cream was provided.During an observation on 09/24/25 at 11:45 am Resident #11's meal provided was puree chicken, mashed potatoes, puree veggie and puree dessert. No ice cream was provided.During an interview on 09/25/25 at 09:30 am with [NAME] A, she stated Resident #11 should have been served ice cream with noon meal on 9/23/25 and 9/24/25. She stated the diet orders and supplements were written on the dietary tray ticket. She stated she forgot to serve Resident #11 ice cream both days (9/23/25 and 9/24/25). She stated she had been trained on following physician diet orders. She stated the potential negative outcome could be the residents not getting proper nutrition and weight loss.During an interview on 09/25/25 at 09:45 am with DM she stated Resident #11 was not served ice cream for the noon meal on 9/23/25 and 9/24/25 because they were out of ice cream and magic cups (frozen supplement). She stated she did receive them on the truck today (9/25/25). She stated the diet order and supplements were printed on the tray card. She stated the DM is responsible for printing the tray tickets. She stated the order was not on the tray card for 9/23/25 and 9/24/25 because she was not able to print the original tray cards because she was out of printer ink. She stated the potential negative outcome could be weight loss from not receiving the proper supplements.During an interview on 9/25/25 at 11:19 am with the ADM, he stated the purpose of ice cream ordered at noon meal is to boost the residents' calories to maintain weight. He stated he was not aware ice cream was not served. He stated all staff have been trained to follow physician diet orders. He stated the person responsible for following the diet order was the cook, DM and ADM. He stated the potential negative outcome could be weight loss. Interview on 9/25/25 at 11:30 am with ADON, she stated the facility did not have a policy on therapeutic diets.

Based on observation, interview, and record review, 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 2 of 4 residents (Resident #13 and Resident #20) reviewed for infection control. 1. LVN B did not perform hand hygiene between all glove changes when providing wound care to Resident #13 and Resident #20. These failures could place residents at risk for cross contamination and infection.The findings include: Resident #13 Record review of the admission record for Resident #13, dated 10/01/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia (a group of conditions that cause a decline in cognitive abilities), schizoaffective disorder, depressive type (mental health disorder) and peripheral vascular disease (a slow and progressive circulation disorder). Record review of the comprehensive MDS assessment for Resident #13, dated 07/03/25 revealed Resident #13 had a total of 1 venous and arterial ulcer present. Record review of the order summary report for Resident #13, dated 10/01/25 revealed the following order: Wound care to RLE [Right lower extremity] every day and PRN as follows: Cleanse with wound cleanser, pat dry with gauze, apply Collagen then calcium alginate, may cover with dry nonadherent dressing or foam dressing one time a day for wound care with a start date of 09/24/25 and no end date. Record review of the current care plan for Resident #13, undated, revealed there was a focus area: The resident has a chronic stasis ulcer of the right lower leg. Goal: The resident will have no signs or symptoms of infection through the review date. Last revised on 08/26/25. During an observation on 09/24/25 at 3:28 PM, LVN B provided wound care to Resident #13's lower leg wound. LVN B put on a clean gown before entering the room. LVN B used hand sanitizer and put on a pair of clean gloves. LVN B removed the old bandage from Resident #13's wound and cleansed the area with wound cleanser and 4x4 gauze. LVN B then patted dry and measured the open area. LVN B placed a 4x4 gauze to cover the open area and stated she needed to go back to her wound cart to get calcium alginate that she thought she had. LVN B then removed her gloves and gown and put them in the trash. LVN B did not perform hand hygiene. LVN B then walked out of the room and went to the wound cart for the calcium alginate. LVN B then applied hand sanitizer to her hands and put on a clean gown and gloves before going back in Resident #13's room to finish wound care. LVN B then placed collagen powder and calcium alginate on the wound bed and covered it with a silicone border dressing. LVN B then removed her gown and gloves and washed her hands with soap and water. Resident #20 Record review of the admission record for Resident #20, dated 09/25/25 revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: heart failure (heart muscle cannot pump blood effectively through the body), osteoarthritis ( wear and tear condition of a joint), and edema (swelling). Record review of the quarterly MDS assessment for Resident #20, dated 07/14/25, revealed Resident #20 was at risk for developing pressure ulcers/injuries. Record review of the order summary report for Resident #20, dated 10/01/25, revealed the following order: Pressure wound to coccyx: Cleanse with Wound Cleanser or Normal Saline, pat dry with gauze. Apply collagen and silicone super absorbent daily. Monitor for signs and symptoms infection. Notify MD if infection noted. One time a day with a start date of 09/06/25 and no end date. Record review of the current care plan for Resident #20, last revised on 09/04/25, revealed there was a focus area: Documented Pressure Ulcer (episodic) arrived 9/3 with sacral pressure wound. Goal: Wound will show signs of improvement. During an observation on 09/24/25 at 2:09 PM, LVN B provided wound care to the pressure wound on Resident #20's coccyx. LVN B put on a clean gown outside the room and used hand sanitizer before going in Resident #20's room. LVN B put on a pair of clean gloves when she entered the room and began preparing the wound supplies for Resident #20. After prepping the supplies, LVN B removed her gloves and used hand sanitizer. LVN B put on a pair of clean gloves and Resident #20 was turned on her side. LVN B then cleansed Resident #20's coccyx wound with wound cleanser and 4x4 gauze. LVN B patted the wound bed dry and applied collage powder to the wound bed. A hydrocolloid foam dressing was used to cover the wound. LVN B then removed her gloves and put on a clean pair of gloves without performing hand hygiene. During an interview on 09/25/25 at 11:06 AM, LVN B stated she had been trained to perform hand hygiene with glove changes. LVN B stated she received an in-service on infection control and hand washing a few weeks ago but she could not remember the exact date. LVN B stated it slipped her mind when she was providing wound care to Resident's #13 and #20 and that was why she did not perform hand hygiene between all the glove changes. LVN B stated there was a risk of spreading infection to the residents. During an interview on 09/25/25 at 12:00 PM, the ADON stated she expected the staff to sanitize their hands between glove changes. The ADON stated she did not know why LVN B did not sanitize her hands between all glove changes. The ADON stated the DON was usually responsible for educating the staff on infection control practices, but the DON was new to the facility and had not worked there long. The ADON stated the residents had a risk for infection spreading. During an interview on 09/25/25 at 12:16 PM, the DON stated she expected the staff to perform hand hygiene between glove changes. The DON stated she was new to the facility and had not provided education on hand hygiene yet. The DON stated the residents had a risk for spreading infection. During an interview on 09/25/25 at 12:22 PM, the ADM stated the ADON was the IP at the facility. The ADM stated he expected the staff to perform hand hygiene between glove changes. The ADM stated he did not think the staff had been trained on infection control practices in the few weeks he had worked at the facility. The ADM stated the residents had a risk for cross-contamination. Record review of the facility policy titled, Infection Prevention and Control Program, with a revised date of October 2018 reflected the following: Policy Statement: An Infection Prevention and Control Program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Record review of the facility policy titled, Handwashing/Hand Hygiene, with a revised date of August 2019 reflected the following: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections.Policy Interpretation and Implementation:2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:g. before handling clean or soiled dressings, gauze pads, etc.;m. after removing gloves.

Based on observation, interview and record review, the facility failed to ensure the resident bedroom measured at least 80 square feet per resident in multiple resident bedrooms for 7 of 26 resident semiprivate rooms (Rooms #6, 13, 14, 19, 20, 21 and 30), in that, The facility failed to provide 80 square feet per resident in resident rooms #6, 13, 14, 19, 20, 21 and 30. This failure could result in crowding, cause difficulty in providing ADL services, and place residents at risk for decreased quality of life.Findings included: On 9/23/25 at 9:55 AM an interview was conducted with the ADM, at the time of the entrance conference. He stated the facility wanted to apply for a room square footage waiver for the semiprivate rooms that did not meet the 80 square foot requirement. Observations were made during a general observation tour with the MS on 09/25/25 beginning at 9:20 AM and indicated the following: room [ROOM NUMBER] had 158.22 square feet for 2 residents instead of the required 160 square feet. room [ROOM NUMBER] had 156.44 square feet for 2 residents instead of the required 160 square feet. room [ROOM NUMBER] had 151.55 square feet for 2 residents instead of the required 160 square feet. room [ROOM NUMBER] had 152.41 square feet for 2 residents instead of the required 160 square feet. room [ROOM NUMBER] had 151.18 square feet for 2 residents instead of the required 160 square feet. room [ROOM NUMBER] had 154 square feet for 2 residents instead of the required 160 square feet. room [ROOM NUMBER] had 156.10 square feet for 2 residents instead of the required 160 square feet. Interview on 09/25/25 at 12:22 PM, the ADM stated the semi-private rooms that do not meet the requirement for square footage requirement were typically used as private rooms, but not recently with the water leaking from the roof. The ADM stated regarding the inadequate room square footage in semi-private rooms, the residents were at risk for a lower quality of life. The ADM stated the residents could feel like there was not enough room to move around. The ADM stated the facility did not have a policy related to room square footage requirements for residents.

Based on interviews and record reviews the facility failed to have evidence all allegations of abuse, neglect or mistreatment were thoroughly investigated for 3 of 7 residents (Resident #1, #2, #3 and #4) reviewed for abuse. The ADM (Abuse Preventionist) failed to document and conduct an investigation regarding the Resident-to-Resident altercation (Between Resident #1 and Resident #2) that occurred and was reported on 1/08/25 by the DON and LVN A. The ADM (Abuse Preventionist) failed to document and conduct an investigation regarding the Resident-to-Resident altercation (Between Resident #2, #3 and #4) that occurred and was reported on 1/12/25 by LVN B to the ADON. The ADM (Abuse Preventionist) failed to document and investigate regarding the bruising that was identified on Resident #2 on 1/14/25. These failures could place residents as risk for abuse and neglect by not investigating allegations of abuse, neglect, exploitation, or mistreatment. Findings included: Resident #1 Record Review of Resident #1's face sheet, dated 02/04/25, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of Hepatitis C (a contagious viral liver infection). Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 07, indicating the resident was severely cognitively impaired. Section E revealed Resident #1 did not exhibit physical behavior (hitting, kicking, pushing, scratching, grabbing, abusing) during the review period [E0200]. Section I Resident #1 had viral Hepatitis. Record review of Resident #1's Physician Order Summary Report, dated 02/04/25, revealed that Resident #1 was not taking any medications for Hepatitis C. Record review of Resident #1's progress notes, dated 12/03/24-2/4/25 revealed the following: *1/08/25 at 4:18 PM LVN A documented: LVN A was sitting at nursing station when another resident (unknown) yelled out, There is a fight in here! BOM and LVN A entered dining area and did not see any physical or verbal altercation. LVN A was informed by another resident (unknown) that Resident #1 hit Resident #2. BOM watched video, and it was verified Resident #1 initiated physical aggression while Resident #2 was sitting in her wc near the table he ate at. Resident #2 was not disturbing the table or making physical contact with anyone upon Resident pulling/pushing Resident #2's wc and swinging his fist backwards towards Resident #2. Resident #2 became agitated but quickly left the area. *1/08/25 at 5:10 PM LVN A documented: Resident #1 was educated on not placing hands on other residents and informed to get staff if there was an incident that needs to be addressed. Resident #1 voiced understanding. Record review of Resident #1's care plan, dated 12/12/24, did not reveal a care plan regarding aggressive behavior but revealed his dx of hepatitis. His care plan did not reveal any revisions regarding the incident on 1/08/25. Record review of facility incident report, dated 1/08/25 revealed the following: Incident description: exact note that LVN A documented in Resident #1's progress note on 1/08/25. Action taken: Stated Resident #2 was assessed with no injuries. Injuries Observed at the time of the incident: No injuries at the time of the incident. Predisposing Environmental Factors: Crowding Agencies/People Notified: Physician C, DON and Family Member D. Record review of the facility incident report, dated 2/4/25, revealed the following: Resident #1 had a physical aggression-initiated incident on 1/08/25. During an interview on 2/4/25 at 12:57 PM, LVN A stated the abuse preventionist was the ADM. She said if she suspected or witnessed abuse, she had been trained to contact the ADM immediately. She said she had abuse training at the facility. She said she had been trained to separate the residents, perform a nursing assessment for injuries, and ensure everyone was safe if there was a resident-to-resident altercation. On 1/08/25, she said she was not in the dining room when the incident occurred with Residents #1 and #2. She stated she had to look back at the video footage. She said when she looked at the footage, she observed Resident #2 sitting at the dining room table, and for some reason unknown to her, Resident #1 became frustrated. She said she observed Resident #1 push Resident #2's wheelchair, and Resident #2 rolled backward. She said Resident #2 rolled backward and did not come into contact with anything. She said Residents #1 and #2 did not make contact with each other. She said as a result, they ensured both residents (Resident #1 and #2) were separated and safe. She said she did an incident report, assessed the residents, and then reported everything she observed on the video footage to the DON. She said this was the first time Resident #1 had acted that way and did not have a history of physically aggressive behavior. She reported the incident to the DON and appropriate parties, such as doctors and family contact. During an interview on 2/4/25 at 1:48 PM, Resident #1 could not recall specifics about the incident on 1/08/25. He stated he might have pushed them, but they asked for it. He said he did not know the other resident's name. He could not report if the other resident were male or female. He stated that they went crying to momma. He said he would handle his issues with [NAME] and [NAME]. He verified that [NAME] and [NAME] were his left and right hands. During an interview on 2/4/25 at 2:23 PM, the ADON stated the ADM was the abuse preventionist. She said if she suspected or witnessed abuse, she had been trained to remove the resident from the area where the abuse was occurring. She said she would go to the ADM, and if he were unavailable, she would go to the DON. She said if a resident-to-resident altercation had occurred, she had been trained to separate the residents, assess for injuries, and report the incident to the ADM and the DON. She stated regarding the incident on 1/08/25, it was her understanding that Resident #2 was attempting to grab something off the dining room table. Resident #1 did not like it, and some yanking and pulling was involved. The ADON stated that she did not witness the incident. During an interview on 2/4/25 at 2:43 PM, the DON stated she understood on 1/08/25 Resident #2 was attempting to remove a decoration from the dining room table. She stated she was unsure if Resident #1 had told Resident #2 a couple of times about the table decoration, but maybe the way Resident #1 approached Resident #2 made her (Resident #2) mad. She stated she considered a person's wheelchair an extension of their body because it was a part of their mobility, but she was never told Resident #1 made contact with Resident #2's wheelchair. She stated that LVN A reported that Resident #1 attempted to swing at Resident #2 but did not make contact. She stated she (the DON) did not observe any camera footage. She stated the camera video surveillance was located in the BOM's office, which would be the only way LVN A could have observed the footage. The DON stated she had no documentation to show she looked into the incident on 1/08/25. She stated she spoke with the ADM that evening about the incident between Resident #1 and Resident #2 because he was not in the facility. She stated she did not remember what she reported to him (the ADM), but it had to be what was reported to her by LVN A. Resident #2 Record Review of Resident #2's face sheet, dated 2/04/25, revealed a [AGE] year-old female that was admitted to the facility on [DATE], with a diagnosis of Alzheimer's (memory loss), Restless leg syndrome (irresistible urge to move legs), intermittent explosive disorder (explosive outburst of anger). Record Review of Resident #2's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 99, indicating the resident was unable to complete the interview. Section E revealed Resident #2 did not exhibit physical behavior (hitting, kicking, pushing, scratching, grabbing, abusing) during the review period [E0200]. Resident #2 did exhibit a presence and frequency of wandering 4-6 days but less than daily [E0900]. Resident #1's wandering did place her at significant risk of getting to a potentially dangerous place and significantly intruded on the privacy of others [E1000.] Record review of Resident #2's care plan, dated 10/12/24, revealed that she had an identified wandering behavior and also took medication (Depakote) related to be being combative. Resident #2's care plan also revealed that she had a new care plan implemented 2/06/25 with a focus that addressed that Resident #2 had a potential to be physically aggressive when she feels threatened and or if someone had something that belonged to her and this was related to her dementia. The goal for the review period (2/06/25) revealed that Resident #2 would not harm self or others. The interventions implemented as of 2/06/25 revealed it was expected that staff attempt to redirect Resident #2 to another place or engage her in activities. The interventions also included recognizing Resident #2's trigger are when staff attempt to redirect her or when voices are raised. Other interventions included keeping her as busy as possible and administering medications as ordered. Record review of Resident #2's Physician's Order, dated 02/04/25, revealed: An order and start date of 1/20/25 for Depakote 250 MG 1 tablet by mouth 2 times a day for intermittent explosive disorder. Record review of Resident #2's progress notes, dated 10/01/24- 02/04/2025 revealed the following: *10/07/24 at 3:26 PM LVN A documented: Resident #2 wandering up and down the hallways. Resident #2 was agitated. LVN A redirecting Resident #2 from entering other residents (unidentified) rooms. Resident #2 cognitive impairment and decreased ability to understand/follow directions. *11/02/25 at 5:52 PM LVN G documented: Resident #2 getting into other resident bed and when moved she pinched staff and yelled out that they were hitting staff. *11/08/24 at 11:10 AM LVN A documented: Resident #2 became agitated upon CNA (unidentified) removing items from residents wc that residents (unidentified) room. When CNA (unidentified) removed items, resident threw water on CNA (unidentified). Resident #2 proceeded to the dining room and picked up a cup of juice and threw it on the CNA (unidentified). *11/09/24 at 12:12 PM LVN A documented: Resident #2 getting into roommate's snacks/drinks. Upon staff attempting to retrieve items, Resident #2 became agitated and attempted physical aggression. *11/09/24 1:14 PM LVN A documented: Resident #2 wandered into another resident's (unidentified) room and took his peanut M&M bag; DON notified and stated she would replace it for the resident (identified). Resident (unidentified) informed and voiced frustration of not being able to keep things in his d/t Resident #2 going in his room attempting to take things. *11/11/24 at 11:53 PM LVN G documented: Resident #2 kept going into other residents (unidentified) rooms and would get into their drawers and get their snacks or their personal. *12/01/24 at 5:39 PM LVN B documented: Resident #1 spent most of shift going into others rooms. Resident #2 was redirected with no improvement. Resident #2 was playing with a chain attached to a door and when asked to stop she took the chain swinging it striking the aide on the arm. *12/21/24 at 2:59 PM LVN A documented: Resident #2 agitated and following other residents around. *1/05/25 at 11:33 AM LVN A documented: Resident #2 has become more agitated, defensive upon staff attempting to redirect, actively going into rooms taking other Residents belongings, and appears anxious with inability to relax. Upon reviewing residents' orders, LVN A noted Depakote was discontinued 11/24/24. If behaviors continue, LVN A will contact PCP to see if Depakote can be resumed. *1/12/25 at 5:12 PM LVN B documented: Resident #2 wanders in hallways and goes into other resident's room throughout shift. This is a common behavior for her. She will go in the room look around and come out. Rightly so the other residents are not happy with her behavior and do not want her to go into their room's. Family, administration and staff are aware and frequently redirect resident, she is compliant the majority of the time. However, some residents have taken it upon themselves to yell at her causing her to become defensive. This evening as residents were gathering in dining room she went into dining room as well. A male resident (unidentified) yelled at her to get out. This nurse redirected resident to hallway, gave her some crackers to keep her distracted. This nurse was coming out of another resident's room and saw resident wheel into dining room. Then nurse heard a male Resident (unidentified) yell out. This nurse went into dining room and removed resident from dining room. the same before mentioned male resident stated, She pulled my hair. A female resident stated, She did pull his hair, and she pulled her hair also. Residents' family member notified of her actions. The ADON notified as well. *1/12/25 at 5:33 PM LVN B documented: a Psychiatric referral was made. *1/14/25 at 10:49 AM LVN A documented: Upon Skin Assessment during Shower, CNA (unidentified) informed LVN A resident had multiple bruises BUE. Resident has behavior of wondering, self transfers, attempting to ambulate w/o assist with unsteady gait. Staff to continue to monitor resident to assure safe environment. *1/16/25 at 10:14 AM the ADON Documented: Resident #2 doesn't c/o pain from bruising , The ADON did note that when she (Resident #2) is using her arms to wheel her chair she does so with very big/hard strokes and the inside part of her arms are hitting the arm of the wheelchair. When the ADON asked where the bruises come from she just smiles and points up and says the lord jesus did it. *1/20/25 at 5:18 PM The Psychiatric Provider Documented: Meeting with facility staff indicates the patient has: Normal appetite. No anxiety and no irritability, and no hostility toward peer(s). No hostility toward caregivers. *1/20/25 at 3:18 PM LVN B documented: The Psychiatric Provider in house for rounds. New order for Depakote 125mg BID received at this time. *1/31/25 at 2:59 PM The Psychiatric Provider Documented: Meeting with facility staff indicates the patient has: Normal appetite. No anxiety and no irritability, and no hostility toward peer(s). No hostility toward caregivers *2/03/25 at 3:15 PM LVN B documented: The Psychiatric Provider in house for rounds. No New orders received at this time. Will continue to monitor Resident #2. *2/03/25 at 4:03 PM The Psychiatric Provider Documented: Meeting with staff reveals: Meeting with facility staff indicates the patient has: Normal appetite. No anxiety and no hostility towards peer(s). No hostility towards caregivers. Record review of facility incident report, dated 11/08/24 revealed the following: Incident description: Nursing (unidentified) witnessed Resident #2 throw water on CNA (unidentified) d/t CNA (unidentified) removing belongings from residents wc that Resident #2 had taken from another residents (unidentified) room. And Resident #2 was unable to give a description of what happened. Action taken: Resident #2 was redirected but it was unsuccessful. Injuries Observed at the time of the incident: No injuries at the time of the incident. Agencies/People Notified: Physician I, DON, ADON and Family Member H. Record review of facility incident report, dated 1/08/25 revealed the following: Incident description: LVN A was sitting at nursing station when another resident (unknown) yelled out, There is a fight in here! BOM and LVN A entered dining area and did not see any physical or verbal altercation. LVN A was informed by another resident (unknown) that Resident #1 hit Resident #2. BOM watched video, and it was verified Resident #1 initiated physical aggression while Resident #2 was sitting in her wc near the table he eats at. Resident #2 was not disturbing the table or making physical contact with anyone upon Resident pulling/pushing Resident #2's wc and swinging his fist backwards towards Resident #2. Resident #2 became agitated but quickly left the area. Action taken: Stated Resident #2 was assessed with no injuries. Injuries Observed at the time of the incident: No injuries at the time of the incident. Predisposing Environmental Factors: Crowding Agencies/People Notified: Physician I, DON and Family Member H. Record review of facility incident report, dated 1/14/25 revealed the following: Incident description: upon Resident #2's shower, CNA (unidentified) reported scattered bruising BUE and one large Bruise RUE noted: Deep Purple/Deep. Resident #2 unable to give a description. Immediate Action taken: Assessed areas with no warmth, surrounding redness or increased tenderness noted. Predisposing Physiological Factors: Confused, gait balance, impaired memory, and incontinent Agencies/People Notified: Physician I, DON, ADON and Family Member H. Record review of the facility incident report, dated 2/4/25, revealed the following: Resident #2 had a physical aggression-initiated incident on 11/08/24 (x2) and 12/26/24. Resident #2 had a bruise identified on 1/14/25. Record review of the picture provided by the BOM on 2/4/25 titled Picture #1 of Resident #2 revealed the following: Resident #2's left eye was dark red around the iris Resident #2 had a large bruise on the right arm Record review of the picture provided by the BOM on 2/4/25 titled Picture #2 of Resident #2 revealed the following: Resident #2 had a large dark purple bruise on the upper right arm. Observed a small dark purple bruise on the right elbow. Observed one light, fading circular bruise near the right wrist. Resident #2 had three small, light purple circular bruises on their left arm near the elbow. Observed four small dark purple bruises scattered down towards Resident #2's left wrist. During an observation of the video provided by the BOM, the following was observed by the HHSC investigator: At the start of the video, from the start of the video to .29 seconds, Resident #1 is seated at the left side of the table while Resident #2 is rolling back and forth to his left. No contact was being made between Resident #1 and Resident #2. :29 seconds Resident #1 takes his left hand and grabs the push handle (right side) of Resident #2. Resident #2 appears startled as she looks around, uses her right hand, and attempts to grab the table. :35 seconds Resident #1 takes his left hand, grabs Resident #2's right armrest, and pushes her back. :35-:45 seconds Resident #1 appeared to say something verbally to Resident #2 (the exact wording is unknown due to the lack of audio, but the Resident's mouth was observed moving). :45 seconds Resident #1 takes his left arm and quickly swings back at Resident #2. It is difficult to see if Resident #1 made contact, but Resident #2's right arm moved back quickly. :46 seconds Resident #2 swings back with her right hand twice. The first time, she hit Resident #1 on his left arm, and the second hit him again but held on for a short duration. :50 seconds observed Resident #2 swing back again. It is unclear if contact was made in Resident #2's face, but it was in the vicinity. An unknown object fell to the floor. :51 seconds-1:00 minute Resident #2 grabs the back of Resident #1's chair and jerking back and forth. 1:00 minute Resident #1 begins to exit the dining room. The video ends at 1 minute and 5 seconds. On 02/05/25 at 1:08 PM, Resident #2 was observed self-propelling down the hallway. The observation revealed That She was using both hands to turn the wheels on her wheelchair. No observations were made where her arms made contact with the wheelchair. On 02/05/25 at 1:18 PM, Resident #2 was observed self-propelling down the hallway. The observation revealed that she used both hands to turn the wheels on her wheelchair. No observations were made where her arms made contact with the wheelchair. During an interview on 2/4/25 at 2:04 PM, Resident #2 could not recall the incident on 1/08/25. She could not state if another resident, specifically Resident #1, had pushed her. When asked about the bruising on her arms, she could not recall where the bruising came from. During an interview on 2/4/25 at 2:54 PM, the BOM stated on 1/08/25 at 6:44 PM, she was in her office when she heard another resident (unknown) yelling, They are fighting! She said another resident (unknown) said, Someone hit your grandma! She stated that she asked Resident #1 if he was okay. She thought Resident #2 had hit him because she has a history of doing things (being physical with other residents) of that nature. The BOM stated Resident #1 told her that he did not hit her (Resident #2). She stated that she told LVN A that she would check the camera footage. She stated that once she had observed the camera footage, she had shown LVN A, and they both had observed Resident #1 swing at Resident #2 first. She said she observed physical contact between Resident #1 and #2. She said she asked LVN A to make a note of the incident. She said she was told by LVN A that she would notate and take care of notifications. The BOM said she was unsure if LVN A called the ADM and DON or just one of them. She said she believed that LVN A just called the DON because the ADM had been out due to having multiple surgeries. She said this was why she did not text or notify the ADM; she knew he was out and because LVN A was making the notifications. The BOM said she did not inform the DON because she observed LVN A on the phone with who she assumed was the DON. She stated she was not close enough to LVN A to know what she reported to the DON. She said she was also trained to check the cameras if there was any further concern, which was why she checked the cameras. She said no one (including the ADM and DON) had questioned her about what she observed on the cameras or about the bruising that was identified on 1/14/25. She stated that the maintenance and the ADM had access to her office, so if the ADM wanted to check the cameras, they could do so without her presence. She said she had been trained that resident-to-resident altercation was a form of abuse. The BOM stated she had a copy of the video surveillance footage and would provide it. She said she used her best judgment and saved a copy of the video because their system would erase it after several days. The BOM stated that she could not remember the date, but after the incident on 1/08/25, she followed up with the ADM. She said that Resident #2 had bruises on her arms and a busted blood vessel in her left eye. The BOM said that she took pictures of Resident #1 arms and eyes. She stated the pictures she took have a date of 1/16/25. She said she would provide the pictures to the investigator. She stated that when she spoke with the ADM about the bruising, he stated that the bruising did not coincide with the time of the incident on 1/08/25 but was concerned about the bruising inside the eye. She said that the ADM was looking at the bruising at the time, and no one knew where the bruising came from, but she expressed concern about the cause of the bruising. During an interview on 2/4/25 at 4:00 PM, the DON stated regarding investigating allegations of abuse, she had been trained to ensure all allegations were investigated and documented thoroughly. She stated that the purpose of the investigation was to find out if there was actual abuse. She stated that the potential negative outcome of not investigating and documenting the investigation was that abuse could reoccur. She stated she knew that a thorough investigation was not conducted because she thought that contact was not made between Resident #1 and Resident #2. She stated their system for monitoring was that when any incident of concern comes in, they will assess the resident and look for injuries. She stated they talked to all parties involved. She stated she ensured that the residents were safe during the process. She stated she typically keeps a soft file. She stated that her soft file was a file in which she kept keeping things such as witness statements and all documents to support that she was investigating an incident. She stated she did not have a soft file for the incident on 1/08/25 between Resident #1 and #2 or a soft file for the identified bruising from 1/14/25. She stated she had been trained to investigate and include all parties thoroughly. She stated she expected the nurse to document and report accordingly in the resident's EMR. She stated that she expected all allegations of abuse, including resident-to-residence altercations and injuries of unknown origin, to be thoroughly documented. She stated the abuse preventionist (ADM) was responsible for investigations. She stated that Resident #2's bruising was not investigated because she was unaware of it. She stated she did not investigate the altercation between Resident #1 and #2 because she was unaware physical contact was made. She stated she only spoke with LVN A regarding the incident that occurred on 1/08/25 between Resident #1 and Resident #2. During an interview on 2/4/25 at 4:30 PM, the ADM stated that on 1/08/25, he received a call from the DON, who explained that residents #1 and #2 had an incident. He stated he asked her if there were any injuries. He was told by the DON that there were no injuries. He said he did not remember the specifics of what was reported by the DON but that whatever was reported was not alarming to him. He stated he read the incident report. He stated by the HHSC definition of abuse, the resident-to-resident altercation did not meet the definition of abuse and did not need to be reported. He stated that he did not observe the camera footage because he was not concerned about what was reported to him by the DON or what he read in the incident report. The ADM said he read that the BOM reviewed the cameras and asked her about the altercation. When he asked her about the incident, the BOM reported that Resident #1 did swing back but did not make any contact. He stated HHSC said the injuries of unknown origin had to be suspicious. He stated that if Resident #2's bruising had been suspicious, that would have been concerning to him. He stated a lot of residents are going to have bruising, especially on their arms. He stated he and the BOM both looked at the bruising. He stated that there was confusion about Resident #2 having a black eye, but when they observed her, she did not have a black eye. He said her eye was red but not concerning to him. He stated that as it relates to any incident, he expected all incidents investigated. He stated he had been trained that all allegations of abuse must be investigated and documented. During an interview on 2/5/25 at 8:30 AM, LVN A stated on 1/14/25, she and the ADON were at the nursing station. She stated that she was informed by CNA C that when she (CNA C) showered Resident #2, she noticed the bruising on her (Resident #2's) arms. She (LVN A) stated she assessed Resident #2. She stated Resident #2 had bruising on both of her upper extremities. She stated there was scattered bruising on both arms. She described the bruising as BUE and dark purple with some yellow color. She stated the darker purple was on the inside of her arms. She stated before this stage that the bruising would have had some redness if it had been fresh. She stated she did not see any bruising to her eye at the time. LVN A stated in her nursing experience that bruising of that (dark purple with some yellow) color meant the bruising was about 3-4 days old. She stated the bruising was resolving and not fresh. LVN A stated she had worked the previous Friday (1/10/25), and the bruising was not there as no one brought it to her attention. She stated that she was off over the weekend. She stated she did not report the incident to the ADM because she is familiar with all documented incidents being reviewed by management. She stated that Resident #2 has a behavior of wandering and attempting to transfer herself. LVN A stated that Resident #2 could not say what happened to her and that she (LVN A) had not witnessed what had caused or could have caused the bruising. LVN A stated that regarding the incident that occurred on 1/08/25 with Resident #1 and #2, she did not report it to the ADM. She said similar to the injury of unknown origin, she was familiar with management reviewing the documented incident and had reported the incident to the DON. She stated she did not feel that the behavior she observed regarding Resident #1 was intentional but more of an agitation. She admitted that she reviewed the surveillance with the BOM but did not observe any physical contact with Residents #1 and #2. She stated she had not been interviewed about the incident on 1/08/25, nor was she interviewed or questioned about the bruising on Resident #2, identified on 1/12/25. During an interview on 2/5/25 at 9:14 AM, the ADON stated on 1/14/25, she and LVN A were standing at the nurse's station. She stated a certified nurse's aide (unsure who it was) came and requested for LVN A to look at bruising on Resident #2. The ADON stated she also observed the area, and on Resident #2 arm (right), she observed where her muscle was, and there was a bruise. She stated on Resident #2's arm (left), there were multiple bruises. She was unsure how many. She stated she had LVN A write an incident report. The ADON stated she had difficulty remembering that far back as it related to the details of that day. She stated she did observe Resident #2 moving in her wheelchair and believed that was where the bruise could have come from. She stated that Resident #2 would also dig in boxes, and the bruises on her left arm could have come from her digging in boxes. She stated that she felt nothing alarming when she observed the bruising. She stated that the bruising she observed was mixed blue and yellow. She stated that Resident #1 had never had bruising like she had observed before. The ADON stated she did ask around on 1/14/25 but did not document it, nor did she know specifically who and what she asked. She stated she did not observe bruising on Resident #2's eye that day (1/16/25). She stated that on 1/16/25, the ADM did have her look at Resident #2 because of the bruising and potential eye injury. She stated there was no bruising to the eye. She stated she could not remember the ADM's exact wording when he spoke to her, but it was enough for her to take a look at Resident #2 bruising and eye. She stated that when she looked at Resident #2's left eye, it was a little bloodshot, but it appeared red from the moment she woke up. She stated as it related to the bruising on her arms, Resident #2 would look up and say, The Lord Jesus Christ did it when asked what happened. The ADON stated Resident #2 is not cognitive enough to recall. The ADON stated she had been trained when there was an injury of unknown origin to find out if it was an area that was concerning, and that is when they needed to find out what happened. She stated concerning areas such as the face, breast area, back, or groin area are areas they would consider suspicious if bruising appeared in those areas. She stated injuries in those areas would alarm her. She stated that they look at each individual separately, but if they have a history of bruising on their forearms, they try to prevent the bruising. She stated that if the residents cannot tell them what happened, they must continue to find out what happened. She stated that the potential negative outcome of not investigating or thoroughly investigating an injury of unknown origin was the injury could go without treatment and cause further injury. During an interview on 2/4/25 at 9:57 AM, LVN B stated Resident #2 had a history of wandering. She stated that the residents are unhappy when she (Resident #2) wande [TRUNCATED]

Based on interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for 4 of 7 residents (Resident #1, #2, #3 and #4) reviewed for abuse. The ADM (Abuse Preventionist) failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC and documenting his investigation regarding the Resident-to-Resident altercation (Between Resident #1 and Resident #2) that occurred and was reported on 1/08/25 by the DON and LVN A. The ADM failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC and documenting his investigation regarding the Resident-to-Resident altercation (Between Resident #2, #3 and #4) that occurred and was reported on 1/12/25 by LVN B to the ADON. The ADM (Abuse Preventionist) failed to follow the facility's abuse policy by not reporting the allegation of abuse to include injury of unknown origin to HHSC and documenting his investigation regarding the bruising that was identified on 1/14/25. The ADON and LVN B failed to follow the facility's abuse policy by not reporting the allegation of abuse to the ADM (Abuse preventionist) regarding the Resident-to-Resident altercation (Between Resident #2, #3 and #4) that occurred and was reported on 1/12/25 by LVN B to the ADON. The ADM and DON failed to report to the Psychiatric Provider that Resident #2 had physical and verbal aggression towards staff and residents after she had referred to psychiatric services as of 1/20/25. These failures could place residents as risk for abuse and neglect. Findings include: Record review of the facility policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, Revised April 2021, revealed the following: Policy Statement Residents have the right to be free from abuse and neglect. This includes but not limited to verbal and physical abuse. Policy Interpretation and Implementation The resident abuse and neglect prevention program consist of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse and neglect by anyone including, but not necessarily limited to Facility staff Other residents Develop and implement policies and protocols to prevent and identify Abuse or mistreatment of residents Neglect of residents Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. Investigate and report any allegations within timeframes required by federal requirements. Record review of the facility policy, Abuse and Neglect, Revised March 2018, revealed the following: Cause Identification The staff will investigate alleged abuse and neglect to clarify what happened and identify possible causes. Record review of the facility policy, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, Revised September 2022, revealed the following: Policy Statement All reports of resident abuse (including injuries of unknown) and neglect are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to Administer and Authorities If resident abuse and neglect or injury of unknown origin is suspected, the suspicion must be reported immediately to the administrator and other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility Immediately is defined as: Within two hours of an allegation involving abuse or result in serious bodily injury Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury Upon receiving any allegations of abuse, neglect and injury of unknown origin, the administrator is responsible for determining what actions (if any) are needed for protection of residents. Investigating Allegations All allegations are thoroughly investigated. The Administrator initiates investigations. Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations. The administrators provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. The individual conducting the investigation as a minimum: Reviews the documentation and evidence Reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident. Interviews the person(s) reporting the incident. Interviews witnesses to the incident. Interviews resident (as medically appropriate) or the resident's representative. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. Interview resident roommate, family members, and visitors; Review all incidents leading up to the incident Documents the investigation completely and thoroughly Record review of the facility policy, Resident-to-Resident Altercation , Revised September 2022, revealed the following: Policy Statement 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 Facility Staff monitor residents for aggressive/inappropriate behavior towards other residents and staff. Behaviors that may provoke a reaction by residents or others include verbally aggressive behavior and physically aggressive behavior. Occurrences of such incidents are promptly reported to the nurse supervisor, director of nursing and to the administrator. The Administrator will report the incident in accordance with the criteria established under Abuse, Neglect-Reporting and Investigating. If two residents are involved in an altercation, staff: Identify what happened Review the events with nursing supervisor, director of nursing and evaluate effectiveness of interventions. Consult with attending physician to identify treatable conditions such as acute psychosis Consult with psychiatric services as needed for assistance in assessing the resident. Report incidents, findings, and corrective measures taken in the resident's medical record. Inquiries concerning resident-to-resident altercations are referred to the director of nurses or to the administrator. Record review of the facility policy, Resident Right, undated, revealed the following: Inservice Objective The purpose of this program is to provide you with a basic understanding of the rights of nursing home residents. A basic understanding of residents' rights is essential to a nurse aides' ability to provide quality care and avoid mistakes that place a resident's safety or well-being at risk. The following is an outline of the information covered in this inservice program. Abuse & Neglect: The right to be free of abuse and neglect Resident #1 Record Review of Resident #1's face sheet, dated 02/04/25, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of Hepatitis C (a contagious viral liver infection). Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 07, indicating the resident was severely cognitively impaired. Section E revealed Resident #1 did not exhibit physical behavior (hitting, kicking, pushing, scratching, grabbing, abusing) during the review period [E0200]. Section I Resident #1 had viral Hepatitis. Record review of Resident #1's Physician Order Summary Report, dated 02/04/25, revealed that Resident #1 was not taking any medications for Hepatitis C. Record review of Resident #1's progress notes, dated 12/03/24-2/4/25 revealed the following: *1/08/25 at 4:18 PM LVN A documented: LVN A was sitting at nursing station when another resident (unknown) yelled out, There is a fight in here! BOM and LVN A entered dining area and did not see any physical or verbal altercation. LVN A was informed by another resident (unknown) that Resident #1 hit Resident #2. BOM watched video, and it was verified Resident #1 initiated physical aggression while Resident #2 was sitting in her wc near the table he ate at. Resident #2 was not disturbing the table or making physical contact with anyone upon Resident pulling/pushing Resident #2's wc and swinging his fist backwards towards Resident #2. Resident #2 became agitated but quickly left the area. *1/08/25 at 5:10 PM LVN A documented: Resident #1 was educated on not placing hands on other residents and informed to get staff if there was an incident that needs to be addressed. Resident #1 voiced understanding. Record review of Resident #1's care plan, dated 12/12/24, did not reveal a care plan regarding aggressive behavior but revealed his dx of hepatitis. His care plan did not reveal any revisions regarding the incident on 1/08/25. Record review of facility incident report, dated 1/08/25 revealed: Incident description: exact note that LVN A documented in Resident #1's progress note on 1/08/25. Action taken: Stated Resident #2 was assessed with no injuries. Injuries Observed at the time of the incident: No injuries at the time of the incident. Predisposing Environmental Factors: Crowding Agencies/People Notified: Physician C, DON and Family Member D. Record review of the facility incident report, dated 2/4/25, revealed: Resident #1 had a physical aggression-initiated incident on 1/08/25. During an interview on 2/4/25 at 12:57 PM, LVN A stated the abuse preventionist was the ADM. She said if she suspected or witnessed abuse, she had been trained to contact the ADM immediately. She said she had abuse training at the facility. She said she had been trained to separate the residents, perform a nursing assessment for injuries, and ensure everyone was safe if there was a resident-to-resident altercation. She stated she had been trained to report all resident-to-resident altercations to the ADM. On 1/08/25, she said she was not in the dining room when the incident occurred with Residents #1 and #2. She stated she had to look back at the video footage. She said when she looked at the footage, she observed Resident #2 sitting at the dining room table, and for some reason unknown to her, Resident #1 became frustrated. She said she observed Resident #1 push Resident #2's wheelchair, and Resident #2 rolled backward. She said Resident #2 rolled backward and did not come into contact with anything. She said Residents #1 and #2 did not make contact with each other. She said as a result, they ensured both residents (Resident #1 and #2) were separated and safe. She said she did an incident report, assessed the residents, and then reported everything she observed on the video footage to the DON. She said this was the first time Resident #1 had acted that way and did not have a history of physically aggressive behavior. She reported the incident to the DON and appropriate parties, such as doctors and family contact. During an interview on 2/4/25 at 1:48 PM, Resident #1 could not recall specifics about the incident on 1/08/25. He stated he might have pushed them, but they asked for it. He said he did not know the other resident's name. He could not report if the other resident were male or female. He stated that they went crying to momma. He said he would handle his issues with [NAME] and [NAME]. He verified that [NAME] and [NAME] were his left and right hands. During an interview on 2/4/25 at 2:23 PM, the ADON stated the ADM was the abuse preventionist. She said if she suspected or witnessed abuse, she had been trained to remove the resident from the area where the abuse was occurring. She said she would go to the ADM, and if he were unavailable, she would go to the DON. She said if a resident-to-resident altercation had occurred, she had been trained to separate the residents, assess for injuries, and report the incident to the ADM and the DON. She stated regarding the incident on 1/08/25, it was her understanding that Resident #2 was attempting to grab something off the dining room table. Resident #1 did not like it, and some yanking and pulling was involved. The ADON stated that she did not witness the incident. During an interview on 2/4/25 at 2:43 PM, the DON stated she understood on 1/08/25 Resident #2 was attempting to remove a decoration from the dining room table. She stated she was unsure if Resident #1 had told Resident #2 a couple of times about the table decoration, but maybe the way Resident #1 approached Resident #2 made her (Resident #2) mad. She said she did not report the incident to HHSC because LVN A reported no physical contact between Resident #1 and Resident #2. She stated she considered a person's wheelchair an extension of their body because it was a part of their mobility, but she was never told Resident #1 made contact with Resident #2's wheelchair. She stated LVN A reported that Resident #1 attempted to swing at Resident #2 but did not make contact. She stated she (the DON) did not observe any camera footage. She stated the camera video surveillance was located in the BOM's office, which would be the only way LVN A could have observed the footage. The DON stated she had no documentation to show she looked into the incident on 1/08/25. She stated she spoke with the ADM that evening about the incident between Resident #1 and Resident #2 because he was not in the facility. She stated she did not remember what she reported to him (the ADM), but it had to be what was reported to her by LVN A. Resident #2 Record Review of Resident #2's face sheet, dated 2/04/25, revealed a [AGE] year-old female that was admitted to the facility on [DATE], with a diagnosis of Alzheimer's (memory loss), Restless leg syndrome (irresistible urge to move legs), intermittent explosive disorder (explosive outburst of anger). Record Review of Resident #2's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 99, indicating the resident was unable to complete the interview. Section E revealed Resident #2 did not exhibit physical behavior (hitting, kicking, pushing, scratching, grabbing, abusing) during the review period [E0200]. Resident #2 did exhibit a presence and frequency of wandering 4-6 days but less than daily [E0900]. Resident #1's wandering did place her at significant risk of getting to a potentially dangerous place and significantly intruded on the privacy of others [E1000.] Record review of Resident #2's care plan, dated 10/12/24, revealed that she had an identified wandering behavior and also took medication (Depakote) related to be being combative. There was no care plan addressing aggressive behavior towards residents or the incident that occurred on 1/08/25. Record review of Resident #2's care plan, dated 10/12/24, revealed that she had a new care plan implemented 2/06/25 with a focus that addressed that Resident #2 had a potential to be physically aggressive when she feels threatened and or if someone had something that belonged to her and this was related to her dementia. The goal for the review period (2/06/25) revealed that Resident #2 would not harm self or others. The interventions implemented as of 2/06/25 revealed it was expected that staff attempt to redirect Resident #2 to another place or engage her in activities. The interventions also included recognizing Resident #2's trigger are when staff attempt to redirect her or when voices are raised. Other interventions included keeping her as busy as possible and administering medications as ordered. Record review of Resident #2's Physician's Order, dated 02/04/25, revealed: An order and start date of 1/20/25 for Depakote 250 MG 1 tablet by mouth 2 times a day for intermittent explosive disorder. Record review of Resident #2's progress notes, dated 10/01/24- 02/04/2025 revealed the following: *10/07/24 at 3:26 PM LVN A documented: Resident #2 wandering up and down the hallways. Resident #2 was agitated. LVN A redirecting Resident #2 from entering other residents (unidentified) rooms. Resident #2 cognitive impairment and decreased ability to understand/follow directions. *11/02/25 at 5:52 PM LVN G documented: Resident #2 getting into other resident bed and when moved she pinched staff and yelled out that they were hitting staff. *11/08/24 at 11:10 AM LVN A documented: Resident #2 became agitated upon CNA (unidentified) removing items from residents wc that residents (unidentified) room. When CNA (unidentified) removed items, resident threw water on CNA (unidentified). Resident #2 proceeded to the dining room and picked up a cup of juice and threw it on the CNA (unidentified). *11/09/24 at 12:12 PM LVN A documented: Resident #2 getting into roommate's snacks/drinks. Upon staff attempting to retrieve items, Resident #2 became agitated and attempted physical aggression. *11/09/24 1:14 PM LVN A documented: Resident #2 wandered into another resident's (unidentified) room and took his peanut M&M bag; DON notified and stated she would replace it for the resident (identified). Resident (unidentified) informed and voiced frustration of not being able to keep things in his d/t Resident #2 going in his room attempting to take things. *11/11/24 at 11:53 PM LVN G documented: Resident #2 kept going into other residents (unidentified) rooms and would get into their drawers and get their snacks or their personal. *12/01/24 at 5:39 PM LVN B documented: Resident #1 spent most of shift going into others rooms. Resident #2 was redirected with no improvement. Resident #2 was playing with a chain attached to a door and when asked to stop she took the chain swinging it striking the aide on the arm. *12/21/24 at 2:59 PM LVN A documented: Resident #2 agitated and following other residents around. *1/05/25 at 11:33 AM LVN A documented: Resident #2 has become more agitated, defensive upon staff attempting to redirect, actively going into rooms taking other Residents belongings, and appears anxious with inability to relax. Upon reviewing residents' orders, LVN A noted Depakote was discontinued 11/24/24. If behaviors continue, LVN A will contact PCP to see if Depakote can be resumed. *1/12/25 at 5:12 PM LVN B documented: Resident #2 wanders in hallways and goes into other resident's room throughout shift. This is a common behavior for her. She will go in the room look around and come out. Rightly so the other residents are not happy with her behavior and do not want her to go into their room's. Family, administration and staff are aware and frequently redirect resident, she is compliant the majority of the time. However, some residents have taken it upon themselves to yell at her causing her to become defensive. This evening as residents were gathering in dining room she went into dining room as well. A male resident (unidentified) yelled at her to get out. This nurse redirected resident to hallway, gave her some crackers to keep her distracted. This nurse was coming out of another resident's room and saw resident wheel into dining room. Then nurse heard a male Resident (unidentified) yell out. This nurse went into dining room and removed resident from dining room. the same before mentioned male resident stated, She pulled my hair. A female resident stated, She did pull his hair, and she pulled her hair also. Residents' family member notified of her actions. The ADON notified as well. *1/12/25 at 5:33 PM LVN B documented: a Psychiatric referral was made. *1/14/25 at 10:49 AM LVN A documented: Upon Skin Assessment during Shower, CNA (unidentified) informed LVN A resident had multiple bruises BUE. Resident has behavior of wondering, self transfers, attempting to ambulate w/o assist with unsteady gait. Staff to continue to monitor resident to assure safe environment. *1/16/25 at 10:14 AM the ADON Documented: Resident #2 doesn't c/o pain from bruising , The ADON did note that when she (Resident #2) is using her arms to wheel her chair she does so with very big/hard strokes and the inside part of her arms are hitting the arm of the wheelchair. When the ADON asked where the bruises come from she just smiles and points up and says the lord jesus did it. *1/20/25 at 5:18 PM The Psychiatric Provider Documented: Meeting with facility staff indicates the patient has: Normal appetite. No anxiety and no irritability, and no hostility toward peer(s). No hostility toward caregivers. *1/20/25 at 3:18 PM LVN B documented: The Psychiatric Provider in house for rounds. New order for Depakote 125mg BID received at this time. *1/31/25 at 2:59 PM The Psychiatric Provider Documented: Meeting with facility staff indicates the patient has: Normal appetite. No anxiety and no irritability, and no hostility toward peer(s). No hostility toward caregivers *2/03/25 at 3:15 PM LVN B documented: The Psychiatric Provider in house for rounds. No New orders received at this time. Will continue to monitor Resident #2. *2/03/25 at 4:03 PM The Psychiatric Provider Documented: Meeting with staff reveals: Meeting with facility staff indicates the patient has: Normal appetite. No anxiety and no hostility towards peer(s). No hostility towards caregivers. Record review of facility incident report, dated 11/08/24 revealed the following: Incident description: Nursing (unidentified) witnessed Resident #2 throw water on CNA (unidentified) d/t CNA (unidentified) removing belongings from residents wc that Resident #2 had taken from another residents (unidentified) room. And Resident #2 was unable to give a description of what happened. Action taken: Resident #2 was redirected but it was unsuccessful. Injuries Observed at the time of the incident: No injuries at the time of the incident. Agencies/People Notified: Physician I, DON, ADON and Family Member H. Record review of facility incident report, dated 1/08/25 revealed the following: Incident description: LVN A was sitting at nursing station when another resident (unknown) yelled out, There is a fight in here! BOM and LVN A entered dining area and did not see any physical or verbal altercation. LVN A was informed by another resident (unknown) that Resident #1 hit Resident #2. BOM watched video, and it was verified Resident #1 initiated physical aggression while Resident #2 was sitting in her wc near the table he ate at. Resident #2 was not disturbing the table or making physical contact with anyone upon Resident pulling/pushing Resident #2's wc and swinging his fist backwards towards Resident #2. Resident #2 became agitated but quickly left the area. Action taken: Stated Resident #2 was assessed with no injuries. Injuries Observed at the time of the incident: No injuries at the time of the incident. Predisposing Environmental Factors: Crowding Agencies/People Notified: Physician I, DON and Family Member H. Record review of facility incident report, dated 1/14/25 revealed the following: Incident description: upon Resident #2's shower, CNA (unidentified) reported scattered bruising BUE and one large Bruise RUE noted: Deep Purple/Deep. Resident #2 unable to give a description. Immediate Action taken: Assessed areas with no warmth, surrounding redness or increased tenderness noted. Predisposing Physiological Factors: Confused, gait balance, impaired memory, and incontinent Agencies/People Notified: Physician I, DON, ADON and Family Member H. Record review of the facility incident report, dated 2/4/25, revealed the following: Resident #2 had a physical aggression-initiated incident on 11/08/24 (x2) and 12/26/24. Resident #2 had a bruise identified on 1/14/25. Record review of the picture provided by the BOM on 2/4/25 titled Picture #1 of Resident #2 revealed the following: Resident #2's left eye was dark red around the iris Resident #2 had a large bruise on the right arm Record review of the picture provided by the BOM on 2/4/25 titled Picture #2 of Resident #2 revealed the following: Resident #2 had a large dark purple bruise on the upper right arm. Observed a small dark purple bruise on the right elbow. Observed one light, fading circular bruise near the right wrist. Resident #2 had three small, light purple circular bruises on their left arm near the elbow. Observed four small dark purple bruises scattered down towards Resident #2's left wrist. During an observation of the video provided by the BOM, the following was observed by the HHSC investigator: At the start of the video, from the start of the video to .29 seconds, Resident #1 is seated at the left side of the table while Resident #2 is rolling back and forth to his left. No contact was being made between Resident #1 and Resident #2. :29 seconds Resident #1 takes his left hand and grabs the push handle (right side) of Resident #2. Resident #2 appears startled as she looks around, uses her right hand, and attempts to grab the table. :35 seconds Resident #1 takes his left hand, grabs Resident #2's right armrest, and pushes her back. :35-:45 seconds Resident #1 appeared to say something verbally to Resident #2 (the exact wording is unknown due to the lack of audio, but the Resident's mouth was observed moving). :45 seconds Resident #1 takes his left arm and quickly swings back at Resident #2. It is difficult to see if Resident #1 made contact, but Resident #2's right arm moved back quickly. :46 seconds Resident #2 swings back with her right hand twice. The first time, she hit Resident #1 on his left arm, and the second hit him again but held on for a short duration. :50 seconds observed Resident #2 swing back again. It is unclear if contact was made in Resident #2's face, but it was in the vicinity. An unknown object fell to the floor. :51 seconds-1:00 minute Resident #2 grabs the back of Resident #1's chair and jerking back and forth. 1:00 minute Resident #1 begins to exit the dining room. The video ends at 1 minute and 5 seconds. On 02/05/25 at 1:08 PM, Resident #2 was observed self-propelling down the hallway. The observation revealed That She was using both hands to turn the wheels on her wheelchair. No observations were made where her arms made contact with the wheelchair. On 02/05/25 at 1:18 PM, Resident #2 was observed self-propelling down the hallway. The observation revealed that she used both hands to turn the wheels on her wheelchair. No observations were made where her arms made contact with the wheelchair. During an interview on 2/4/25 at 2:04 PM, Resident #2 could not recall the incident on 1/08/25. She could not state if another resident, specifically Resident #1, had pushed her. When asked about the bruising on her arms, she could not recall where the bruising came from. During an interview on 2/4/25 at 2:54 PM, the BOM stated on 1/08/25 at 6:44 PM, she was in her office when she heard another resident (unknown) yelling, They are fighting! She said another resident (unknown) said, Someone hit your grandma! She stated that she asked Resident #1 if he was okay. She thought Resident #2 had hit him because she has a history of doing things (being physical with other residents) of that nature. The BOM stated Resident #1 told her that he did not hit her (Resident #2). She stated that she told LVN A that she would check the camera footage. She stated that once she had observed the camera footage, she had shown LVN A, and they both had observed Resident #1 swing at Resident #2 first. She said she observed physical contact between Resident #1 and #2. She said she asked LVN A to make a note of the incident. She said she was told by LVN A that she would notate and take care of notifications. The BOM said she was unsure if LVN A called the ADM and DON or just one of them. She said she believed that LVN A just called the DON because the ADM had been out due to having multiple surgeries. She said this was why she did not text or notify the ADM; she knew he was out and because LVN A was making the notifications. The BOM said she did not inform the DON because she observed LVN A on the phone with who she assumed was the DON. She stated she was not close enough to LVN A to know what she reported to the DON. The BOM stated she had been trained to report all allegations of abuse to the ADM, and if the ADM was unavailable, she had been trained to report to the charge nurse. She stated that is what she did on 1/08/25. She stated the ADM was not in the facility and reported to LVN A, the charge nurse at the time. She said she was unsure if the DON was in the facility at the time of the incident. She said she was also trained to check the cameras if there was any further concern, which was why she checked the cameras. She said no one (including the ADM and DON) had questioned her about what she observed on the cameras or about the bruising that was identified on 1/14/25. She stated that the maintenance and the ADM had access to her office, so if the ADM wanted to check the cameras, they could do so without her presence. She said she had been trained that resident-to-resident altercation was a form of abuse. The BOM stated she had a copy of the video surveillance footage and would provide it. She said she used her best judgment and saved a copy of the video because their system would erase it after several days. The BOM stated that she could not remember the date, but after the incident on 1/08/25, she followed up with the ADM. She said that Resident #2 had bruises on her arms and a busted blood vessel in her left eye. The BOM said that she took pictures of Resident #1 arms and eyes. She stated the pictures she took have a date of 1/16/25. She said she would provide the pictures to the investigator. She stated that when she spoke with the ADM about the bruising, he stated that the bruising did not coincide with the time of the incident on 1/08/25 but was concerned about the bruising inside the eye. She said that the ADM was looking at the bruising at the time, and no one knew where the bruising came from, but she expressed concern about the cause of the bruising. During an interview on 2/4/25 at 4:00 PM, the DON stated regarding following the facility policy, specifically not reporting abuse to include resident-to-resident altercation and injury of unknown origin to HHSC and the abuse preventionist, that a potential negative outcome for residents could be a severe injury. She said the purpose of having an abuse policy and following it was to ensure that the residents are given the quality of care that they need. The DON stated she was familiar with and had been trained on the facility's abuse policy. She said she was unaware of physical contact between Resident #1 and #2. She stated that their monitoring system related to the abuse policy and reporting was that she would check the 24-hour report if it were a weekday, and if it were a Monday, she would run a 72-hour report. She stated that if she is not at work, she is unsure if anyone will check the reports for concerning incidents. She said that she also checks the resident progress notes daily. The DON stated she was unaware of the bruising identified on 1/14/25. She said she would have been at work that day, but no one ever reported that Resident #2 had bruising on her arms. The DON stated that she and all of her staff had been trained on the abuse policy and that she was unaware of any staff who had not been trained. She also stated that she had been trained to report reportable incidents to HHSC. The DON stated that she expected all staff to follow the abuse policy and report all reportable incidents to HHSC. S [TRUNCATED]

Based on interviews 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, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Abuse Preventionist for 4 of 7 residents (Resident #1, #2, #3 and #4) reviewed for abuse. The ADM (Abuse Preventionist) failed to report the allegation of abuse to HHSC regarding the Resident-to-Resident altercation (Between Resident #1 and Resident #2) that occurred and was reported on 1/08/25 by the DON and LVN A within the appropriate time frame. The ADON and LVN B failed to report the allegation of abuse to the ADM (Abuse Preventionist) regarding the Resident-to-Resident altercation (Between Resident #2, #3 and #4) that occurred and was reported on 1/12/25 by LVN B to the ADON within the appropriate timeframe. The ADM (Abuse Preventionist) failed to report the allegation of abuse to include injury of unknown origin to HHSC regarding the bruising that was identified on Resident #2 on 1/14/25 within the appropriate timeframe. These failures could place residents as risk for abuse and neglect. Findings included: Record review of the facility policy, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, Revised September 2022, revealed the following: Policy Statement All reports of resident abuse (including injuries of unknown) and neglect are reported to local, state and federal agencies (as required by current regulations) . Policy Interpretation and Implementation Reporting Allegations to Administer and Authorities If resident abuse and neglect or injury of unknown origin is suspected, the suspicion must be reported immediately to the administrator and other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility Immediately is defined as: Within two hours of an allegation involving abuse or result in serious bodily injury Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury Record review of the facility policy, Resident-to-Resident Altercation , Revised September 2022, revealed the following: Policy Statement All altercations, including those that may represent resident-to-resident abuse, are reported to the nursing supervisor, the director of nursing services and to the administrator. Policy Interpretation and Implementation Occurrences of such incidents are promptly reported to the nurse supervisor, director of nursing and to the administrator. The Administrator will report the incident in accordance with the criteria established under Abuse, Neglect-Reporting and Investigating. Inquiries concerning resident-to-resident altercations are referred to the director of nurses or to the administrator. Resident #1 Record Review of Resident #1's face sheet, dated 02/04/25, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of Hepatitis C (a contagious viral liver infection). Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 07, indicating the resident was severely cognitively impaired. Section E revealed Resident #1 did not exhibit physical behavior (hitting, kicking, pushing, scratching, grabbing, abusing) during the review period [E0200]. Section I Resident #1 had viral Hepatitis. Record review of Resident #1's Physician Order Summary Report, dated 02/04/25, revealed that Resident #1 was not taking any medications for Hepatitis C. Record review of Resident #1's care plan, dated 12/12/24, did not reveal a care plan regarding aggressive behavior but revealed his dx of hepatitis. His care plan did not reveal any revisions regarding the incident on 1/08/25. Record review of facility incident report, dated 1/08/25 revealed the following: Incident description: exact note that LVN A documented in Resident #1's progress note on 1/08/25. Action taken: Stated Resident #2 was assessed with no injuries. Injuries Observed at the time of the incident: No injuries at the time of the incident. Predisposing Environmental Factors: Crowding Agencies/People Notified: Physician C, DON and Family Member D. Record review of the facility incident report, dated 2/4/25, revealed Resident #1 had a physical aggression-initiated incident on 1/08/25. Record review of Resident #1's progress notes, dated 12/03/24-2/4/25 revealed the following: *1/08/25 at 4:18 PM LVN A documented: LVN A was sitting at nursing station when another resident (unknown) yelled out, There is a fight in here! BOM and LVN A entered dining area and did not see any physical or verbal altercation. LVN A was informed by another resident (unknown) that Resident #1 hit Resident #2. BOM watched video, and it was verified Resident #1 initiated physical aggression while Resident #2 was sitting in her wc near the table he eats at. Resident #2 was not disturbing the table or making physical contact with anyone upon Resident pulling/pushing Resident #2's wc and swinging his fist backwards towards Resident #2. Resident #2 became agitated but quickly left the area. *1/08/25 at 5:10 PM LVN A documented: Resident #1 was educated on not placing hands on other residents and informed to get staff if there is an incident that needs to be addressed. Resident #1 voiced understanding. During an interview on 2/4/25 at 12:57 PM, LVN A stated the abuse preventionist was the ADM. She said that if she suspected or witnessed abuse, she had been trained to contact the ADM immediately. She said she had abuse training at the facility. She said she had been trained to separate the residents, perform a nursing assessment for injuries, and ensure that everyone was safe if there was a resident-to-resident altercation. She stated she had been trained to report all resident-to-resident altercations to the ADM. On 1/08/25, she said she was not in the dining room when the incident occurred with Resident #1 and #2. She stated that she had to look back at the video footage. She said when she looked at the footage, she observed Resident #2 sitting at the dining room table, and for some reason unknown to her, Resident #1 became frustrated. She said she observed Resident #1 push Resident #2's wheelchair, and Resident #2 rolled backward. She said Resident #2 rolled backward and did not come into contact with anything. She said Residents #1 and #2 did not make contact with each other. She said as a result, they ensured that both residents (Resident #1 and #2) were separated and safe. She said she did an incident report, assessed the residents, and then reported everything she observed on the video footage to the DON. She said that this was the first time Resident #1 had acted that way and did not have a history of physically aggressive behavior. She reported the incident to the DON and appropriate parties, such as doctors and family contact. During an interview on 2/4/25 at 2:43 PM, the DON stated that she understood that 1/08/25 Resident #2 was attempting to remove a decoration from the dining room table. She stated she was unsure if Resident #1 had told Resident #2 a couple of times about the table decoration, but maybe the way Resident #1 approached Resident #2 made her (Resident #2) mad. She said she did not report the incident to HHSC because LVN A reported no physical contact between Resident #1 and Resident #2. She stated that she considered a person's wheelchair an extension of their body because it was a part of their mobility, but she was never told that Resident #1 made contact with Resident #2's wheelchair. She stated that LVN A reported that Resident #1 attempted to swing at Resident #2 but did not make contact. She stated she spoke with the ADM that evening about the incident between Resident #1 and Resident #2 because he was not in the facility. She stated she did not remember what she reported to him (the ADM), but it had to be what was reported to her by LVN A. Resident #2 Record Review of Resident #2's face sheet, dated 2/04/25, revealed a [AGE] year-old female that was admitted to the facility on [DATE], with a diagnosis of Alzheimer's (memory loss), Restless leg syndrome (irresistible urge to move legs), intermittent explosive disorder (explosive outburst of anger). Record Review of Resident #2's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 99, indicating the resident was unable to complete the interview. Section E revealed Resident #2 did not exhibit physical behavior (hitting, kicking, pushing, scratching, grabbing, abusing) during the review period [E0200]. Resident #2 did exhibit a presence and frequency of wandering 4-6 days but less than daily [E0900]. Resident #1's wandering did place her at significant risk of getting to a potentially dangerous place and significantly intruded on the privacy of others [E1000.] Record review of Resident #2's care plan, dated 10/12/24, revealed that she had an identified wandering behavior and also took medication (Depakote) related to be being combative. There was no care plan addressing aggressive behavior towards residents or the incident that occurred on 1/08/25. Record review of Resident #2's care plan, dated 10/12/24, revealed that she had a new care plan implemented 2/06/25 with a focus that addressed that Resident #2 had a potential to be physically aggressive when she feels threatened and or if someone had something that belonged to her and this was related to her dementia. The goal for the review period (2/06/25) revealed that Resident #2 would not harm self or others. The interventions implemented as of 2/06/25 revealed it was expected that staff attempt to redirect Resident #2 to another place or engage her in activities. The interventions also included recognizing Resident #2's trigger are when staff attempt to redirect her or when voices are raised. Other interventions included keeping her as busy as possible and administering medications as ordered. Record review of Resident #2's Physician's Order, dated 02/04/25, revealed: An order and start date of 1/20/25 for Depakote 250 MG 1 tablet by mouth 2 times a day for intermittent explosive disorder. Record review of facility incident report, dated 1/08/25 revealed the following: Incident description: LVN A was sitting at nursing station when another resident (unknown) yelled out, There is a fight in here! BOM and LVN A entered dining area and did not see any physical or verbal altercation. LVN A was informed by another resident (unknown) that Resident #1 hit Resident #2. BOM watched video, and it was verified Resident #1 initiated physical aggression while Resident #2 was sitting in her wc near the table he eats at. Resident #2 was not disturbing the table or making physical contact with anyone upon Resident pulling/pushing Resident #2's wc and swinging his fist backwards towards Resident #2. Resident #2 became agitated but quickly left the area. Action taken: Stated Resident #2 was assessed with no injuries. Injuries Observed at the time of the incident: No injuries at the time of the incident. Predisposing Environmental Factors: Crowding Agencies/People Notified: Physician I, DON and Family Member H. During an observation of the video provided by the BOM, the following was observed by the HHSC investigator: At the start of the video, from the start of the video to .29 seconds, Resident #1 is seated at the left side of the table while Resident #2 is rolling back and forth to his left. No contact was being made between Resident #1 and Resident #2. :29 seconds Resident #1 takes his left hand and grabs the push handle (right side) of Resident #2. Resident #2 appears startled as she looks around, uses her right hand, and attempts to grab the table. :35 seconds Resident #1 takes his left hand, grabs Resident #2's right armrest, and pushes her back. :35-:45 seconds Resident #1 appeared to say something verbally to Resident #2 (the exact wording is unknown due to the lack of audio, but the Resident's mouth was observed moving). :45 seconds Resident #1 takes his left arm and quickly swings back at Resident #2. It is difficult to see if Resident #1 made contact, but Resident #2's right arm moved back quickly. :46 seconds Resident #2 swings back with her right hand twice. The first time, she hit Resident #1 on his left arm, and the second hit him again but held on for a short duration. :50 seconds observed Resident #2 swing back again. It is unclear if contact was made in Resident #2's face, but it was in the vicinity. An unknown object fell to the floor. :51 seconds-1:00 minute Resident #2 grabs the back of Resident #1's chair and jerking back and forth. 1:00 minute Resident #1 begins to exit the dining room. The video ends at 1 minute and 5 seconds. Record review of facility incident report, dated 1/14/25 revealed the following: Incident description: upon Resident #2's shower, CNA (unidentified) reported scattered bruising BUE and one large Bruise RUE noted: Deep Purple/Deep. Resident #2 unable to give a description. Immediate Action taken: Assessed areas with no warmth, surrounding redness or increased tenderness noted. Predisposing Physiological Factors: Confused, gait balance, impaired memory, and incontinent Agencies/People Notified: Physician I, DON, ADON and Family Member H. Record review of the facility incident report, dated 2/4/25, revealed Resident #2 had a bruise identified on 1/14/25. Record review of the picture provided by the BOM on 2/4/25 titled Picture #1 of Resident #2 revealed the following: *Resident #2's left eye was dark red around the iris *Resident #2 had a large bruise on the right arm Record review of the picture provided by the BOM on 2/4/25 titled Picture #2 of Resident #2 revealed the following: *A large dark purple bruise on the upper right arm. * A small dark purple bruise on the right elbow. Observed one light, fading circular bruise near the right wrist. * Three small, light purple circular bruises on their left arm near the elbow. *Four small dark purple bruises scattered down towards Resident #2's left wrist. Record review of Resident #2's progress notes revealed the following: *1/12/25 at 5:12 PM LVN B documented: Resident #2 wanders in hallways and goes into other resident's room throughout shift. This is a common behavior for her. She will go in the room look around and come out. Rightly so the other residents are not happy with her behavior and do not want her to go into their room's. Family, administration and staff are aware and frequently redirect resident, she is compliant the majority of the time. However, some residents have taken it upon themselves to yell at her causing her to become defensive. This evening as residents were gathering in dining room she went into dining room as well. A male resident (unidentified) yelled at her to get out. This nurse redirected resident to hallway, gave her some crackers to keep her distracted. This nurse was coming out of another resident's room and saw resident wheel into dining room. Then nurse heard a male Resident (unidentified) yell out. This nurse went into dining room and removed resident from dining room. the same before mentioned male resident stated, She pulled my hair. A female resident stated, She did pull his hair, and she pulled her hair also. Residents' family member notified of her actions. The ADON notified as well. *1/14/25 at 10:49 AM LVN A documented: Upon Skin Assessment during Shower, CNA (unidentified) informed LVN A resident had multiple bruises BUE. Resident has behavior of wondering, self transfers, attempting to ambulate w/o assist with unsteady gait. Staff to continue to monitor resident to assure safe environment. *1/16/25 at 10:14 AM the ADON Documented: Resident #2 doesn't c/o pain from bruising , The ADON did note that when she (Resident #2) is using her arms to wheel her chair she does so with very big/hard strokes and the inside part of her arms are hitting the arm of the wheelchair. When the ADON asked where the bruises come from she just smiles and points up and says the lord jesus did it. During an interview on 2/4/25 at 2:54 PM, the BOM stated on 1/08/25 at 6:44 PM, she was in her office when she heard another resident (unknown) yelling, They are fighting! She said another resident (unknown) said, Someone hit your grandma! She stated that she asked Resident #1 if he was okay. She thought Resident #2 had hit him because she has a history of doing things (being physical with other residents) of that nature. The BOM stated that Resident #1 told her that he did not hit her (Resident #2). She stated that she told LVN A that she would check the camera footage. She stated that once she had observed the camera footage, she had shown LVN A, and they both had observed Resident #1 swing at Resident #2 first. She said she observed physical contact between Resident #1 and #2. She said she asked LVN A to make a note of the incident. She said she was told by LVN A that she would notate and take care of notifications. The BOM said she was unsure if LVN A called the ADM and DON or just one of them. She said she believed that LVN A just called the DON because the ADM had been out due to having multiple surgeries. She said this was why she did not text or notify the ADM; she knew he was out and because LVN A was making the notifications. The BOM said she did not inform the DON because she observed LVN A on the phone with who she assumed was the DON. She stated she was not close enough to LVN A to know what she reported to the DON. The BOM stated she had been trained to report all allegations of abuse to the ADM, and if the ADM was unavailable, she had been trained to report to the charge nurse. She stated that is what she did on 1/08/25. She stated the ADM was not in the facility and reported to LVN A, the charge nurse at the time. She said she was unsure if the DON was in the facility at the time of the incident. She said she was also trained to check the cameras if there was any further concern, which was why she checked the cameras. She said no one (including the ADM and DON) had questioned her about what she observed on the cameras or about the bruising that was identified on 1/14/25. She stated that the maintenance and the ADM had access to her office, so if the ADM wanted to check the cameras, they could do so without her presence. She said she had been trained that resident-to-resident altercation was a form of abuse. The BOM stated she had a copy of the video surveillance footage and would provide it. She said she used her best judgment and saved a copy of the video because their system would erase it after several days. The BOM stated that she could not remember the date, but after the incident on 1/08/25, she followed up with the ADM. She said that Resident #2 had bruises on her arms and a busted blood vessel in her left eye. The BOM said that she took pictures of Resident #1 arms and eyes. She stated the pictures she took have a date of 1/16/25. She stated that when she spoke with the ADM about the bruising, he stated that the bruising did not coincide with the time of the incident on 1/08/25 but was concerned about the bruising inside the eye. She said that the ADM was looking at the bruising at the time, and no one knew where the bruising came from, but she expressed concern about the cause of the bruising. During an interview on 2/4/25 at 4:00 PM, the DON stated the potential negative outcome of not reporting reportable incidents to HHSC was that the incidents may not have been adequately investigated at the correct time. She stated failure to report to HHSC could lead to further incidents between residents. She stated that reporting incidents to HHSC was to protect the residents. She stated she was familiar with and had been trained to report reportable incidents to HHSC. She stated that she was unaware until her interview with the investigator that the bruising identified on Resident #2 on 1/14/25 was not reported to HHSC. She stated that the altercation with Resident #1 and #2 was not reported to HHSC. She stated that their system for monitoring and ensuring that reportable incidents are reported to HHSC was that they conducted in-service to staff. She stated they monitored risk management closely. She stated they also monitored the incident and accident report. She stated that if the staff had entered the bruising for Resident #2 had an unknown injury, that would have triggered her to look into it further, but instead, the staff entered the data as bruise. She stated she did not observe the bruising on Resident #2 because she was unaware that she had bruising. She stated she had been trained to report all allegations of ANE to HHSC. The DON stated she expected all allegations of abuse, including resident-to-resident altercations and injury of unknown origin, to be reported to HHSC. She stated that all staff members were responsible for reporting allegations to HHSC because anyone could report them, but she or the ADM could ultimately report them (allegations of ANE) to HHSC. She stated she did not report the injuries of unknown origin because she was unaware of the incident. She stated she did not report the altercation between the residents because it was reported that no contact was made between them (Residents #1 and #2). During an interview on 2/4/25 at 4:30 PM, the ADM stated that on 1/08/25, he received a call from the DON, who explained that Residents #1 and #2 had an incident. He stated he asked her if there were any injuries. He was told by the DON that there were no injuries. He said he did not remember the specifics of what was reported by the DON but that whatever was reported was not alarming to him. He stated he read the incident report. He stated by the HHSC definition of abuse, the resident-to-resident altercation did not meet the definition of abuse and did not need to be reported. He stated that also, by HHSC standards, there were no injuries, so the incident involving Resident #1 and #2 on 1/08/25 did not have to be reported to HHSC. He stated that he did not observe the camera footage because he was not concerned about what was reported to him by the DON or what he read in the incident report. He stated the two residents involved did not have the cognitive ability to be affected psychosocially and that even if the two residents were cognitively intact, he would not have reported the incident to HHSC because, by HHSC standards, the definition of abuse was not met. The ADM said he read that the BOM reviewed the cameras and asked her about the altercation. When he asked her about the incident, the BOM reported that Resident #1 did swing back but did not make any contact. The ADM stated even if Resident #1 had made contact, he would not have reported it because there was no bruise. He stated Resident #1 did not know what he was doing. The ADM stated Resident #2 did have bruising all over her arm, but by HHSC definition, he did not report it. He stated HHSC said the injury had to be suspicious. He stated that if Resident #2's bruising had been suspicious, that would have been concerning to him. He stated a lot of residents are going to have bruising, especially on their arms. He stated he and the BOM both looked at the bruising. He stated that there was confusion about Resident #2 having a black eye, but when they observed her, she did not have a black eye. He said her eye was red but not concerning to him. He stated that as it relates to any incident, he expected all incidents to be reported to him. He stated if it was alarming, meets the definition of abuse, and there are injuries, he would report the incidents to HHSC. He stated the reason why he did not report the incident that occurred on 1/08/25 between Resident #1 and #2 was that it did not meet the definition of abuse, and there were no injuries. He stated he did not report the injury of unknown origin because it was not suspicious in nature or in a suspicious location. He stated he had been trained to report all allegations of abuse to HHSC. During an interview on 2/5/25 at 8:30 AM, LVN A stated on 1/14/25, she and the ADON were at the nursing station. She stated that she was informed by CNA C that when she (CNA C) showered Resident #2 on 1/14/25, she noticed the bruising on her (Resident #2's) arms. She (LVN A) stated she assessed Resident #2. She stated Resident #2 had bruising on both of her upper extremities. She stated there was scattered bruising on both arms. She described the bruising as BUE and dark purple with some yellow color. She stated the darker purple was on the inside of her arms. She stated before this stage that the bruising would have had some redness if it had been fresh. She stated she did not see any bruising to her eye at the time. LVN A stated in her nursing experience that bruising of that (dark purple with some yellow) color meant the bruising was about 3-4 days old. She stated the bruising was resolving and not fresh. LVN A stated she had worked the previous Friday (1/10/25), and the bruising was not there as no one brought it to her attention. She stated that she was off over the weekend. She stated she did not report the incident to the ADM because she was familiar with all documented incidents being reviewed by management. She stated that Resident #2 has a behavior of wandering and attempting to transfer herself. LVN A stated Resident #2 could not say what happened to her and that she (LVN A) had not witnessed what had caused or could have caused the bruising. LVN A stated that regarding the incident that occurred on 1/08/25 with Resident #1 and #2, she did not report it to the ADM. She said similar to the injury of unknown origin, she was familiar with management reviewing the documented incident and had reported the incident to the DON. She stated she did not feel that the behavior she observed regarding Resident #1 was intentional but more of an agitation. She admitted that she reviewed the surveillance with the BOM but did not observe any physical contact with Residents #1 and #2. During an interview on 2/5/25 at 9:14 AM, the ADON stated on 1/14/25, she and LVN A were standing at the nurse's station. She stated a certified nurse's aide (unsure who it was) came and requested for LVN A to look at bruising on Resident #2. The ADON stated she also observed the area, and on Resident #2 arm (right), she observed where her muscle was, and there was a bruise. She stated on Resident #2's arm (left), there were multiple bruises. She was unsure how many. She stated she had LVN A write an incident report. The ADON stated she had difficulty remembering that far back as it related to the details of that day. She stated she did observe Resident #2 moving in her wheelchair and believed that was where the bruise could have come from. She stated that Resident #2 would also dig in boxes, and the bruises on her left arm could have come from her digging in boxes. She stated that she felt nothing alarming when she observed the bruising. She stated that the bruising she observed was mixed blue and yellow. She stated that Resident #2 had never had bruising like she had observed before. She stated she did not observe bruising on Resident #2's eye that day (1/16/25). She stated that on 1/16/25, the ADM did have her look at Resident #2 because of the bruising and potential eye injury. She stated there was no bruising to the eye. She stated she could not remember the ADM's exact wording when he spoke to her, but it was enough for her to take a look at Resident #2 bruising and eye. She stated that when she looked at Resident #2's left eye, it was a little bloodshot, but it appeared red from the moment she woke up. She stated as it related to the bruising on her arms, Resident #2 would look up and say, The Lord Jesus Christ did it when asked what happened. The ADON stated Resident #2was not cognitive enough to recall. She stated that if it were a concerning bruise, they would report it to HHSC. She stated concerning areas such as the face, breast area, back, or groin area are areas they would consider suspicious if bruising appeared in those areas. She stated injuries in those areas would alarm her. She stated that they look at each individual separately, but if they have a history of bruising on their forearms, they try to prevent the bruising. She stated she had been trained on the abuse policy, and she stated the potential negative outcome for not reporting injuries of unknown origin to HHSC or the abuse preventionist was the injury could go without treatment and cause further injury. During an interview on 2/5/25 at 1:35 PM, the ADM stated that Resident #2's eye was red on 1/16/25. He stated it did not concern him. He stated it looked like something could have gotten in her eye, and maybe Resident #2 rubbed it. He stated the potential negative outcome of not reporting incidents to HHSC was that it could jeopardize the safety of the residents. During an interview on 2/6/25 at 11:30 AM, CNA C stated she was the shower aide and provided all showers for the residents at the NF. She said the abuse preventionist was the ADM, and if she suspected or witnessed abuse, she had been trained to separate the resident from the abuser and report it to the charge nurse. She stated she had received abuse training. CNA C stated that 1/14/25, she was the staff member who got Resident #2 up for the morning. She stated that Resident #2 had bruising on the inside of her left arm. She stated the bruising was still on Resident #2's arm. She stated she did not know how Resident #2 received the bruising. She reported the bruising to LVN B as she had been trained to do. She stated LVN B asked her what happened to Resident #2, and she explained to LVN B that she did not know. CNA C stated Resident #2 could not remember what happened. CNA C stated Resident #2 was not in any pain on 1/14/25. CNA C stated that LVN A did an assessment on her computer of Resident #2. CNA C stated she knew nothing that could have caused Resident #2's arm bruising. She stated that Resident #2 received her showers on Tuesdays, Thursdays, and Saturdays. She stated the bruises were identified on Tuesday (1/14/25) and did not shower Resident #2 on Saturday (1/12/25) as she called in that day. She stated that the previous Thursday (1/09/25), she showered Resident #2, but the bruising was not present. CNA C stated she does not document showers or skin assessments, but if she does find anything, she reports it to the CNAs and the nurses. She stated she did not have a reason why she did not report the injuries to the ADM. During an interview on 2/4/25 at 9:57 AM, LVN B stated on 1/12/25, she heard another resident yelling. She stated she went to the dining room, and a resident (unknown) reported that Resident #2 had pulled Resident #3 and Resident #4's hair. LVN B stated she immediately redirected Resident #2 out of the dining room. She stated she assessed all three residents to ensure they were okay. She stated she did not note any injuries. She stated she immediately notified the ADON and all appropriate parties, such as the family, of what happened. Resident #3 Record Review of Resident #3's face sheet, dated 02/04/25, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of anxiety (increased worry) and lack of coordination. Record Review of Resident #3's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 08, indicating the resident was moderately cognitively impaired. Section E revealed Resident #3 did not exhibit physical behavior (hitting, kicking, pushing, scr [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure the rights of the residents to be free from abuse for 2 of 7 residents (Resident #1 and #2) reviewed for abuse. The facility failed to keep Resident #2 safe from Resident #1 on 1/08/25 when a resident-to-resident altercation occurred resulting in Resident #1 hitting Resident #2. This failure could place residents at risk for serious psychosocial harm from abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Resident #1 Record Review of Resident #1's face sheet, dated 02/04/25, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of Hepatitis C (a contagious viral liver infection). Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 07, indicating the resident was severely cognitively impaired. Section E revealed Resident #1 did not exhibit physical behavior (hitting, kicking, pushing, scratching, grabbing, abusing) during the review period [E0200]. Section I Resident #1 had viral Hepatitis. Record review of Resident #1's Physician Order Summary Report, dated 02/04/25, revealed that Resident #1 was not taking any medications for Hepatitis C. Record review of Resident #1's progress notes, dated 12/03/24-2/4/25 revealed the following: *1/08/25 at 4:18 PM LVN A documented: LVN A was sitting at nursing station when another resident (unknown) yelled out, There is a fight in here! BOM and LVN A entered dining area and did not see any physical or verbal altercation. LVN A was informed by another resident (unknown) that Resident #1 hit Resident #2. BOM watched video, and it was verified Resident #1 initiated physical aggression while Resident #2 was sitting in her wc near the table he ate at. Resident #2 was not disturbing the table or making physical contact with anyone upon Resident pulling/pushing Resident #2's wc and swinging his fist backwards towards Resident #2. Resident #2 became agitated but quickly left the area. *1/08/25 at 5:10 PM LVN A documented: Resident #1 was educated on not placing hands on other residents and informed to get staff if there was an incident that needs to be addressed. Resident #1 voiced understanding. Record review of Resident #1's care plan, dated 12/12/24, did not reveal a care plan regarding aggressive behavior but revealed his dx of hepatitis. His care plan did not reveal any revisions regarding the incident on 1/08/25. Record review of facility incident report, dated 1/08/25 revealed the following: Incident description: LVN A was sitting at nursing station when another resident (unknown) yelled out, There is a fight in here! BOM and LVN A entered dining area and did not see any physical or verbal altercation. LVN A was informed by another resident (unknown) that Resident #1 hit Resident #2. BOM watched video, and it was verified Resident #1 initiated physical aggression while Resident #2 was sitting in her wc near the table he ate at. Resident #2 was not disturbing the table or making physical contact with anyone upon Resident pulling/pushing Resident #2's wc and swinging his fist backwards towards Resident #2. Resident #2 became agitated but quickly left the area. Action taken: Stated Resident #2 was assessed with no injuries. Injuries Observed at the time of the incident: No injuries at the time of the incident. Predisposing Environmental Factors: Crowding Agencies/People Notified: Physician C, DON and Family Member D. Record review of the facility incident report, dated 2/4/25, revealed Resident #1 had a physical aggression-initiated incident on 1/08/25. During an interview on 2/4/25 at 12:57 PM, LVN A stated the abuse preventionist was the ADM. She said if she suspected or witnessed abuse, she had been trained to contact the ADM immediately. She said she had abuse training at the facility. She said she had been trained to separate the residents, perform a nursing assessment for injuries, and ensure everyone was safe if there was a resident-to-resident altercation. She stated she had been trained to report all resident-to-resident altercations to the ADM. On 1/08/25, she said she was not in the dining room when the incident occurred with Residents #1 and #2. She stated she had to look back at the video footage. She said when she looked at the footage, she observed Resident #2 sitting at the dining room table, and for some reason unknown to her, Resident #1 became frustrated. She said she observed Resident #1 push Resident #2's wheelchair, and Resident #2 rolled backward. She said Resident #2 rolled backward and did not come into contact with anything. She said Residents #1 and #2 did not make contact with each other. She said as a result, they ensured both residents (Resident #1 and #2) were separated and safe. She said she did an incident report, assessed the residents, and then reported everything she observed on the video footage to the DON. She said this was the first time Resident #1 had acted that way and did not have a history of physically aggressive behavior. She reported the incident to the DON and appropriate parties, such as doctors and family contact. During an interview on 2/4/25 at 1:48 PM, Resident #1 could not recall specifics about the incident on 1/08/25. He stated he might have pushed them, but they asked for it. He said he did not know the other resident's name. He could not report if the other resident were male or female. He stated that they went crying to momma. He said he would handle his issues with [NAME] and [NAME]. He verified that [NAME] and [NAME] were his left and right hands. During an interview on 2/4/25 at 2:23 PM, the ADON stated the ADM was the abuse preventionist. She said if she suspected or witnessed abuse, she had been trained to remove the resident from the area where the abuse was occurring. She said she would go to the ADM, and if he were unavailable, she would go to the DON. She said if a resident-to-resident altercation had occurred, she had been trained to separate the residents, assess for injuries, and report the incident to the ADM and the DON. She stated regarding the incident on 1/08/25, it was her understanding that Resident #2 was attempting to grab something off the dining room table. Resident #1 did not like it, and some yanking and pulling was involved. The ADON stated that she did not witness the incident. During an interview on 2/4/25 at 2:43 PM, the DON stated she understood on 1/08/25 Resident #2 was attempting to remove a decoration from the dining room table. She stated she was unsure if Resident #1 had told Resident #2 a couple of times about the table decoration, but maybe the way Resident #1 approached Resident #2 made her (Resident #2) mad. She said she did not report the incident to HHSC because LVN A reported no physical contact between Resident #1 and Resident #2. She stated she considered a person's wheelchair an extension of their body because it was a part of their mobility, but she was never told Resident #1 made contact with Resident #2's wheelchair. She stated LVN A reported Resident #1 attempted to swing at Resident #2 but did not make contact. She stated she (the DON) did not observe any camera footage. She stated the camera video surveillance was located in the BOM's office, which would be the only way LVN A could have observed the footage. The DON stated she had no documentation to show she looked into the incident on 1/08/25. She stated she spoke with the ADM that evening about the incident between Resident #1 and Resident #2 because he was not in the facility. She stated she did not remember what she reported to him (the ADM), but it had to be what was reported to her by LVN A. Resident #2 Record Review of Resident #2's face sheet, dated 2/04/25, revealed a [AGE] year-old female that was admitted to the facility on [DATE], with a diagnosis of Alzheimer's (memory loss), Restless leg syndrome (irresistible urge to move legs), intermittent explosive disorder (explosive outburst of anger). Record Review of Resident #2's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 99, indicating the resident was unable to complete the interview. Section E revealed Resident #2 did not exhibit physical behavior (hitting, kicking, pushing, scratching, grabbing, abusing) during the review period [E0200]. Resident #2 did exhibit a presence and frequency of wandering 4-6 days but less than daily [E0900]. Resident #1's wandering did place her at significant risk of getting to a potentially dangerous place and significantly intruded on the privacy of others [E1000.] Record review of Resident #2's care plan, dated 10/12/24, revealed that she had an identified wandering behavior and took medication (Depakote) related to be being combative. There was no care plan addressing aggressive behavior towards residents. Record review of Resident #2's Physician's Order, dated 02/04/25, revealed: An order and start date of 1/20/25 for Depakote 250 MG 1 tablet by mouth 2 times a day for intermittent explosive disorder. Record review of Resident #2's progress notes, dated 10/01/24- 02/04/2025 revealed the following: *10/07/24 at 3:26 PM LVN A documented: Resident #2 wandering up and down the hallways. Resident #2 was agitated. LVN A redirecting Resident #2 from entering other residents (unidentified) rooms. Resident #2 cognitive impairment and decreased ability to understand/follow directions. *11/02/25 at 5:52 PM LVN G documented: Resident #2 getting into other resident bed and when moved she pinched staff and yelled out that they were hitting staff. *11/08/24 at 11:10 AM LVN A documented: Resident #2 became agitated upon CNA (unidentified) removing items from residents wc that residents (unidentified) room. When CNA (unidentified) removed items, resident threw water on CNA (unidentified). Resident #2 proceeded to the dining room and picked up a cup of juice and threw it on the CNA (unidentified). *11/09/24 at 12:12 PM LVN A documented: Resident #2 getting into roommate's snacks/drinks. Upon staff attempting to retrieve items, Resident #2 became agitated and attempted physical aggression. *11/09/24 1:14 PM LVN A documented: Resident #2 wandered into another resident's (unidentified) room and took his peanut M&M bag; DON notified and stated she would replace it for the resident (identified). Resident (unidentified) informed and voiced frustration of not being able to keep things in his room d/t Resident #2 going in his room attempting to take things. *11/11/24 at 11:53 PM LVN G documented: Resident #2 kept going into other residents (unidentified) rooms and would get into their drawers and get their snacks or their personal. *12/01/24 at 5:39 PM LVN B documented: Resident #1 spent most of shift going into others rooms. Resident #2 was redirected with no improvement. Resident #2 was playing with a chain attached to a door and when asked to stop she took the chain swinging it striking the aide on the arm. *12/21/24 at 2:59 PM LVN A documented: Resident #2 agitated and following other residents around. *1/05/25 at 11:33 AM LVN A documented: Resident #2 has become more agitated, defensive upon staff attempting to redirect, actively going into rooms taking other Residents belongings, and appears anxious with inability to relax. Upon reviewing residents' orders, LVN A noted Depakote was discontinued 11/24/24. If behaviors continue, LVN A will contact PCP to see if Depakote can be resumed. *1/12/25 at 5:12 PM LVN B documented: Resident #2 wanders in hallways and goes into other resident's room throughout shift. This is a common behavior for her. She will go in the room look around and come out. Rightly so the other residents are not happy with her behavior and do not want her to go into their room's. Family, administration and staff are aware and frequently redirect resident, she is compliant the majority of the time. However, some residents have taken it upon themselves to yell at her causing her to become defensive. This evening as residents were gathering in dining room she went into dining room as well. A male resident (unidentified) yelled at her to get out. This nurse redirected resident to hallway, gave her some crackers to keep her distracted. This nurse was coming out of another resident's room and saw resident wheel into dining room. Then nurse heard a male Resident (unidentified) yell out. This nurse went into dining room and removed resident from dining room. the same before mentioned male resident stated, She pulled my hair. A female resident stated, She did pull his hair, and she pulled her hair also. Residents' family member notified of her actions. The ADON notified as well. *1/12/25 at 5:33 PM LVN B documented: a Psychiatric referral was made. *1/20/25 at 5:18 PM The Psychiatric Provider Documented: Meeting with facility staff indicates the patient has: Normal appetite. No anxiety and no irritability, and no hostility toward peer(s). No hostility toward caregivers. *1/20/25 at 3:18 PM LVN B documented: The Psychiatric Provider in house for rounds. New order for Depakote 125mg BID received at this time. *1/31/25 at 2:59 PM The Psychiatric Provider Documented: Meeting with facility staff indicates the patient has: Normal appetite. No anxiety and no irritability, and no hostility toward peer(s). No hostility toward caregivers *2/03/25 at 3:15 PM LVN B documented: The Psychiatric Provider in house for rounds. No New orders received at this time. Will continue to monitor Resident #2. *2/03/25 at 4:03 PM The Psychiatric Provider Documented: Meeting with staff reveals: Meeting with facility staff indicates the patient has: Normal appetite. No anxiety and no hostility towards peer(s). No hostility towards caregivers. Record review of facility incident report, dated 11/08/24 revealed the following: Incident description: Nursing (unidentified) witnessed Resident #2 throw water on CNA (unidentified) d/t CNA (unidentified) removing belongings from residents wc that Resident #2 had taken from another residents (unidentified) room. And Resident #2 was unable to give a description of what happened. Action taken: Resident #2 was redirected but it was unsuccessful. Injuries Observed at the time of the incident: No injuries at the time of the incident. Agencies/People Notified: Physician I, DON, ADON and Family Member H. Record review of facility incident report, dated 1/08/25 revealed the following: Incident description: LVN A was sitting at nursing station when another resident (unknown) yelled out, There is a fight in here! BOM and LVN A entered dining area and did not see any physical or verbal altercation. LVN A was informed by another resident (unknown ) that Resident #1 hit Resident #2. BOM watched video, and it was verified Resident #1 initiated physical aggression while Resident #2 was sitting in her wc near the table he eats at. Resident #2 was not disturbing the table or making physical contact with anyone upon Resident pulling/pushing Resident #2's wc and swinging his fist backwards towards Resident #2. Resident #2 became agitated but quickly left the area. Action taken: Stated Resident #2 was assessed with no injuries. Injuries Observed at the time of the incident: No injuries at the time of the incident. Predisposing Environmental Factors: Crowding Agencies/People Notified: Physician I, DON and Family Member H. Record review of the facility incident report, dated 2/4/25, revealed the following: During an observation of the video provided by the BOM, the following was observed by the HHSC investigator: At the start of the video, from the start of the video to .29 seconds, Resident #1 is seated at the left side of the table while Resident #2 is rolling back and forth to his left. No contact was being made between Resident #1 and Resident #2. :29 seconds Resident #1 takes his left hand and grabs the push handle (right side) of Resident #2. Resident #2 appears startled as she looks around, uses her right hand, and attempts to grab the table. :35 seconds Resident #1 takes his left hand, grabs Resident #2's right armrest, and pushes her back. :35-:45 seconds Resident #1 appeared to say something verbally to Resident #2 (the exact wording is unknown due to the lack of audio, but the Resident's mouth was observed moving). :45 seconds Resident #1 takes his left arm and quickly swings back at Resident #2. It is difficult to see if Resident #1 made contact, but Resident #2's right arm moved back quickly. :46 seconds Resident #2 swings back with her right hand twice. The first time, she hit Resident #1 on his left arm, and the second hit him again but held on for a short duration. :50 seconds observed Resident #2 swing back again. It is unclear if contact was made in Resident #2's face, but it was in the vicinity. An unknown object fell to the floor. :51 seconds-1:00 minute Resident #2 grabs the back of Resident #1's chair and jerking back and forth. 1:00 minute Resident #1 begins to exit the dining room. The video ends at 1 minute and 5 seconds. During an interview on 2/4/25 at 2:04 PM, Resident #2 could not recall the incident on 1/08/25. She could not state if another resident, specifically Resident #1, had pushed her. During an interview on 2/4/25 at 2:54 PM, the BOM stated on 1/08/25 at 6:44 PM, she was in her office when she heard another resident (unknown) yelling, They are fighting! She said another resident (unknown) said, Someone hit your grandma! She stated that she asked Resident #1 if he was okay. She thought Resident #2 had hit him because she has a history of doing things (being physical with other residents) of that nature. The BOM stated Resident #1 told her that he did not hit her (Resident #2). She stated that she told LVN A that she would check the camera footage. She stated that once she had observed the camera footage, she had shown LVN A, and they both had observed Resident #1 swing at Resident #2 first. She said she observed physical contact between Resident #1 and #2 . She said she asked LVN A to make a note of the incident. She said she was told by LVN A that she would notate and take care of notifications. The BOM said she was unsure if LVN A called the ADM and DON or just one of them. She said she believed that LVN A just called the DON because the ADM had been out due to having multiple surgeries. She stated the ADM was not in the facility and reported to LVN A, the charge nurse at the time. She said she was unsure if the DON was in the facility at the time of the incident. She said she was also trained to check the cameras if there was any further concern, which was why she checked the cameras. She said she had been trained that resident-to-resident altercation was a form of abuse. The BOM stated she had a copy of the video surveillance footage and would provide it. She said she used her best judgment and saved a copy of the video because their system would erase it after several days. During an interview on 2/5/25 at 8:30 AM, LVN A stated regarding the incident that occurred on 1/08/25 with Resident #1 and #2, she did not report it to the ADM. She said she was familiar with management reviewing the documented incident and had reported the incident to the DON. She stated she did not feel that the behavior she observed regarding Resident #1 was intentional but more of an agitation. She admitted that she reviewed the surveillance with the BOM but did not observe any physical contact with Residents #1 and #2. During an interview on 2/4/25 at 4:00 PM, the DON stated The DON stated she was familiar with and had been trained on the facility's abuse policy. She said she was unaware of physical contact between Resident #1 and #2. She stated that their monitoring system related to the abuse policy and reporting was that she would check the 24-hour report if it were a weekday, and if it were a Monday, she would run a 72-hour report. She stated that if she was not at work, she was unsure if anyone will check the reports for concerning incidents. She said she also checked the resident progress notes daily. She stated everyone was responsible for following the abuse policy. She stated all staff were responsible for following the abuse policy. She stated she had been trained to keep all residents free from abuse and expected all staff to keep residents safe from abuse. The DON stated the potential negative outcome for residents was the failure could lead to further incidents between residents. During an interview on 2/4/25 at 4:30 PM, the ADM stated on 1/08/25, he received a call from the DON, who explained Residents #1 and #2 had an incident. He stated he asked her if there were any injuries. He was told by the DON that there were no injuries. He said he did not remember the specifics of what was reported by the DON but that whatever was reported was not alarming to him. He stated he read the incident report. He stated by the HHSC definition of abuse, the resident-to-resident altercation did not meet the definition of abuse. He stated that he did not observe the camera footage because he was not concerned about what was reported to him by the DON or what he read in the incident report. He stated that the two residents involved did not have the cognitive ability to be affected psychosocially and that even if the two residents were cognitively intact by HHSC standards, the definition of abuse was not met. The ADM said he read that the BOM reviewed the cameras and asked her about the altercation. When he asked her about the incident, the BOM reported that Resident #1 did swing back but did not make any contact. The ADM stated that even if Resident #1 had made contact, he would not have reported it because there was no bruise. He stated Resident #1 did not know what he was doing. Record review of the facility policy, Resident Right, undated, revealed the following: Inservice Objective The purpose of this program is to provide you with a basic understanding of the rights of nursing home residents. A basic understanding of residents' rights is essential to a nurse aides' ability to provide quality care and avoid mistakes that place a resident's safety or well-being at risk. The following is an outline of the information covered in this inservice program. Abuse & Neglect: The right to be free of abuse and neglect Record review of the facility policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, Revised April 2021, revealed the following: Policy Statement Residents have the right to be free from abuse and neglect. This includes but not limited to verbal and physical abuse. Policy Interpretation and Implementation The resident abuse and neglect prevention program consist of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse and neglect by anyone including, but not necessarily limited to . Other residents Develop and implement policies and protocols to prevent and identify Abuse or mistreatment of residents Neglect of residents Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #2) of 5 residents reviewed for care plans. The facility failed to develop an accurate, consistent, and complete care plan for Resident #2's activities of daily living (ADL's), mobility, disease process, cognition, communication, falls, and medications. This failure could place residents at risk of not receiving the care required to meet their individualized needs. Findings included: Record review of the face sheet, dated 11/05/2024, revealed Resident #2 was a [AGE] year-old male who admitted to the facility on [DATE] with the following diagnoses: malignant neoplasm of unspecified bronchus or lung (lung cancer), generalized muscle weakness (decreased strength), unsteadiness on feet, other lack of coordination. Record review of Resident #2's initial MDS dated [DATE], revealed Resident #2 did not have a BIMS score due to being rarely or never understood. Section GG - Functional Abilities and Goals - Admission revealed Resident #2 required supervision or touching assistance with eating and required partial/moderate assistance to shower/bathe self and partial/moderate assistance with tub/shower transfers. Section N - Medications revealed Resident #2 was taking an antidepressant medication while a resident in the facility. Section V - Care Area Assessment Summary revealed Resident #2 was triggered for communication and falls and the Care Planning Decision column indicated these areas were to be addressed in the care plan. Record review of Resident #2's comprehensive care plan initiated on 11/05/24 revealed the following: A focus area for an ADL self-care deficit had a goal section that was blank and interventions for bathing/showering, eating and transfers that were blank. A focus area for limited physical mobility contained no interventions. A focus area that stated the resident was resistive to care, contained no interventions. A focus area for congestive heart failure contained no goals. A focus area for impaired cognitive function/dementia or impaired thought process had incomplete sections for focus, goals, and interventions. A focus area for communication problems had an incomplete focus statement, incomplete goal, and a blank section for interventions. A focus area for actual falls, initiated on 10/08/24, had a blank section for interventions. A focus area for antidepressant medication had a blank section for interventions. During an interview on 11/06/24 at 10:57 AM with the DON, she stated she was not aware that Resident #2's comprehensive care plan was incomplete until yesterday (11/05/24). She stated the comprehensive care plan should be completed by 48 hours after admission and should be updated quarterly and as needed. She stated nursing administration was responsible for completing the comprehensive care plan based on nursing assessment and input from members of the IDT. She stated the purpose of the comprehensive care plan was to inform staff of what care was required for the resident and it was a tool used by all direct care staff and ancillary staff. The DON stated nursing administration was responsible for monitoring and assuring comprehensive care plans were complete and accurate. She stated she was aware that the facility had an issue with care plans being completed and planned to conduct a full audit of care plans for all residents. She stated a potential negative outcome for failure to implement a complete comprehensive care plan was that the resident would not get the care they required. During an interview on 11/06/24 at 11:08 AM with the ADM, he stated he was not aware that the comprehensive care plan for Resident #2 was incomplete. He stated the purpose of the comprehensive care plan was to know how to care for folks. He stated nursing administration was responsible for completing the care plan in an accurate and timely manner. The ADM stated the care plan was used by everyone-mainly nursing staff and therapy for obtaining information about a resident's care needs. He stated his expectation of staff was that comprehensive care plans were complete, accurate and updated. He stated a potential negative outcome for failure to develop and implement a complete comprehensive care plan was that staff would not be able to care for someone 100% without an accurate care plan. Record review of the facility policy, Care Plans, Comprehensive Person-Centered, Revised March 2022, revealed the following documentation: Policy Statement A 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. Policy Interpretation and Implementation 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. 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. . 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . . 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.

Based on interviews, and record review, the facility failed to develop and implement a baseline care plan within 48 hours for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #1) of 5 residents reviewed for baseline care plans. The facility failed to complete a baseline care plan within 48 hours of admission for Resident #1. This failure could place newly admitted residents at risk for not receiving the necessary care and services needed. The findings included: Record review of the face sheet, dated 11/06/2024, revealed Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses: vascular dementia (memory loss caused by impaired blood supply to the brain), unspecified sequelae of cerebral infarction (alteration of sensation following stroke), receptive-expressive language disorder (difficulty understanding and expressing self through language), type 2 diabetes mellitus (uncontrolled blood sugar), hypertension (elevated blood pressure), Crohn's Disease (bowel disease affecting the lining of the digestive tract). Record review of Resident #1's initial MDS, dated [DATE] revealed a BIMS score of 99, indicating the resident was unable to complete the interview. Section GG - Functional Abilities and Goals - Admission revealed Resident #1 was independent with eating and transfers, required partial/moderate assistance to shower/bathe self and required supervision or touching assistance with tub/shower transfers, dressing and personal hygiene. 11/05/2024 Record review of Resident #1's electronic medical record revealed no baseline care plan. During an interview on 11/05/24 at 3:17 PM with the ADON/MDS-Care Plan Nurse, she stated each resident should have a baseline care plan in place within 48 hours of admission to the facility. She stated the DON and ADON were responsible for assuring baseline care plans were being completed. She stated the charge nurse was responsible for entering resident information into the baseline care plan during the admission process. The ADON stated the facility had been having issues with their electronic health system failing to prompt nurses to initiate the baseline care plan. She stated, we knew this was a problem and have been trying to fix it. She stated a potential negative outcome for failure to implement a baseline care plan was that it could lead to problems such as falls, or elopement based on staff not knowing the resident was at risk for certain things. During an interview on 11/06/24 at 10:57 AM with the DON, she stated she was not aware that Resident #1 did not have a baseline care plan until yesterday (11/05/24). She stated the baseline care plan should be completed within 48 hours of admission. She stated the purpose of the baseline care plan was to inform staff of what care is required for the resident and it was used by all direct care staff and ancillary staff. The DON stated nursing administration was responsible for assuring baseline care plans were complete and accurate. She stated she was aware that the facility had an issue with care plans being completed and planned to conduct a full audit of care plans for all residents. She stated she would be re-educating nursing staff on initiating the baseline care plan in the next few days. She stated a potential negative outcome for failure to develop and implement a baseline care plan was that the resident would not get the care they required. During an interview on 11/06/24 at 11:08 AM with the ADM, he stated he was not aware that Resident #1 did not have a baseline care plan. He stated the purpose of the baseline care plan was to know how to care for folks. He stated the baseline care plan should be completed within 72 hours of admission. He stated nursing staff and nursing administration were responsible for completing the baseline care plan in an accurate and timely manner. The ADM stated the care plan was used by everyone-mainly nursing staff and therapy. He stated his expectation of staff was that baseline care plans were accurate and were completed timely. He stated a potential negative outcome for failure to develop and implement a baseline care plan was that staff would not be able to care for someone 100% without an accurate care plan. Record review of the facility policy titled Care Plans - Baseline, revised March 2022, revealed the following: Policy Statement 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. Policy Interpretation and Implementation 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 the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR recommendation, if applicable

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, that include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 3 of 14 residents (Residents #1, #8 and #21) reviewed for care plans. The facility failed to develop a care plan for Resident #1's cognitive loss, communication, psychosocial well-being and pressure ulcer risk. The facility failed to develop a care plan for Resident #8's cognitive loss, vision, falls, nutrition and psychotropic drug use. The facility failed to develop a care plan for Resident #21's delirium, communication, urinary function, psychosocial well-being, mood, dental care, pressure ulcer risk and pain. These failures could place residents at risk of not receiving the care required to meet their individualized needs. Findings included: Resident #1 Record review of the admission record for Resident #1, dated 07/29/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: parkinson's disease (brain disorder that causes uncontrollable movements), essential hypertension (high blood pressure), and muscle weakness. Record review of Resident #1's comprehensive MDS assessment dated [DATE] revealed Section V Care Areas triggered were 02. Cognitive loss/dementia, 04. Communication, 07. Psychosocial well-being, and 16. Pressure ulcer were checked as triggered. Record review of the current care plan for Resident #1, undated, revealed there was no specific care plan regarding cognitive loss, communication, psychosocial well-being and pressure ulcers. Resident #8 Record review of the admission record for Resident #8, dated 07/29/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: altered mental status (memory problems), dehydration (loss of body fluids), and type 2 diabetes mellitus (blood sugar problems). Record review of Resident #8's comprehensive MDS assessment dated [DATE] revealed Section V Care Areas triggered were 02. Cognitive loss/dementia, 03. Visual function, 11. Falls, 12. Nutritional Status, and 17. Psychotropic drug use were checked as triggered. Record review of the current care plan for Resident #8, undated, revealed there was not a completed care plan regarding cognitive loss, visual function, falls, nutritional status or psychotropic drug use. Resident #21 Record review of the admission record for Resident #21, dated 07/29/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease (memory problems), anxiety (mood disorder) and dementia (cognitive loss of function). Record review of Resident #21's comprehensive MDS assessment dated [DATE] revealed Section V Care Areas triggered were 01. Delirium, 04. Communication, 06. Urinary Incontinence and Indwelling catheter, 07. Psychosocial well-being, 08. Mood State, 15. Dental Care, 16. Pressure ulcer, and 19. Pain were checked as triggered. Record review of the current care plan for Resident #21, undated, revealed there was not a completed care plan regarding delirium, communication, urinary incontinence and indwelling catheter, psychosocial well-being, mood state, dental care, pressure ulcers, or pain. During an interview on 07/31/24 at 10:24 AM, the DON stated the ADON was responsible for completing the care plans and she was responsible for ensuring the care plans were getting completed. The DON stated the ADON was out of the facility at this time on vacation and was not available by phone for interview. The DON stated she did not know why the care plans for Resident #1, Resident #8 and Resident #21 were not completed. The DON stated care plans are reviewed by her when there is a concern, and she cannot remember the last time the care plans were audited. The DON stated a potential negative outcome to the residents was they may not get the care they need. During an interview on 07/31/24 at 10:51 AM, the ADM stated the ADON was responsible for completing the care plans at the facility. The ADM stated the DON is responsible to ensure the ADON is completing the care plans. The ADM stated she did not know why the ADON did not complete the care plans for Resident #1, Resident #8 and Resident #21. The ADM stated they were not able to get ahold of the ADON at this time as she was on vacation. The ADM stated a potential negative outcome to the residents was they may get improper care from staff. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of March 2022, reflected the following: Policy Statement: A 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