Every finding on record at Frank M. Tejeda Texas State Veterans Home

Based on interview and record review, the facility failed to develop and implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 4 (Resident #1, Resident #3, Resident #4, and Resident #5) of 8 residents reviewed for abuse and neglect, in that: The facility failed to develop and implement policies and procedures determining when to report crimes to local law enforcement. This failure could place residents at a greater risk of abuse and neglect. The findings included: Record review of Resident #1's face sheet dated 08/26/26 revealed a [AGE] year-old male with an initial admission date of 09/02/20 and a current admission date of 07/05/26. The pertinent diagnosis included Dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life, caused by damage to the brain cells). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 (indicating his cognition was intact). Record review of Resident #3's face sheet dated 08/26/26 revealed an [AGE] year-old male with an admission date of 10/31/26. The pertinent diagnosis included Dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life, caused by damage to the brain cells). Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed Resident #3 had a BIMS score of 14 (indicating his cognition was intact). Record review of the provider self-report dated 08/25/26 for the alleged abuse incident between Resident #1 and Resident #3 revealed the time of the incident was 5:45 AM on 08/18/26 and HHSC was notified of the incident at 9:30 AM on 08/18/26. Further review revealed the incident was not reported to the police. During an interview with Resident #3 at 9:26 AM on 08/25/26, he stated he was in the dining room on the morning of 08/18/26 but did not remember the specific time. Resident #3 stated he was in his wheelchair getting coffee. Resident #3 stated Resident #1 was behind him and told him to move out of the way. Resident #3 stated Resident #1 started shaking his chair. Resident #3 stated he tried to get Resident #1 to stop shaking his chair and hit Resident #1 on the arm in the process. Resident #3 stated he told the nurses later about the incident. During an interview with Resident #1 at 9:36 AM on 08/25/26, he stated he went to the dining hall on the morning of 08/18/26 before breakfast to get some hot water for his tea. Resident #1 stated Resident #3 was in front of the spigot he needed to use to get the hot water. Resident #1 stated he asked Resident #3 to move out of the way, but Resident #3 told him he was not going to move. Resident #1 stated he tried to go around Resident #3 but Resident #3 hit him in the left shoulder as he tried to pass him. Resident #1 stated it did not really hurt, and it did not leave a bruise. Resident #1 stated he went to tell the nurses about the incident after it happened. Record review of Resident #4's face sheet dated 08/24/26, revealed a [AGE] year-old male, last admitted [DATE]. Resident #4 had an admitting dx of Ulcerative Colitis (a long-lasting chronic condition that is part of a group of conditions), Hypertension (chronic high blood pressure), and Dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life, caused by damage to the brain cells). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed Resident #4 had a BIMS score of 03 (indicating severe cognitive impairment). Record review of Resident #5's face sheet dated 08/24/26 revealed a [AGE] year-old male, last admitted on [DATE]. Resident #5 had an admitting dx of Cerebral Infarction (the death of brain tissue caused by a blocked or severely reduced blood supply, which starves cells of oxygen and nutrients), Type II Diabetes Mellitus (a chronic condition where the body resists insulin or does not make enough of it, causing sugar to build up in the blood), and Unspecified Dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life, caused by damage to the brain cells). Record review of Resident #5's comprehensive MDS assessment dated [DATE] revealed Resident #5 had a BIMS score of 04 (indicating severe cognitive impairment). Record review of provider self-report dated 05/22/26 for the alleged abuse incident when Resident #5 was hit by Resident #4 on 05/18/26 resulting in a quarter sized pink area on his cheek witnessed by CNA D revealed law enforcement was not contacted. During an interview with Resident #5 at 12:53 PM on 08/24/26, Resident #5 stated he did not remember being hit by anyone at this facility and did not feel neglected or abused. Resident #5 nodded his head yes when asked if he felt safe at the facility. During an interview with Resident #4 at 12:55 PM on 08/24/26, Resident #4 stated he did not remember ever hitting anyone and did not feel he had abused anyone. Resident #4 also stated he felt safe and had no concerns about the facility. During an interview with Resident #5's responsible party at 10:30 AM on 08/25/26, she stated she was aware of the incident at the facility on 05/18/26 but did not recall what exactly she was told by the facility other than Resident #5 was hit by another resident. She stated was told the facility was investigating the concern. Resident #5's responsible party also stated she felt like the facility took care of her family member and had no concerns about his care. During an interview with Resident #4's responsible party at 10:40 AM on 08/25/26, she stated she was called and notified that Resident #4 hit another resident when it occurred back in May. Resident #4's responsible party was informed and assured the facility handled the situation appropriately and had no concerns about the facility at this time. During an interview with the Administrator at 10:03 AM on 08/26/26, she stated the police were not notified for the incident between Resident #1 and Resident #3 or the incident between Resident #4 and Resident #5. The Administrator stated they generally notified the police when there was an injury to a resident and there was an allegation of abuse, but if there was no injury, they did not call the police. During an interview with the DCO at 1:00 PM on 08/26/26, she stated the only abuse policy they had at this time was the policy labeled Abuse Guidance: Preventing, Identifying and Reporting which did not include a timeframe for reporting to law enforcement. The DCO stated they did not have a policy outlining when to notify local law enforcement about crimes committed in the facility.

Based on interview and record review, the facility must ensure all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after allegation is made for 5 of 8 residents (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) reviewed for abuse and misappropriation. The facility failed to report alleged abuse of Resident #5 by Resident #4 to law enforcement within 2 hours on 05/18/26.The facility failed to report alleged abuse of Resident #1 by Resident #3 to law enforcement and HHSC within 2 hours on 08/18/26.The facility failed to report alleged misappropriation of property of Resident #2's rings to HHSC within 24 hours of learning about the allegation on 08/10/26. These failures could place residents at increased risk of abuse and neglect.The findings included:1) Record review of Resident #4's face sheet dated 08/24/26, revealed a [AGE] year-old male, last admitted [DATE]. Resident #4 had an admitting dx of Ulcerative Colitis (a long-lasting chronic condition that is part of a group of conditions), Hypertension (chronic high blood pressure), and Dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life, caused by damage to the brain cells). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed Resident #4 had a BIMS score of 03 (indicating severe cognitive impairment). Record review of Resident #5's face sheet dated 08/24/26 revealed a [AGE] year-old male, last admitted on [DATE]. Resident #5 had an admitting dx of Cerebral Infarction (the death of brain tissue caused by a blocked or severely reduced blood supply, which starves cells of oxygen and nutrients), Type II Diabetes Mellitus (a chronic condition where the body resists insulin or does not make enough of it, causing sugar to build up in the blood), and Unspecified Dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life, caused by damage to the brain cells). Record review of Resident #5's comprehensive MDS assessment dated [DATE] revealed Resident #5 had a BIMS score of 04 (indicating severe cognitive impairment). Record review of provider self-report dated 05/22/26 for the alleged abuse incident when Resident #5 was hit by Resident #4 on 05/18/26 resulting in a quarter sized pink area on his cheek witnessed by CNA D revealed law enforcement was not contacted. During an interview with Resident #5 at 12:53 PM on 08/24/26, Resident #5 stated he did not remember being hit by anyone at this facility and did not feel neglected or abused. Resident #5 nodded his head yes when asked if he felt safe at the facility. During an interview with Resident #4 at 12:55 PM on 08/24/26, Resident #4 stated he did not remember ever hitting anyone and did not feel he had abused anyone. Resident #4 also stated he felt safe and had no concerns about the facility. During an interview with Resident #5's responsible party at 10:30 AM on 08/25/26, she stated she was aware of the incident at the facility on 05/18/26 but did not recall what exactly she was told by the facility other than Resident #5 was hit by another resident. She stated was told the facility was investigating the concern. Resident #5's responsible party also stated she felt like the facility took care of her family member and had no concerns about his care. During an interview with Resident #4's responsible party at 10:40 AM on 08/25/26, she stated she was called and notified that Resident #4 hit another resident when it occurred back in May. Resident #4's responsible party was informed and assured the facility handled the situation appropriately and had no concerns about the facility at this time. During an interview with CNA D at 9:07 PM on 08/25/26, she stated on 05/18/26 she witnessed Resident #4 hit Resident #5. CNA D stated she observed Resident #4 shadow boxing from across the room. She stated Resident #4 had a napkin wrapped around his wrist while shadow boxing. CNA D stated she started across the room to talk to Resident #4 when the napkin fell from being wrapped around his hand and Resident #4 went to catch the napkin and hit Resident #5 in the face/cheek area. CNA D stated she immediately separated them and called other staff to assist Resident #5 while she went to talk to Resident #4. CNA D stated she saw a quarter sized pink area on Resident #5's face/cheek area immediately after the incident. During an interview with the DON at 9:30 AM on 08/26/26, she stated due to the cognition of the residents in the locked unit and there was little to no injury when Resident #5 was hit by Resident #4, the facility did not report the incident to the law enforcement. During an interview with the Administrator at 10:03 AM on 08/26/26, she stated they generally notified the police when there was an injury to a resident and there was an allegation of abuse, but if there was no injury, they did not call the police. The Administrator stated she did not remember an injury occurring when Resident #5 was hit by Resident #4, which is why law enforcement was not notified. 2) Record review of Resident #1's face sheet dated 08/26/26 revealed a [AGE] year-old male with an initial admission date of 09/02/20 and a current admission date of 07/05/26. The pertinent diagnosis included Dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life, caused by damage to the brain cells). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 (indicating his cognition was intact). Record review of Resident #3's face sheet dated 08/26/26 revealed an [AGE] year-old male with an admission date of 10/31/26. The pertinent diagnosis included Dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life, caused by damage to the brain cells). Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed Resident #3 had a BIMS score of 14 (indicating his cognition was intact). Record review of the provider self-report dated 08/25/26 for the alleged abuse incident between Resident #1 and Resident #3 revealed the time of the incident was 5:45 AM on 08/18/26 and HHSC was notified of the incident at 9:30 AM on 08/18/26. Further review revealed the incident was not reported to the police. During an interview with Resident #3 at 9:26 AM on 08/25/26, he stated he was in the dining room on the morning of 08/18/26 but did not remember the specific time. Resident #3 stated he was in his wheelchair getting coffee. Resident #3 stated Resident #1 was behind him and told him to move out of the way. Resident #3 stated Resident #1 started shaking his chair. Resident #3 stated he tried to get Resident #1 to stop shaking his chair and hit Resident #1 on the arm in the process. Resident #3 stated he told the nurses later about the incident. During an interview with Resident #1 at 9:36 AM on 08/25/26, he stated he went to the dining hall on the morning of 08/18/26 before breakfast to get some hot water for his tea. Resident #1 stated Resident #3 was in front of the spigot he needed to use to get the hot water. Resident #1 stated he asked Resident #3 to move out of the way, but Resident #3 told him he was not going to move. Resident #1 stated he tried to go around Resident #3 but Resident #3 hit him in the left shoulder as he tried to pass him. Resident #1 stated it did not really hurt, and it did not leave a bruise. Resident #1 stated he went to tell the nurses about the incident after it happened. During an interview with the DON at 1:04 PM on 08/25/26, she stated she first learned about the incident between Resident #1 and Resident #3 at around 7:00 AM when RN C called her. The DON stated she told RN C to gather more information and then call her back. The DON stated she called back up to the facility at around 8:00 AM and confirmed there had been contact between the two residents. The DON stated she then called the administrator to talk to her about the incident. The DON stated they talked about the incident during their morning meeting which typically started at 9:00 AM. The DON stated the facility reported the incident to HHSC after their morning meeting. The DON stated the nurse that first learned about the incident was the person that was supposed to call the administrator to inform her of the incident. The DON stated the facility had 2 hours to report alleged abuse allegations to HHSC. The DON stated it was important to report incidents to HHSC and the police in a timely manner so those entities could conduct their own investigations and ensure the residents were safe. During an interview with LVN B at 3:30 PM on 08/25/26, she stated she first learned about the incident between Resident #1 and Resident #3 at around 5:45 AM on 08/18/26 when RN C told her about it. LVN B stated she talked to both residents after she was told about it. LVN B stated she did not notify the DON or the Administrator about this incident after it happened. During an interview with the Administrator at 10:03 AM on 08/26/26, she stated she first learned about the incident between Resident #1 and Resident #3 at around 8:30 AM on 08/10/26 when the DON called her. The Administrator stated it was RN C's responsibility to have informed her about the incident after it happened. The Administrator stated the incident between those two residents occurred sometime around 6:00 AM on 08/10/26. The Administrator stated she reported the incident to HHSC at around 9:00 AM to 9:30 AM on 08/10/26. The Administrator stated the facility had 2 hours to report alleged abuse incidents to HHSC and 24 hours to report other incidents where there was no major injury involved. The Administrator stated she reported the incident between Resident #1 and Resident #3 to HHSC within 2 hours of when she found out. The Administrator stated it was important to report incidents to HHSC and law enforcement as necessary so they can conduct their own investigations and protect residents from possible abuse, neglect and exploitation. During an interview with RN C at 3:26 PM on 08/26/26, RN C stated she first learned about the incident between Resident #1 and Resident #3 sometime between 5:00 AM and 6:00 AM on 08/10/26 when Resident #1 told her about it. RN C stated Resident #1 told her Resident #3 hit him on the arm in the dining room. RN C stated Resident #1 told her he was not in pain at that moment. RN C stated she spoke with Resident #3 and he confirmed that he did hit Resident #1 in the dining room. RN C stated she reported this incident to the DON after she learned about it. RN C stated she believed she reported it to the administrator as well. RN C stated it was important to inform the supervisors after an incident so they can put actions in place to protect residents and further report them to HHSC and law enforcement if necessary. 3) Record review of Resident #2's face sheet dated 08/26/26 revealed a [AGE] year-old female with an initial admission date of 08/07/23 and a current admission date of 11/19/24. The pertinent diagnosis included Dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life, caused by damage to the brain cells). Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 4 (indicating severe cognitive impairment). Record review of the provider self-report dated 08/17/26 for the alleged misappropriation of property incident where Resident #2 lost her rings revealed the time of incident was left blank, but it occurred on 08/10/26 and HHSC was notified of the incident at 3:30 PM on 08/11/26. During an interview with CNA A at 9:17 AM on 08/26/26, she stated she was working on 08/10/26 when Resident #2's rings went missing. CNA A stated she first learned about it when Resident #2's visitor informed her sometime between 11:00 AM and 12:00 PM on 08/10/26 that they could not locate Resident #2's rings in her room. CNA A stated she went to Resident #2's room and looked for the rings for about 10 minutes but was unable to find them. CNA A stated she then told her supervisor about the missing rings right after she was unable to find them. During an interview with the Administrator at 10:03 AM on 08/26/26, she stated she first learned about Resident #2's missing rings sometime between 3:00 PM and 6:00 PM on 08/10/26. The Administrator stated she reported the missing rings to HHSC at 3:20 PM on 08/11/26. The Administrator stated she reported the missing rings to HHSC within 24 hours of when she found out about them. The administrator stated the rings were never found and are still missing. Record review of facility provided policy Abuse Guidance: Preventing, Identifying and Reporting last revision dated January 2025 revealed the following: Report alleged or suspicions of abuse to HHSC by email reporting or via TULIP reporting within the designated time frames in accordance with HHSC's PL 2024-14 (Replaces PL 2019-17)are reported immediately,but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury,or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observation, interview, and record review, the facility failed to protect right of residents to be free from verbal abuse, for 1 of 4 (Resident #1) reviewed for abuse. The facility failed to protect Resident #1 from verbal abuse, when CNA A. was verbally abusive on 5/5/2026. This failure could place residents at risk for abuse with psychological injury, intimidation and a decreased quality of life.The findings included: Record review of Resident #1's face sheet, dated 5/5/2026, revealed a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses including: hypertension (elevated blood pressure), dementia (neurological condition that cause memory loss), MDD (Major Depressive Disorder- mood disorder with persistent sadness, emptiness, or a loss of interest in activities), anxiety (a response to stress with a feeling of being overwhelmed), muscle weakness, bipolar disorder (mental health disorder with severe shifts in mood, energy, and daily functioning), and schizophrenia (a severe brain disorder that impairs how an individual interprets reality). Record review of Resident #1's CP, dated 2/17/2026, revealed the resident was care planned for cognitive impairment, falls, Parkinson's Disease, aggressive behaviors, anxiety, and DNR. Record review of Resident #1's QMDS, dated [DATE], revealed the resident had a BIMS score of 15, cognitively intact. Further review revealed she required minimal to moderate assistance with ADLs and a mechanical lift for transfers. During an interview on 5/7/2026 at 3:14 PM, the RP for Resident #1 said CNA A told Resident #1, you have been on the call light for 34 times, and I know you hear me. During an interview on 5/8/2028 at 1:31 PM CNA A said on 5/5/2026, she told Resident #1, you been on the call light 32 times, yes, I counted, and that was an excessive amount of time to be on the call light, and I had to take care of other residents. CNA A said she received the in-service for A&N a week ago. CNA A said she understood to say that to a resident was verbally abusive. CNA A further stated she should not say things like that because it was verbal abuse and Resident #1 would not call for help during an emergency. During an interview on 5/8/2026 at 1:45 PM, the ADM said what CNA A did was verbally abusive and it would cause emotional harm to a resident and may cause them not to use the call light in fear of being scolded. The ADM said she was not aware of what CNA A had done. The ADM said CNA would be removed immediately from the schedule, terminated and reported to EMR. During an interview on 5/8/202 at 2:15 PM, the ADON said verbal abuse could affect residents emotionally and mentally and they could feel they were being reprimanded for using the call light and may not use it if they really need it in case of an emergency. During an observation and interview on 5/8/2026 at 3:05 PM Resident #1 was awake, in her bed, laying on her left side. The camera was removed from her room per RP's and Resident #1's, permission said she did not know why the girl (CNA A) was so angry, but she did not want her to come back to do anything for her because she said those things like she was a small child. Record review of facility's policy titled, Abuse Guidance: Preventing, Identifying and Reporting, dated 1/2024, stated, Every resident has the right to be free from abuse. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members. Any violation of these rights is against the law for any nursing community employee to threaten, coerce, intimidate, or retaliate against the resident for exercising their rights.

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources are reported immediately but not later than 2 hours (for an injury of unknown origin involving serious bodily injury) or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 2 of 10 Residents (Resident #1 and Resident #2) reviewed for abuse. 1.The facility Administrator failed to identify the unauthorized use of Resident #1's credit card by a staff member for a personal purchase as an alleged violation of misappropriation of funds following a grievance submission on 03/06/2026. 2.The Social Worker failed to report an alleged violation of theft or misappropriation of resident property for Resident #2 on 03/13/2026 to the Administrator of the facility and the Administrator failed to report the violation of theft or misappropriation of resident property not later than 24 hours to other officials (including to the State Survey Agency) in accordance with State law through established procedure. These deficient practices could place residents at risk of harm by not having theft or misappropriation of resident property investigated.Findings included: 1. Record review of Resident #1's admission record, dated 04/02/2026, reflected a [AGE] year-old female admitted [DATE]. Her diagnoses included type 2 diabetes mellitus (a metabolic disorder that occurs when the body becomes resistant to insulin), unspecified dementia (associated with a decline in cognitive function severe enough to interfere with daily life), and cognitive communication deficit (refers to difficulties in communication that arise from impaired cognitive functions, such as attention, memory, reasoning, and problem-solving). Record review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE] and signed 03/02/2026 as completed, reflected a BIMS score of 14, indicating intact cognition, organized thinking and did not reveal concerns of short-term or long-term memory. Resident #1 was documented as dependent on staff for toileting hygiene and independent for eating, showering, and mobility functions. Record review of Resident #1's care plan, initiated 03/17/2026, indicated Resident #1 had impaired cognitive function/dementia or impaired thought process related to dementia. Record review of Resident #1's progress note, dated 02/28/2026 documented by LVN A During morning rounds resident states she doesn't feel good. Cough, congestion and wheezing noted. Provider informed and ordered to send resident to ER [emergency room] to be evaluated and treated. Record review of Resident #1's progress note, dated 02/28/2026 documented by LVN A Received call from [hospital] and was informed that resident will be admitted with Flu A. Record review of Resident #1's progress note, dated 03/02/2026 documented by LVN B, Resident Arrived Via [by way of] transport wheelchair. received discharge papers from driver. Resident #1 was unavailable for observation or interview. Record review of Resident #1's Grievance/Concern Report - Residents and Families, dated 03/06/2026 revealed the date of occurrence of her submitted grievance was on 03/02/2026. Concern/Details: [Resident #1] stated her daughter called her and stated that her credit card was charged for $152.00 at [grocery store's] curbside. She stated she did not make a purchase that day (3/2/26) from [grocery store] . The grievance was received by the Social Services Director. Action Taken: [Resident #1] stated she has the credit card in her wallet and it is not missing. Her daughter is canceling this credit card and will get a new one. Record review of Resident #1's Money Order, dated 03/09/2026, revealed Serial Number: 5509421227 in the amount of $155.00, pay to Resident #1, From: Responsible Party with Memo: Trust fund of Resident #1. Record review of Resident #1's Email Correspondence, dated 03/10/2026, revealed an email correspondence from Resident #1's Responsible Party addressed to the Business Office Manager, I just wanted to give you an update on my mom debit card. The issue has been resolved by the bank and [grocery store] she should be receiving or received a refund soon. I will keep her card off so there are no further issues or concerns. Record review of Resident #1's Statement, dated 03/10/2026 reflected the Health Information Manager's account of the incident, On February 28th, 2026 I made a curbside order and resident [Resident #1] credit card was used in error. Reason credit card was used in error I had previously ordered subway for resident [Resident #1] x2 [twice] using cc [credit card] which saved into my [phone] wallet account. I failed to change the cc [credit card] and pick MY own cc [credit card] and that is when a charge of $152.42 was charged to resident [Resident #1] . I reached out to RP [Responsible Party] and advised her [grocery store] had contacted me. I explained to her in detail what happened and she understood and I offered to fix this immediately. I purchased money order for RP [Responsible Party] and we agreed to post it to resident account. Once I confirmed money was posted to report to administrator situation. However, she beat me to this pulled me in office, and we discussed the entire situation. RP [Responsible Party] is not going to press charges, is not upset, she fully understood this was an innocent mistake. We agreed that she would tell resident that she has taken care of issue.Reason for this is because we agreed resident to be at peace knowing nobody took advantage of her and no details given to her so that she would not be given information that was not full story, added to or changed in any way. [sic] Record review of Resident #1's Resident Statement Landscape, dated 03/12/2026, reflected a money order in the amount of $155 was received and credited to Resident #1's resident account. Record review of facility document titled, In-Service Education, dated 03/11/2026 reflected Subject: Code of Conduct.Instructor: ADM. the Health Information Manager was the only staff in attendance and educated on the Confidentiality and HIPAA Compliance, as well as [facility] Code of Conduct for team members. Specifically, as it relates to assisting residents with purchasing personal items and/or food items. 2. Record review of Resident #2's admission record, dated 04/02/2026, reflected a [AGE] year-old male admitted [DATE]. His diagnoses included atherosclerotic heart disease (condition where the coronary arteries become narrowed or blocked due to buildup, which reduces blood flow to the heart muscle), personal history of transient ischemic attack (temporary blockage of blood flow to the brain), and seizures (a sudden burst of electrical activity in the brain). Record review of Resident #2's quarterly Minimum Data Set (MDS), dated [DATE] and signed 01/28/2026 as completed, reflected a BIMS score of 13, indicating intact cognition, organized thinking and did not reveal concerns of short-term or long-term memory. Resident #2's functional abilities were documented as being independent for self-care and mobility. Record review of Resident #2's care plan, created on 12/29/2023 and revised on 01/15/2024, indicated Resident #2 was able to participate in activities of my choice with my physical cognitive ability. Record review of Resident #2's Grievance/Concern - Residents and Families, dated 03/13/2026 revealed the date occurrence of his submitted grievance was on 03/09/2026 - 03/11/2026. Concern/Details: Missing 57 dollars from locked drawer, with resident remembering it was locked, with the key being in another drawer, that was not locked, with resident's socks, in the corner, where it is visible. Social Worker was the team member receiving report from Resident #2 and actions taken on 03/13/2026, Social worker examined drawer, not broken, and can not be opened without a key. Key visible where it was kept in other drawer, despite resident covering it w/ socks. No money found. Resident #2 notified in person of the facility response to his grievance, Response: educated resident on proper key use for locking drawer, that he has right to keep key on person, have a log for spending, and that no one else has access to his drawer when locked, and that he has the right to file a police report. He stated he understood and did not want to file a police report at this time. The Administrator was made aware of the grievance and on 03/16/2026 signed off on the actions and response taken by the Social Worker followed by a secondary review on 03/18/2026 by the On Site Representative, the veteran's advocate on 03/18/2026. Resident #2 was unavailable for observation or interview. During an interview on 04/02/2026 at 3:00 p.m. the DON said all staff were expected to report allegations of ANE immediately to the Abuse Coordinator, the Administrator. She said she recalled Resident #1's grievance reported on 03/06/2026. She said she was notified immediately of the grievance. She said she recalled the Health Information Manager made a personal curbside purchase using Resident #1's credit card. She said Resident #1's credit card information had been stored in Health Information Manager personal cell phone after a food order she had made for her previously. She said the Health Information Manager notified her that she did not pay attention when making her personal curbside order with the grocery store and she used the wrong credit card and charged Resident #1's credit card. She said the funds were returned to Resident #1's resident account, the Health Information Manager was in-serviced on concern, the incident was not reported to the State, but perhaps it should have been. She said she was unsure if the Health Information Manager was counseled, but that she was present for the in-service conducted on 03/11/2026 that addressed confidentiality and HIPAA compliance, the facility's code of conduct for team members, specifically as it related to assisting residents with purchasing personal items and/or food items. The DON said she was unable to recall the date the credit card was used by the Health Information Manager and did not recall that Resident #1 was transferred to the hospital on 2/28/2026, which was the date of the unauthorized use of credit card reported. She said she was not notified of the grievance filed by Resident #2 on 03/13/2026 and would need to follow up with the Social Worker for additional details. She said Resident #2 did not have a history of filing grievances of alleged theft or misappropriation of property and his cognition was intact. During a phone interview on 04/02/2026 at 8:54 p.m. the Administrator said she educated the staff to report suspected or witnessed ANE immediately. She said she was responsible for following the State provider letter and required to report any incidents that were inappropriate. The Administrator said reporting timeframe for ANE was within 2 hours of being notified and other incidents within 24 hours of being notified. She said she refers to the State provider letter for specifics on misappropriation, exploitation, and unusual circumstances. The Administrator said she was made aware of Resident #1's grievance submitted to the Social Services Director on 3/06/2026, which she reviewed thoroughly on 03/10/2026 followed by On Site Representative review on 03/17/2026. She said she was notified the Health Information Manager used Resident 1's credit card without her authorization for a personal purchase by accident and it was not intentional. She said the Health Information Manager helped Resident #1 with making online orders often and her credit card was stored on Health Information Manager's personal cell phone. She said she spoke with the Responsible Party regarding the unintentional incident, and it was worked out. Administrator first said she was not aware, followed by stating she did not recall that Resident #1 was transferred to the hospital on [DATE], the day the Health Information Manager made the personal grocery store purchase with her credit card. She said Resident #1's account was credited on 03/12/2026 and the grievance was resolved. The Administrator said staff should not be using their personal phones or using any resident credit card information. She said the Health Information Manager has been employed with the facility for a while and did not feel the incident was intentional and it was a true accident. She said the Health Information Manager was disciplined and educated in the Code of Conduct and not using a resident's personal credit card or using their personal cell phone to make online orders for any resident. She said the Health Information Manager was the ambassador for Resident #1 and the expectation was for residents to be helped with anything in their power, she believed the incident was an honest mistake, she did not try to hide it, and her understanding was the team member made the report to her. The Administrator said she did not consider the tenure of a staff member when deciding if their actions were intentional or unintentional she was just making a statement of the confidence she has in the Health Information Manager to emphasize there have been no issues with staff exploiting residents at the facility. She said the incident was not reported to the State as it was not intentional and did not rise to the level of an alleged violation. The Administrator said she was aware of the grievance Resident #2 submitted on 03/16/2026 of his concern of missing money. She said Resident #2 brought the concern to the Social Worker's attention. She said a lot of guys [male residents] loan their money out. The Administrator said she was not sure if the missing money grievance was confirmed. She said the grievance of missing money was not brought to her attention as an allegation of theft. She said Resident #2 was alert and oriented, he wasforgetful at times, and he did not have a history of making allegations of missing money or property. She said she was not afraid to report incidents and if there was a specific allegation and not just a mention or grievance of missing money, then she would not report it to the State Agency. The Administrator said the Social Worker was responsible for monitoring the grievance log, ensuring the grievances were responded to in a timely manner, but at the end of the day she and the On Site Representative were responsible for reviewing and signing off on them. An Employee Coaching record review for the Health Information Manager regarding the unauthorized use of Resident #1's credit card was requested from the DON and the Administrator on 04/02/2026 and as of 04/13/2026 an employee coaching record was not provided prior to exit. Record review of document titled, Code of Conduct, undated, reflected the following: I will respect resident rights. I will not mistreat, neglect or abuse residents, and I will not take any resident property. I will immediately report any resident mistreatment, abuse, neglect, or theft of resident property, to my supervisor. I will report any actual or suspected violations of applicable laws, or this Code of Conduct, to my supervisor, community administrator. Record review of document titled, Grievances, dated 01/2023 reflected the following: The investigation of complaints and grievances is a vital function to protect the health, safety, and welfare of residents. Each resident has the right to receive prompt resolution of grievances, including those regarding the behavior of other residents. Record review of document titled, Statement of Resident Rights, dated January 2023 reflected the following: Resident/Patient Rights include: 3. To be free from abuse and exploitation; 14. To keep and use personal property, secure from theft or loss. Record review of document titled, Abuse Guidance: Preventing, Identifying and Reporting dated January 2024 reflected the following: Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members. It is the responsibility of our team members, Community consultants, attending physicians, family members, visitors, etc. to promptly report any incident of suspected neglect or resident abuse, including injuries of an unknown source, and theft or misappropriation of resident property to Community management.Reporting/Response- All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities are individuals as may be required by law and per the current state/federal reporting requirements. Types of abuse Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful (whether temporary or permanent) use of a resident's belongings or money without the resident's consent. Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Record review of QAPI Collaboration: The facility will communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation with the QAPI Committee.Increased training on specific components of identifying and reporting that staff may not be aware of or are confused about.Tracking patterns of similar occurrences.

Based on interview and record review, the facility failed to ensure that alleged violations of abuse, neglect, and exploitation were thoroughly investigated, and the results of the investigation were reported to the State Survey Agency within five working days for 2 of 10 residents (Resident #1 and Resident #2) reviewed for abuse, neglect, and exploitation. 1.The facility failed to have evidence of an investigation of alleged misappropriation of funds of Resident #1.2.The facility failed to have evidence of an investigation of alleged theft of property of Resident #2. These deficient practices could place residents at risk of harm by not having theft or misappropriation of resident property investigated.Findings included: 1. Record review of Resident #1's admission record, dated 04/02/2026, reflected a [AGE] year-old female admitted [DATE]. Her diagnoses included type 2 diabetes mellitus (a metabolic disorder that occurs when the body becomes resistant to insulin), unspecified dementia (associated with a decline in cognitive function severe enough to interfere with daily life), and cognitive communication deficit (refers to difficulties in communication that arise from impaired cognitive functions, such as attention, memory, reasoning, and problem-solving). Record review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE] and signed 03/02/2026 as completed, reflected a BIMS score of 14, indicating intact cognition, organized thinking and did not reveal concerns of short-term or long-term memory. Resident #1 was documented as dependent on staff for toileting hygiene and independent for eating, showering, and mobility functions. Record review of Resident #1's care plan, initiated 03/17/2026, indicated Resident #1 had impaired cognitive function/dementia or impaired thought process. Resident #1 was unavailable for observation or interview. Record review of Resident #1's Grievance/Concern Report - Residents and Families, dated 03/06/2026 revealed the date of occurrence of her submitted grievance was on 03/02/2026. Concern/Details: [Resident #1] stated her daughter called her and stated that her credit card was charged for $152.00 at [grocery store's] curbside. She stated she did not make a purchase that day (3/2/26) from [grocery store] . The grievance was received by the Social Services Director. Action Taken: [Resident #1] stated she has the credit card in her wallet and it is not missing. Her daughter is canceling this credit card and will get a new one. Record review of Resident #1's Statement, dated 03/10/2026 reflected the Health Information Manager's account of the incident, On February 28th, 2026 I made a curbside order and resident [Resident #1] credit card was used in error. Reason credit card was used in error I had previously ordered subway for resident [Resident #1] x2 [twice] using cc [credit card] which saved into my [phone] wallet account. I failed to change the cc [credit card] and pick MY own cc [credit card] and that is when a charge of $152.42 was charged to resident [Resident #1] . I reached out to RP [Responsible Party] and advised her [grocery store] had contacted me. I explained to her in detail what happened and she understood and I offered to fix this immediately. I purchased money order for RP [Responsible Party], and we agreed to pos it to resident account. Once I confirmed money was posted to report to administrator situation. However, she beat me to this pulled me in office, and we discussed the entire situation. RP [Responsible Party] is not going to press charges, is not upset, she fully understood this was an innocent mistake. We agreed that she would tell resident that she has taken care of issue.Reason for this is because we agreed resident to be at peace knowing nobody took advantage of her and no details given to her so that she would not be given information that was not full story, added to or changed in any way. [sic] 2. Record review of Resident #2's admission record, dated 04/02/2026, reflected a [AGE] year-old male admitted [DATE]. His diagnoses included atherosclerotic heart disease (condition where the coronary arteries become narrowed or blocked due to buildup, which reduces blood flow to the heart muscle), personal history of transient ischemic attack (temporary blockage of blood flow to the brain), and seizures (a sudden burst of electrical activity in the brain). Record review of Resident #2's quarterly Minimum Data Set (MDS), dated [DATE] and signed 01/28/2026 as completed, reflected a BIMS score of 13, indicating intact cognition, organized thinking and did not reveal concerns of short-term or long-term memory. Resident #2's functional abilities were documented as being independent for self-care and mobility. Record review of Resident #2's care plan, created on 12/29/2023 and revised on 01/15/2024, indicated Resident #2 was able to participate in activities of my choice with my physical cognitive ability. Record review of Resident #2's Grievance/Concern - Residents and Families, dated 03/13/2026 revealed the date occurrence of his submitted grievance was on 03/09/2026 - 03/11/2026. Concern/Details: Missing 57 dollars from locked drawer, with resident remembering it was locked, with the key being in another drawer, that was not locked, with resident's socks, in the corner, where it is visible. Social Worker was the team member receiving report from Resident #2 and actions taken on 03/13/2026, Social worker examined drawer, not broken, and can not be opened without a key. Key visible where it was kept in other drawer, despite resident covering it w/ socks. No money found. Resident #2 notified in person of the facility response to his grievance, Response: educated resident on proper key use for locking drawer, that he has right to keep key on person, have a log for spending, and that no one else has access to his drawer when locked, and that he has the right to file a police report. He stated he understood and did not want to file a police report at this time. The Administrator was made aware of the grievance and on 03/16/2026 signed off on the actions and response taken by the Social Worker followed by a secondary review on 03/18/2026 by the On Site Representative, veteran's advocate on 03/18/2026. Resident #2 was unavailable for observation or interview. During an interview on 04/02/2026 at 3:00 p.m. the DON said all staff were expected to report allegations of ANE immediately to the Abuse Coordinator, the Administrator. She said she did recall Resident #1's grievance of unauthorized use of her credit card, but as this was an unintentional occurrence the incident was not reported to the State, but perhaps it should have been. She said as this allegation was not reported to the State Survey Agency an investigation did not occur. She said she was not notified of Resident #2's grievance on theft of funds from his room that was reported on 03/16/2026. She said she was not aware if the incident was investigated any further by the Administrator. During a phone interview on 04/02/2026 at 8:54 p.m. the Administrator said she was the Abuse and Neglect Coordinator for the facility. She said she was responsible for following the State Survey Agency provider letter and investigating allegations of ANE within 5 days of being notified. She said she recalled the grievance Resident #1 submitted on the unauthorized use of her credit card. She said the incident was not reported to the State as it was not intentional and did not rise to the level of an alleged violation and she did not investigate further. She said she recalled the grievance Resident #2 submitted regarding theft of funds from his room. She said the grievance was handled by the Social Worker and she was not familiar with the details. She said not all grievances involving money were allegations to be reported to the State Survey Agency and felt it did not warrant reporting. She said she did not investigate the grievance as it was not an official allegation. Record review of document titled, Code of Conduct, undated, reflected the following: I will respect resident rights. I will not mistreat, neglect or abuse residents, and I will not take any resident property. I will immediately report any resident mistreatment, abuse, neglect, or theft of resident property, to my supervisor. I will report any actual or suspected violations of applicable laws, or this Code of Conduct, to my supervisor, community administrator. Record review of document titled, Grievances, dated 01/2023 reflected the following: The investigation of complaints and grievances is a vital function to protect the health, safety, and welfare of residents. Each resident has the right to receive prompt resolution of grievances, including those regarding the behavior of other residents. Record review of document titled, Statement of Resident Rights, dated January 2023 reflected the following: Resident/Patient Rights include: 3. To be free from abuse and exploitation; 14. To keep and use personal property, secure from theft or loss. Record review of document titled, Abuse Guidance: Preventing, Identifying and Reporting dated January 2024 reflected the following: Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members. It is the responsibility of our team members, Community consultants, attending physicians, family members, visitors, etc. to promptly report any incident of suspected neglect or resident abuse, including injuries of an unknown source, and theft or misappropriation of resident property to Community management.Reporting/Response- All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities are individuals as may be required by law and per the current state/federal reporting requirements. Types of abuse Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful (whether temporary or permanent) use of a resident's belongings or money without the resident's consent. Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Record review of QAPI Collaboration: The facility will communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation with the QAPI Committee.Increased training on specific components of identifying and reporting that staff may not be aware of or are confused about.Tracking patterns of similar occurrences.

Based on observations, interviews, and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as was possible, and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 38 residents (Resident #157, Resident #110) and 1 of 8 halls (300 hall) reviewed, in that: 1. The facility failed to ensure no hazardous products were left accessible to residents of 300 hall. 2. The facility failed to store a package of cigarettes found on Resident # 157's bed.3. The facility failed to secure a cigarette lighter found on Resident #110's bedside table. These deficient practices could place residents at-risk of avoidable accidents, decline in physical condition, and injury. The findings were:1. Observation on 03/05/2026 at 10:40 a.m., revealed ADON C, outside of room [ROOM NUMBER], disinfecting her personal protection eyewear with germicidal wipes and putting the canister of wipe back in the isolation bin outside of the room by the door. The bin did not have a lock, and residents could access the canister. The canister had a caution label about possible eye irritation and flammability. During an interview on 03/05/2026 at 10:42 a.m., ADON C stated the canister had a caution label and stated the wipes could be hazardous for resident with dementia and should be under lock. They did not think about the risk for the residents when they put the isolation bin in place for the droplets precaution and used the wipe to sanitize the goggles and face shield. She stated there were residents with dementia in the facility who could either ambulate or use a wheelchair without assistance. During an interview on 03/05/2026 at 4:45 p.m., the DON confirmed the canister of wipes should have been kept away from the residents for safety. Residents with dementia could misuse the wipes which could cause injury to them. Review of facility's policy, titled Accident prevention, dated January 2023, revealed, The community ensures that the resident environment remains as free of accident hazards as possible. Accidents hazards are defined as physical features in the environment that can endanger a resident's safety. Hazard may include, but are not limited to, the following: [ .] Chemicals that aren't secured. 2. Record review of Resident #157's face sheet dated 3/04/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Anemia (indicates your blood is not transporting enough oxygen to your body's tissues ), dysphagia ( difficulty swallowing ), and flaccid bladder (is a type of disorder where muscle tone in bladder loses the ability to contract, preventing proper emptying). Record review of Resident # 157's Quarterly MDS assessment dated [DATE] revealed a BIMS of 15, which indicated intact cognition. Record review of Resident # 157's care plan dated 10/29/2024 revealed interventions conduct safety checks as needed related to smoking materials, ensuring safety. Record review Resident #157's quarterly smoking assessment, dated 12/17/2025, revealed stored cigarettes were to be kept under supervision for safekeeping. Observation on 3/4/2026 at 10:40 am revealed a box of cigarettes on Resident #157's bed, with 3 cigarettes in the box. Interview with Resident # 157 on 3/4/2026 at 10:50 am revealed that he was a smoker and did not know how the box of cigarettes got on top of his bed, but would gladly smoke them. Interview with CNA G on 3/4/2026 at 11:05 am revealed that she was the assigned nursing assistant for resident # 157 and confirmed that a box of cigarettes was on top of Resident # 157's bed. However, during her morning rounds about 1.5 hours ago, she did not see the box of cigarettes. Interview with PCN on 3/4/2026 at 11:05 am confirmed she was the assigned nurse for Resident #157. She removed a box of cigarettes from Resident #157's bed and stated that cigarettes should be locked up and stored for safety. PCN explained that family members sometimes bring cigarettes to residents for storage with the nursing department. They typically give residents 2 or 3 cigarettes to smoke while visiting with them in the smoking area, and residents save the remaining cigarettes for later use and do not give the cigarettes to the nursing staff for safekeeping. She added that, since Resident #157 had a high BIMS, a negative outcome was unforeseen. Interview with the DON on 3/5/2026 at 10:20 am revealed her expectation was for nursing staff to confiscate all smoking paraphernalia for safekeeping. The DON stated resident # 157 should not have had a box of cigarettes on his bed, as even with a high BIMS, he could have started smoking in his room and set off the fire alarm. She said the assigned ADON to the unit should have ensured no cigarettes were on the resident's bed with her, as the DON monitoring this task at random. 3. Observation on 03/03/2026 at 10:55 a.m. revealed Resident #110 was asleep in his bed which was located closest to the door of his room. Further observation revealed a cigarette lighter on the resident's bedside table and accessible to those passing in the hallway. During an interview with the DOR on 03/03/2026 at 10:56 a.m., the DOR stated the cigarette lighter should have been secured. The DOR removed the lighter and took it to be secured at the nurses' station. During an attempted interview with Resident #110 on 03/03/2026 at 3:42 p.m., Resident #110 declined to participate. During an interview with the Administrator on 03/06/2026 at 2:00 p.m., the Administrator stated her expectation was for staff to ensure all smoking materials were kept secure for the safety of the residents. Record review of facility policy smoking guidelines residents, team members & visitors. dated 1/2022, revised January 2023, revealed: Residents should not keep personal cigarettes, lighters, matches.

Based on observation, interviews and record reviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 medication cart (300 Hall medication cart) of 6 medication carts reviewed. The facility failed to ensure an open multidose vial of Lidocaine Hydrochloride injection 1% (local anesthetic) was labeled when opened. This deficient practice could affect residents and result in cross contamination or decreased effectiveness.The findings included: Observation on 03/04/2026 at 3:15 pm with LVN B of 300 Hall medication cart revealed a vial of Lidocaine HCL injection 1%, expiration dated 11/27, opened in the cart. No open date was on the vial. During an interview on 03/04/2026 at 3:17 p.m., LVN B stated nurses are trained to check the carts for open, undated, or expired medications. She stated she did not know why the vial of Lidocaine had not been dated. She stated an open multidose vial needed to be dated because the vial would only be good for 28 days. She stated she would throw away the vial. During an interview on 03/04/2026 at 3:30 p.m., PCN stated the Lidocaine was not on the list of medications that have a time and date required once opened. She stated the Pharmacist would be at the facility the following week and she would bring it to their attention. She stated the Lidocaine should have been on the list because it was a multidose vial and once opened it was only good for 28-day use. During an interview on 3/06/2026 at 1:40 p.m., the DON stated the Lidocaine 1% should not have been on the medication cart because it was used when a Rocephin (antibiotic) injection was give and no residents were prescribed Rocephin. She stated she did not recall when it was last used in the facility. Record review of the facility's policy and procedure titled Pharmacy Services Provisions of Medications and Biologicals undated reflected medications and biologicals are labeled in accordance with currently accepted professional standards and with local and state drug-labeling regulations. Record review of CDC guidelines titled Preventing Unsafe Injection Practices/Injection Safety dated March 26.2024 reflected Once a multi-dose vial is opened, the vial should be dated and discarded withing 28 days.

]Based on observation, interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 medication cart (400 Hall Medication Cart) of 6 medication carts reviewed. The facility failed to remove 2 male intermittent catheters with a use by date of 11/09/2025 from 400 Hall medication cart. This deficient practice could result in compromised sterility, safety, and efficacy of the device.Observation on 03/05/2026 at 11:24 a.m. of nurses' medication cart on 400 Hall revealed 2 male intermittent catheters with a use by hourglass symbol dated 11/09/2025. (The hourglass symbol is a standardized international symbol used on medical devices to show the final date the manufacturer guarantees the product's safety and effectiveness using the catheter after this date may compromise sterility, safety, and efficacy, increasing the risk of infection or device failure). During an interview on 03/05/2026 at 11:30 a.m., RN A stated the 2 male intermittent catheters should have been removed from the cart due to the use by date, which signified the device could have a loss of integrity. During an interview on 03/06/2026 at 1:40 p.m., the DON stated supplies kept on the medication carts needed to be checked for use by dates and expiration dates. She stated the use by dates were important to have full protection of the device. During an interview on 03/06/2026 at 2:00 p.m., the ADM stated expired items needed to be removed from medication carts and checked accordingly to ensure proper use, effectiveness, and function of the item. Record review of the facility's policy and procedure titled Medication Management dated 03/13/19 reflected Medications are stored, dispensed and destroyed in a manner to ensure safety and conformance with state and federal laws. Record review of U.S. Food and Drug Administration article dated Shelf Life of Medical Devices dated 02/27/1997 reflected shelf life is the term or period during which a commodity remains suitable for the intended use. An expiration date is the termination of shelf life, after which a percentage of the commodity, such as medical devices, may no longer function as intended.

Based on observations, interviews and record reviews, the facility failed to ensure assessments accurately reflected the status of the residents for 1of 24 residents (Residents #7) reviewed for resident assessments. The Facility failed to ensure Resident #7's CPAP (continuous positive airway pressure, is a medical device and therapy primarily used to treat obstructive sleep apnea, a condition where the airway collapses or becomes blocked during sleep, causing pauses in breathing and reduced oxygen levels. The device delivers a steady stream of pressurized air through a mask worn over the nose and/or mouth, keeping the airway open and allowing normal breathing throughout the night) was accurately reflected on his quarterly MDS assessment, dated 12/31/2025. This deficient practice could place residents at risk of missed or inaccurate care.The findings included: Record review of Resident #7's electronic face sheet dated 03/04/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: paraplegia (inability to voluntarily move the lower parts of the body), post-traumatic stress disorder (a mental health condition that's caused by an extremely stressful or terrifying event), major depressive disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy) and obstructive sleep apnea (a sleep disorder characterized by repeated episodes of complete (apnea) or partial (hypopnea) collapse of the upper airway, causing oxygen desaturation or sleep arousal). Review of Resident #7's quarterly MDS assessment dated [DATE] did not reflect he received CPAP. Record review of Resident #7's comprehensive care plan dated 08/05/2025 reflected Focus, at risk for experiencing shortness of breath r/t obstructive sleep apnea, Interventions/Tasks, administer CPAP as ordered by physician. Record review of Resident #7's Active Orders as of: 03/04/2026 reflected CPAP, QHS while sleeping, every night shift for obstructive sleep apnea, pressure 4.0 to 20.0 tube temperature 60 degrees, humidity per resident preference, start dated 02/23/2025. Record review of Resident #7's MAR dated 12-1-2025 to 12-31-2025 reflected he had CPAP applied every night. Observation on 03/06/2026 at 1:00 p.m., Resident #7 was sitting in his room, with a CPAP machine sitting on the bedside table. During an interview on 03/06/2026 at 1:05 p.m., Resident #7 stated he used CPAP every night since he was admitted . During an interview on 03/06/2026 at 1:30 p.m., the MDS nurse stated she missed the CPAP, which should have been noted under non-invasive mechanical ventilator. MDS B said she did not know how she missed it and was accountable for the accuracy of the MDS. She stated an inaccurate MDS could result in missed care for a resident. During an intervie3w on 03/06/2026 at 1:35 p.m., the DOCR stated Resident #7's quarterly MDS assessment dated [DATE] needed to reflect he received CPAP, and it did not. During an interview on 03/06/2026 at 1:40 p.m., the DON stated MDS accuracy was important to show what the resident needed for care and inaccuracy could lead to missed care. During an interview on 03/06/2026 at 2:00 p.m., the ADM stated MDS accuracy was important and it showed the care a resident required. During an interview on 03/06/2026 at 2:00 p.m. when surveyor asked the ADM for a facility policy and procedure for accuracy of MDS assessments and did not receive one by exit. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, dated October 2025 reflected The RAI process has multiple regulatory requirements. Federal regulation required the assessment accurately reflects the resident's status.

Based on observations, interviews, and record reviews, the facility failed to ensure the safe and sanitary storage of residents' food items in 1 of 4 residents' refrigerators (Resident #65) reviewed for personal food storage, in that: The personal refrigerator in Resident #65's room contained food items that were unlabeled and undated. This deficient practice could put residents at risk of foodborne illness from consuming spoiled food. The findings were:Observation on 3/3/2026 at 10:35 a.m. in Resident #65's, revealed that the personal refrigerator contained fried chicken in an unlabeled, undated storage bag. Observation on 3/3/2026 at 11:35 a.m. of the personal refrigerator revealed that the fried chicken in an unlabeled in Resident #65's room, undated storage bag was still present. Interview with Resident #65 on 03/3/2026 at 10:36 a.m., the resident revealed the fried chicken had been in his personal refrigerator for about 2 days. Interview with CNA G on 03/3/2026 at 11:50 a.m., CNA G stated she was assigned to Resident #65 and confirmed that the personal refrigerator in the resident's room room contained fried chicken, which was undated and unlabeled. CNA G stated she did not know who was responsible for checking the president's personal refrigerator for expired food, but would check with the charge nurse. Interview with PNC on 3/3/2026 at 11:55 a.m. revealed she was the assigned nurse for to Resident #65 and confirmed there was fried chicken in an unlabeled and undated storage bag in the personal refrigerator for the resident. She added all staff were responsible for removing undated and unlabeled food items from residents' personal refrigerators, and the resident risked some form of food-borne illness by possibly consuming food that was unlabeled and undated. During an interview with the DON on 03/3/26, at 1:15 p.m., the DON confirmed perishable food and drinks in residents' personal refrigerators should be labeled and dated to prevent Residents from consuming spoiled food. The DON stated all staff were responsible for removing undated, unlabeled food items from residents' refrigerators daily, including assisting families in labeling and dating food items brought in. The DON stated that families sometimes bring food for residents without notifying the nursing staff. She added that her charge nurses were responsible for overseeing this task, and her ADONs would be monitoring at random. Record review of the facility policy, Personal Refrigerator, dated February 2017, revised 1/2023, revealed: Routinely check the refrigerator to identify unsafe for consumption foods and discard any items that appeared to have gone bad or are expired.

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 5 residents (Residents #8) reviewed for infection control, in that: 1. a The facility failed to ensure LVN F sanitized between their fingers while providing wound care for Resident #8. 1.b The facility failed to ensure LVN F changed gloves after cleaning the wound and before applying the treatment, while providing wound care for Resident #8. These failures deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 1.Record review of Resident #8's face sheet , dated 03/05/2026, revealed an admission date of 10/15/2018 and, a readmission date of10/27/2022, with diagnoses that included: Quadriplegia (Paralysis of all 4 limbs), Hypertension (High blood pressure), Chronic kidney disease (gradual loss of kidney function), Pressure ulcer of right buttock, stage 4 (deep, open wound that extends through the skin, underlying tissue, muscle, and bone), Osteomyelitis (Bone infection), Type 2 diabetes mellitus (high level of sugar in the blood). Record review of Resident #8's Quarterly MDS assessment, dated 02/10/2026, revealed the resident had a BIMS score of 15, indicating he was cognitively intact. Resident #8 was dependent on the staff for care, had an indwelling catheter and an ostomy (surgical procedure that creates an opening (stoma) in the body for the discharge of body wastes). The resident was coded as having a stage 4 pressure ulcer. Record review of Resident #8's care plan dated 02/26/2026, revealed a problem of My skin is fragile and I am at risk for skin injury--new or worsening skin condition. 2. Thin, fragile, loose skin. , 3. Immobility, History of full thickness skin breakdown noted. and an intervention of Apply treatment as ordered. a. An observation on 03/05/2026 at 11:13 a.m., revealed while providing wound care for Resident #8, LVN F, while sanitizing her hands during care, did not sanitize between her fingers. b. An observation on 03/05/2026 at 11:13 a.m., revealed while providing wound care for Resident #8, LVN F cleansed the wound and, without changing her gloves and sanitizing her hands, applied the ointment treatment around the bed of the wound. During an interview on 03/05/2026 at 11:20 a.m. LVN F stated she should have sanitized between her fingers when she used sanitizer just like she did when she used soap and water. She did not know why she did not sanitize between her fingers. Further interview revealed, LVN F stated, after cleaning the wound, her gloves were soiled and she should have changed her gloves before starting the treatment. She stated she received infection control training within the year. During an interview with the DON on 03/05/2026 at 4:45 p.m., she stated that staff should sanitize all surfaces of their hands to ensure appropriate hand hygiene and prevention of infection to the resident. She stated the nurse should have changed her gloves after cleaning the wound to not cross contaminate the ointment she was using on the resident. She stated infection control training was provided and staff's skills were checked annually. Record review of the facility's policy titled Fundamentals of Infection Control Precautions , dated 03/2023, revealed, Recommended techniques for performing hand hygiene [ .] applying product to the palm of one hand and rubbing hands together, covering all surfaces of hands and fingers. Record review of Facility's policy, titled Hand Hygiene, undated, revealed Handwashing should be done at the following times [ .] after contact with blood, bodily fluids and contaminated items. [ .] Hand sanitizing steps [ .] Next rub the remaining sanitizer between both palms of hands, vigorously rub hands together in a circular motion [ .] between fingers and up both wrist areas.

Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and service to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 residents (Resident #50) reviewed for incontinent care and catheter care., in that: The facility failed to ensure that, while providing incontinent care for Resident #50, CNA D used a front to back motion to clean Resident #50. This failure could place residents at-risk for infection and skin break down due to improper care practices.The findings were: Record review of Resident #50's face sheet, dated 03/26/2026 , revealed an admission date of 10/31/2024 and, diagnoses that included: Parkinson's disease (brain condition that causes problems with movement, mental health, sleep, pain and other health issues), Dementia (decline in cognitive abilities), Chronic kidney disease (gradual loss of kidney function), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Retention of urine (inability to voluntarily pass urine). Record review of Resident #50's quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated the resident was cognitively intact, and was indicated to always be continent of bowel and had an indwelling catheter. Record review of Resident #50's care plan, dated 02/26/2025, revealed a problem of I require a catheter for DX: NEUROMUSCULAR DYSFUNCTION OF BLADDER, UNSPECIFIED (lack of control of the bladder due to nerve damages) and an intervention of Monitor for s/sx infection. Observation on 03/05/2026 at 2:14 p.m., revealed while providing catheter/incontinent care for Resident #50, CNA D used a back-and-forth motion to wipe the resident's buttocks instead of a front to back motion. During an interview on 03/05/2026 at 2:30 p.m. with CNA D, he stated he should have wiped front to back instead of using a back-and-forth motion to clean Resident #50's buttocks to prevent possible infection for the resident. He stated he was nervous and made a mistake. He stated he received infection control training and incontinent care training within the year. During an interview with the DON on 03/05/2026 at 4:45 p.m., she stated that staff should not do back and forth motion with wipes during incontinent care. The staff should do a front to back pass with a wipe and change wipe before doing another pass to prevent fecal matter to enter the urinary tract and cause infection. She stated infection control and incontinent care training were provided for the staff at least once a year. Record review of Facility's policy, titled Competency assessment perineal care, dated February 2018, revealed use 1 wipe per swipe, wash perineal area, wiping front to back.

Based on interview and record review, the facility failed to ensure residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for 2 of 8 residents (Resident #2 and Resident #3) reviewed for abuse and neglect. The facility did not ensure it protected residents from abuse when Resident #1 threw lukewarm coffee, yelled, and cussed at Resident #2 and Resident #3 on 07/07/2025. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included: Record review of Resident #1's admission Record, dated 06/08/25, reflected a [AGE] year-old man admitted [DATE] with diagnoses to include dementia (loss of cognitive functioning-such as thinking, remembering, and reasoning-to the extent that it interferes with a person's daily life and activities) and anxiety disorder (feeling apprehensive, uneasy, or nervous about something). Record review of Resident #1's quarterly MDS assessment, dated 04/22/25, reflected Resident #1 had not exhibited wandering behavior and had a BIMS score of 13/15, indicating intact cognition. Resident #1 did not have physical behavioral symptoms directed toward others. Record review of Resident #1's care plan, undated, reflected At risk for psycho-social issues: emotional distress or behaviors r/t: dementia w/agitation dx, exposure to war. 7/5/25 Resident to staff and resident to resident physical aggression, yelled/cursed out loud, pushed LVN and threw warm/cool coffee at staff and two residents. With interventions 7/5/25- Increased monitoring when in common areas and around other residents. And 7/5/25- Senior Psych Med Intervention., Administer Medications as ordered., Calm and re-assure resident/patient is safe, Keep environment calm, quiet and avoid loud noises as much as possible., Redirect/educate/intervene as needed., Refer to Mental Health Providers as indicated. Referred to [Psych Services]., Refer to social service as indicated., and Separate away from other resident as needed. Record review of Resident #2's admission Record, dated 06/08/25, reflected an [AGE] year-old male admitted [DATE] with diagnoses to include dementia (loss of cognitive functioning-such as thinking, remembering, and reasoning-to the extent that it interferes with a person's daily life and activities), Alzheimer's disease (most common form of dementia), anxiety (feeling apprehensive, uneasy, or nervous about something), and depressive episodes. Record review of Resident #2's admission MDS assessment, dated 06/30/25, reflected Resident #2 had not exhibited wandering behavior and had a BIMS score of 10/15, indicating moderate impaired cognition. Record review of Resident #2's care plan, undated, reflected Psycho-social/Behavioral Risk: Depressive Episodes, Hx of Childhood Abuse. Loneliness at times., dated 06/26/25 with interventions RISK-BEHAVIORS MONITORING-Calm and re-assure resident/patient is safe. Record review of Resident #3's admission Record, dated 06/10/25, reflected an [AGE] year-old female admitted [DATE] with diagnoses to include major depressive disorder and cognitive communication deficit. Record review of Resident #3's quarterly MDS assessment, dated 05/15/25, reflected Resident #3 had a BIMS score of 6/15, indicating severe impaired cognition. Record review of Resident #3's care plan, undated, reflected I have mood/behavior problems-feels tired, trouble concentrating on things, sad mood/depressed. Record review of Resident #1's Nursing Progress Note, dated 07/05/25 at 08:05 AM and authored by LVN A, reflected During breakfast [Resident #1] was sitting next to [Resident #3] and [Resident #2]. [Resident #3] was talking with [Resident #2] when [Resident #1] became upset and started yelling and cussing at [Resident #2]. Staff attempted to redirected, [Resident #1] then stood up, continuing to yell/cuss. Stating no one in here cares if I'm yelling. I can do what I want, what are you going to do about it. [Resident #1] then pushed [LVN A], and threw lukewarm/cool coffee across staff, [Resident #3] and [Resident #2]. Able to redirect resident to bedroom at this time, while [Resident #1] continued yelling down hallway. [Resident #1] states He is the one that started it by talking to my lady. [Resident #1] assessed. No injuries noted. [Psych] notified and [medications prescribed]. Continue to monitor behaviors. PCP/RN Supervisor/Administrator/DON notified. [Resident #1] consented to medication at this time. Record review of Resident #2's Nursing Progress Note, dated 07/05/25 at 08:05 AM and authored by LVN A, reflected, During breakfast [Resident #2] was sitting at a table with [Resident #3] and [Resident #1]. [Resident #1] became upset and started yelling/cussing at [Resident #2]. Staff attempted to redirect [Resident #1]. [Resident #2] stayed seated, while [Resident #1] continued yelling/cursing, then threw luke warm/cool coffee on [Resident #2]/[Resident #3]/staff. [Resident #2] was redirected to bedroom at this time. Resident #2 was assessed. No injuries noted r/t coffee. [Resident #2] was calm and sitting at bedside. PCP/RN Supervisor/Administrator/DON notified. No new orders. Record review of Resident #3's Nursing Progress Note, dated 07/05/25 at 08:05 AM and authored by LVN A, reflected, During breakfast [Resident #3] was sitting at table with [Resident #1] and [Resident #2]. [Resident #1] became upset with [Resident #2] and started yelling/cussing. Staff attempted to redirect [Resident #1]. [Resident #3] stayed seated in wheelchair, while [Resident #1] continued yelling/cursing, then threw luke warm/cool coffee on [Resident #3]/[Resident #2]/staff. [Resident #3] was redirected to bedroom at this time. [Resident #3 assessed. No injuries noted r/t coffee. [Resident #3] calm and sitting at bedside. PCP/RN Supervisor/Administrator/DON notified. No new orders at this time. RP notified. Interview on 07/10/25 at 10:24 AM, LVN A revealed Resident #3 was a little confused. She revealed Resident #2 was talking to Resident #3 and Resident #2 said to Resident #3: you're talking to Resident #2 now. LVN A revealed Resident #1 was yelling at Resident #2, while Resident #2 and Resident #3 remained quiet. LVN A revealed she moved Resident #2 and Resident #3 away from Resident #1 and told Resident #1 to not yell because he was scaring the residents. She revealed Resident #1 got coffee and while LVN A stood in between Resident #1 and Resident #2 and Resident #3, LVN A revealed Resident #1 pushed her and threw his coffee (the coffee was cool) on Resident #2 and Resident #3. LVN A revealed they had to get their clothes changed. LVN A revealed Resident #1 denied the incident and he always said nothing is his fault. LVN A revealed she interviewed Resident #3 and Resident #3 seemed unaffected because she was still wanting to sit with Resident #1 at mealtimes. LVN A further revealed Resident #1 did not typically behave this way with other residents. Interview on 07/10/25 at 11AM, Resident #1 revealed he liked to try to get along with all the residents, but he felt he made it known with his demeanor for others to not mess with him or he thought so. He revealed sometimes he did yell at others but not unless someone messed with him. He revealed he did not intentionally throw coffee on someone. He revealed he held his cup of coffee and then a staff member grabbed him, which spilled the coffee out of his cup and onto the individuals. Interview on 07/10/25 at 01:35 PM, Resident #2 revealed there was a resident walking around and kissing every girl. He was unable to identify the resident's name. Resident #2 revealed he stopped this resident and then this resident threw coffee on him. He revealed he did not like this and said, how would you like it if someone threw coffee on you? He revealed it was hot coffee (clarified that he felt it was hot to him), but he was okay physically. He revealed he had not seen this resident since this incident but if he saw him, he would get upset. He revealed he did not tell the staff about his feelings. Interview on 07/10/25 at 02:01 PM, Resident #3 revealed she did not recall this incident on 07/05/25, however, she felt safe with Resident #1. Interview on 07/10/25 at 02:22 PM, the DON revealed Resident #1 never had any physical interaction with other residents. She revealed he would have more verbal interactions. Interview on 07/10/25 at 02:50 PM, Social Worker B revealed she interviewed Resident #2 and Resident #3, and they were fine after the 07/05/25 incident. She revealed she interviewed them on the Monday she came back to work (2 days after the incident occurred), because the incident occurred on a Saturday. She revealed Resident #2 did not have a problem with Resident #1 and Resident #3 liked spending time with Resident #1. Interview on 07/10/25 at 03:30 PM, Social Worker C (who was Resident #2's new Social Worker as he moved to the secured unit) revealed she interviewed Resident #2 today and he had to be reminded about the incident on 07/05/25 and that he didn't seem affected by the incident as he said he felt okay after that incident. Interview on 07/11/25 at 11:50 AM, the DON revealed LVN A did not grab Resident #1 during 07/05/25 incident, and the DON revealed she would not allow a staff member grab any resident (as was stated by Resident #1 in his interview) and staff were trained to not grab any resident. Interview 07/11/25 at 11:52 AM, the Psych Doctor revealed Resident #1 did get agitated and had a short fuse (meaning he was quick to react). He revealed Resident #1 had no aggressive behaviors around others and his aggression happened with cause. He revealed he was aware of all incidents involving Resident #1's behaviors so he had been working on improving Resident #1's behaviors and was not just relying on medications. Interview on 07/11/25 at 4:11PM. the ADM revealed she did not think this incident on 07/05/25 was abuse otherwise she would have reported it. She revealed this incident was not reportable per the Long-Term Care Provider Letter. She revealed Resident #1 threw his coffee out of frustration and did not aim it towards any one. Record review of facility policy titled, Abuse Guidance: Preventing, Identifying, and Reporting, revised January 2024, reflected, If anyone harms or threatens to harm a resident/patient, neglect their care, takes their property, or violates their dignity, the resident, has the right to file a complaint. Identification- It is the responsibility of our team members, consultants, attending physicians, family members, visitor, etc. to promptly report any incident of suspected neglect or resident abuse. Reporting/Response- All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies.

Based on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 2 of 8 residents (Resident #2 and Resident #3) reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an incident that occurred on 07/05/2025 in which Resident #1 threw lukewarm coffee, yelled, and cussed at Resident #2 and Resident #3. This incident has still not been reported in TULIP. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included:Record review of Resident #1's admission Record, dated 06/08/25, reflected a [AGE] year-old man admitted [DATE] with diagnoses to include dementia (loss of cognitive functioning-such as thinking, remembering, and reasoning-to the extent that it interferes with a person's daily life and activities) and anxiety disorder (feeling apprehensive, uneasy, or nervous about something). Record review of Resident #1's quarterly MDS assessment, dated 04/22/25, reflected Resident #1 had not exhibited wandering behavior and had a BIMS score of 13/15, indicating intact cognition. Resident #1 did not have physical behavioral symptoms directed toward others. Record review of Resident #1's care plan, undated, reflected At risk for psycho-social issues: emotional distress or behaviors r/t: dementia w/agitation dx, exposure to war. 7/5/25 Resident to staff and resident to resident physical aggression, yelled/cursed out loud, pushed LVN and threw warm/cool coffee at staff and two residents. With interventions 7/5/25- Increased monitoring when in common areas and around other residents. And 7/5/25- Senior Psych Med Intervention., Administer Medications as ordered., Calm and re-assure resident/patient is safe, Keep environment calm, quiet and avoid loud noises as much as possible., Redirect/educate/intervene as needed., Refer to Mental Health Providers as indicated. Referred to [Psych Services]., Refer to social service as indicated., and Separate away from other resident as needed. Record review of Resident #2's admission Record, dated 06/08/25, reflected an [AGE] year-old male admitted [DATE] with diagnoses to include dementia (loss of cognitive functioning-such as thinking, remembering, and reasoning-to the extent that it interferes with a person's daily life and activities), Alzheimer's disease (most common form of dementia), anxiety (feeling apprehensive, uneasy, or nervous about something), and depressive episodes. Record review of Resident #2's admission MDS assessment, dated 06/30/25, reflected Resident #2 had not exhibited wandering behavior and had a BIMS score of 10/15, indicating moderate impaired cognition. Record review of Resident #2's care plan, undated, reflected Psycho-social/Behavioral Risk: Depressive Episodes, Hx of Childhood Abuse. Loneliness at times., dated 06/26/25 with interventions RISK-BEHAVIORS MONITORING-Calm and re-assure resident/patient is safe. Record review of Resident #3's admission Record, dated 06/10/25, reflected an [AGE] year-old female admitted [DATE] with diagnoses to include major depressive disorder and cognitive communication deficit. Record review of Resident #3's quarterly MDS assessment, dated 05/15/25, reflected Resident #3 had a BIMS score of 6/15, indicating severe impaired cognition. Record review of Resident #3's care plan, undated, reflected I have mood/behavior problems-feels tired, trouble concentrating on things, sad mood/depressed. Record review of Resident #1's Nursing Progress Note, dated 07/05/25 at 08:05 AM and authored by LVN A, reflected During breakfast [Resident #1] was sitting next to [Resident #3] and [Resident #2]. [Resident #3] was talking with [Resident #2] when [Resident #1] became upset and started yelling and cussing at [Resident #2]. Staff attempted to redirected, [Resident #1] then stood up, continuing to yell/cuss. Stating no one in here cares if I'm yelling. I can do what I want, what are you going to do about it. [Resident #1] then pushed [LVN A], and threw lukewarm/cool coffee across staff, [Resident #3] and [Resident #2]. Able to redirect resident to bedroom at this time, while [Resident #1] continued yelling down hallway. [Resident #1] states He is the one that started it by talking to my lady. [Resident #1] assessed. No injuries noted. [Psych] notified and [medications prescribed]. Continue to monitor behaviors. PCP/RN Supervisor/Administrator/DON notified. [Resident #1] consented to medication at this time. Record review of Resident #2's Nursing Progress Note, dated 07/05/25 at 08:05 AM and authored by LVN A, reflected, During breakfast [Resident #2] was sitting at a table with [Resident #3] and [Resident #1]. [Resident #1] became upset and started yelling/cussing at [Resident #2]. Staff attempted to redirect [Resident #1]. [Resident #2] stayed seated, while [Resident #1] continued yelling/cursing, then threw luke warm/cool coffee on [Resident #2]/[Resident #3]/staff. [Resident #2] was redirected to bedroom at this time. Resident #2 was assessed. No injuries noted r/t coffee. [Resident #2] was calm and sitting at bedside. PCP/RN Supervisor/Administrator/DON notified. No new orders. Record review of Resident #3's Nursing Progress Note, dated 07/05/25 at 08:05 AM and authored by LVN A, reflected, During breakfast [Resident #3] was sitting at table with [Resident #1] and [Resident #2]. [Resident #1] became upset with [Resident #2] and started yelling/cussing. Staff attempted to redirect [Resident #1]. [Resident #3] stayed seated in wheelchair, while [Resident #1] continued yelling/cursing, then threw luke warm/cool coffee on [Resident #3]/[Resident #2]/staff. [Resident #3] was redirected to bedroom at this time. [Resident #3 assessed. No injuries noted r/t coffee. [Resident #3] calm and sitting at bedside. PCP/RN Supervisor/Administrator/DON notified. No new orders at this time. RP notified. Interview on 07/10/25 at 10:24 AM, LVN A revealed Resident #3 was a little confused. She revealed Resident #2 was talking to Resident #3 and Resident #2 said to Resident #3: you're talking to Resident #2 now. LVN A revealed Resident #1 was yelling at Resident #2, while Resident #2 and Resident #3 remained quiet. LVN A revealed she moved Resident #2 and Resident #3 away from Resident #1 and told Resident #1 to not yell because he was scaring the residents. She revealed Resident #1 got coffee and while LVN A stood in between Resident #1 and Resident #2 and Resident #3, LVN A revealed Resident #1 pushed her and threw his coffee (the coffee was cool) on Resident #2 and Resident #3. LVN A revealed they had to get their clothes changed. LVN A revealed Resident #1 denied the incident and he always said nothing is his fault. LVN A revealed she interviewed Resident #3 and Resident #3 seemed unaffected because she was still wanting to sit with Resident #1 at mealtimes. LVN A further revealed Resident #1 did not typically behave this way with other residents. Interview on 07/10/25 at 11AM, Resident #1 revealed he liked to try to get along with all the residents, but he felt he made it known with his demeanor for others to not mess with him or he thought so. He revealed sometimes he did yell at others but not unless someone messed with him. He revealed he did not intentionally throw coffee on someone. He revealed he held his cup of coffee and then a staff member grabbed him, which spilled the coffee out of his cup and onto the individuals. Interview on 07/10/25 at 01:35 PM, Resident #2 revealed there was a resident walking around and kissing every girl. He was unable to identify the resident's name. Resident #2 revealed he stopped this resident and then this resident threw coffee on him. He revealed he did not like this and said, how would you like it if someone threw coffee on you? He revealed it was hot coffee (clarified that he felt it was hot to him), but he was okay physically. He revealed he had not seen this resident since this incident but if he saw him, he would get upset. He revealed he did not tell the staff about his feelings. Interview on 07/10/25 at 02:01 PM, Resident #3 revealed she did not recall this incident on 07/05/25, however, she felt safe with Resident #1. Interview on 07/10/25 at 02:22 PM, the DON revealed Resident #1 never had any physical interaction with other residents. She revealed he would have more verbal interactions. Interview on 07/10/25 at 02:50 PM, Social Worker B revealed she interviewed Resident #2 and Resident #3, and they were fine after the 07/05/25 incident. She revealed she interviewed them on the Monday she came back to work (2 days after the incident occurred), because the incident occurred on a Saturday. She revealed Resident #2 did not have a problem with Resident #1 and Resident #3 liked spending time with Resident #1. Interview on 07/10/25 at 03:30 PM, Social Worker C (who was Resident #2's new Social Worker as he moved to the secured unit) revealed she interviewed Resident #2 today and he had to be reminded about the incident on 07/05/25 and that he didn't seem affected by the incident as he said he felt okay after that incident. Interview on 07/11/25 at 11:50 AM, the DON revealed LVN A did not grab Resident #1 during 07/05/25 incident, and the DON revealed she would not allow a staff member grab any resident (as was stated by Resident #1 in his interview) and staff were trained to not grab any resident. Interview 07/11/25 at 11:52 AM, the Psych Doctor revealed Resident #1 did get agitated and had a short fuse (meaning he was quick to react). He revealed Resident #1 had no aggressive behaviors around others and his aggression happened with cause. He revealed he was aware of all incidents involving Resident #1's behaviors so he had been working on improving Resident #1's behaviors and was not just relying on medications. Interview on 07/11/25 at 4:11PM. the ADM revealed she did not think this incident on 07/05/25 was abuse otherwise she would have reported it. She revealed this incident was not reportable per the Long-Term Care Provider Letter. She revealed Resident #1 threw his coffee out of frustration and did not aim it towards any one. Record review of TULIP did not reflect a facility reported incident that corresponded to the allegations in the incident described above. Record review of facility policy titled, Abuse Guidance: Preventing, Identifying, and Reporting, revised January 2024, reflected, If anyone harms or threatens to harm a resident/patient, neglect their care, takes their property, or violates their dignity, the resident, has the right to file a complaint. Identification- It is the responsibility of our team members, consultants, attending physicians, family members, visitor, etc. to promptly report any incident of suspected neglect or resident abuse. Reporting/Response- All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies.

Based on observations, interviews, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 residents (Residents #23, #90 and #135), reviewed for infection control. 1. The facility failed to implement contact precautions for Resident #23 after it was ordered by the physician. 2. The facility failed to ensure proper infection control practices during wound care for Resident #23, when LVN D did not change gloves or sanitize their hands after cleansing the resident's wound, and before picking up and placing a new dressing on the resident's wound. 3. The facility failed to use proper infection control practices during medication administration for Resident #90, when MA G grabbed the cup of water with a pinching movement between her thumb and forefinger, with her forefinger inside the cup, thumb on outside of cup and her hand resting on the top lip of the cup to take it into the resident's room. 4. The facility failed to ensure proper infection control practices during supervised self-medication administration of eyedrops for Resident #135, MA C failed instruct the resident to sanitize their hands prior to self-applying the eyedrops, and failed to observe the resident as they self-applied eyedrops and then proceeded to wipe excess medication that had leaked down the resident's face with both hands and used their soiled hands to replace the cap on the bottle of eyedrops. These deficient practices could place residents at risk for infection and decline in health. Findings included: 1. Record review of Resident #23's face sheet dated 01/08/2025 revealed she was a [AGE] year-old woman who was admitted on [DATE] with diagnoses which included: Dementia (a general term for loss of memory, language, problem-solving and other thinking ability severe enough to interfere with daily life), Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar), and Resistance to Vancomycin related antibiotics. Record review of Resident #23's Quarterly MDS, dated [DATE], revealed a BIMS score of 08, indicating moderate cognitive impairment. Record review of Resident #23's Order Summary, dated 01/08/2025, revealed orders for: - Contact isolation precautions: Isolate in place required in which all care, therapy and other services are provided in room r/t an active infection dated 01/07/2025. - Tx [treatment] to right lateral foot Cleanse with normal saline, pat dry. Apply 10% iodine solution to wound bed. Cover with 4x4 gauze and abd pad, wrap with kerlix, secure with tape or ace wrap. Wrap foot with moisture wicking pad and apply heel protector. Change twice daily and as needed. Observation on 01/08/2025 at 11:32 a.m. revealed Resident #23 was sitting in her wheelchair in the day room watching TV, with 2 other residents sitting on both sides of her. Further observation of the outside of Resident #23's room revealed an Enhanced Barrier Precautions sign on the wall to the right of the door, and a yellow Contact Isolation Sign posted on the front of her door. The door was in the open position and the Contact Isolation sign was not immediately visible when looking straight at the room. There was PPE supply available outside the door. During an Interview with LVN E on 01/08/2025 at 11:41 a.m., LVN E stated she was not aware of the order for Contact Isolation for Resident #23, and immediately checked to verify. LVN E stated Resident #23 had a wound on her foot and therefore had been on Enhanced Barrier Precautions but was not aware of the change in orders to Contact Isolation. LVN E stated that the order for contact isolation was not provided to her during shift change this morning and was not included in the 24-hour report. LVN E stated Resident #23 should not be in the day room in close contact with other residents while under contact isolation, and immediately asked one of the CNA's to assist Resident #23 back into her room. LVN E stated that not implementing and following contact isolation procedures when ordered could result in spread of infection. During an interview with LVN F on 01/08/2025 at 11:46 a.m., LVN F stated he was the Infection Control Nurse and confirmed the order for Contact Isolation for Resident #23 was given the day before (01/07/2025) due to an MDRO (multi-drug resistant organism) found in Resident #23's urine culture. LVN F stated he verbally told the Nurse on duty yesterday about the order for Contact Isolation for Resident #23 and placed the contact isolation sign on her door. LVN F stated he did not know why that information was not passed to the next shift and stated it should have been put it on the 24-hour report as well. LVN F stated that not implementing Contact Isolation procedures when ordered could result in spread of infection and noted that the Enhanced Barrier Precautions sign should have been removed when Resident #23 was placed on contact isolation, as having both the EBP sign and Contact Isolation sign up could be confusing for staff. Observation of wound care for Resident #23 on 01/09/2025 starting at 11:54 a.m. revealed LVN D cleansed the wound on the right lateral foot with saline, patted dry with gauze, and then without changing gloves and sanitizing hands, picked up and placed a new clean gauze padding covered with Betadine on top of the wound, and completed wrapping as per physician order. During an interview with LVN D on 01/09/2025 at 12:10 p.m., LVN D stated yea, I guess I should have when asked if she should have changed her gloves and sanitized her hands after cleansing the wound, and before picking up and applying clean dressing to wound. LVN D stated gloves should be changed whenever going from dirty to clean. LVN D stated that by not changing her gloves and sanitizing in between cleaning the wound and placing a clean dressing, it could spread infection. Record review of the Licensed Nurse Competencies Checklist dated 02/19/2024 for LVN D revealed she was checked off as being competent in demonstrates understanding and competency of Dressing Change Clean & Sterile. 2. Record review of Resident #90's face sheet dated 01/10/2025 revealed he was an [AGE] year-old man, admitted [DATE] with diagnoses which included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions); Parkinsonism (movement disorder), and Diabetes Mellitus Type 2 (a long-term condition in which the body has trouble controlling blood sugar). Record review of Resident #90's MDS Quarterly dated 11/06/2024 revealed a BIMS score of 03, indicating severe cognitive impairment. Observation on 01/09/2025 at 07:37 a.m. of Resident #90's medication pass, revealed MA G, while preparing medications for Resident #90, filled a plastic cup with water. MA G then grabbed the cup of water with a pinching movement between her thumb and forefinger, with her forefinger inside the cup, thumb on outside of cup and her hand resting on the top lip of the cup to take it into the resident's room. During an interview with MA G on 01/09/2025 at 09:29 a.m., MA G stated she should not have touched the inside or top lip of the water cup with her hands/finger for Resident #90, as this could result in cross-contamination. MA G stated she knew better, and has received training in infection control, but just forgot while trying to carry all the medications and supplies into Resident #90's room at the same time. During an interview with the DON on 01/10/2025 at 01:56 p.m., the DON stated staff should not touch the inside or lip of resident's drinking cups as this could lead to cross contamination. The DON stated MA G has received training in infection control. Record review of MA G's Competency Checklist dated 01/10/2024 revealed she was checked off as meeting competency in infection control. 3. Record review of Resident #135's face sheet dated 01/09/2025 revealed he was a [AGE] year old man with an admitted [DATE] and diagnoses which included: Asthma (condition where airways swell, causing extra mucus, making it difficult to breathe), abnormalities of gait and mobility, and chronic allergic conjunctivitis (infection of the outer membrane of the eyeball and inner eyelid). Record review of Resident #135's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Record review of Resident #135's Care Plan initiated 08/22/2024 revealed focus areas which included: - At risk for infection or recurrent/chronic infection r/t compromised medical condition: 9/24/24: Conjunctivitis (infection of the outer membrane of the eyeball and inner lid) and 01/07/2025: Conjunctivitis; and - I am at risk for vision loss/impairment: Conjunctivitis - 11/20/2024. Record review of Resident #135's order summary dated 01/09/2025 revealed an order for Ciprofloxacin HCL Ophthalmic Solution 0.3% instill 2 drops in both eyes two times a day for conjunctivitis for 7 days supervised self-administration with a start date of 01/07/2025. Record review of Resident #135's Self-Administration of Medication assessment dated [DATE] revealed Resident #135 was checked as having basic competency to identify his medications, state what the medication was used for and to administer eye drops or eye ointments with Approval by IDT for self-administration of medications. Observation on 01/09/2025 at 08:13 a.m. of Resident #135's medication administration pass by MA C revealed MA C administered all of Resident #135's oral medications to him, however, she provided the container of Ciprofloxacin HCL Ophthalmic Solution 0.3% directly to Resident #135 for him to self-administer, noting he wanted to administer his own eye drops. Resident #135 was not prompted by MA C to wash or sanitize his hands prior to administration of the eye drops and was observed to administer the drops in his eyes, resulting in excess fluid running down his cheeks from both eyes. Resident #135 was then observed to wipe the excess fluid off his cheeks with both hands. He then grabbed the bottle of Ciprofloxacin with the same hand that had wiped off excess fluid from his eyes and handed it back to MA C, who replaced the bottle of Ciprofloxacin into its box container and then into the medication cart, without cleaning the outside of the bottle, or prompting Resident #135 to wash his hands. Interview on 01/10/2025 at 11:40 p.m. with the DON revealed that the expectation for supervised self-administration of medication was that the Nurse or Medication Aide would observe the self-administration to ensure the correct number of drops and correct technique was used by the resident, including infection control procedures such as hand washing. If correct procedure or infection control procedure was not followed by the resident, she would expect the supervising medication aide to intervene and educate the resident on correct procedure. The DON stated that by not having the resident wash his hands prior to and after administration of eyedrops and after touching the excess fluid from his eyes could result in cross contamination, leading to further incidents of conjunctivitis. The DON further stated the Medication Aide should have sanitized the outside of the Ciprofloxacin bottle after the resident had grabbed it with hands that had wiped fluid from his eyes, to prevent spread of infection. Record review of CDC Guidelines at https://www.cdc.gov/conjunctivitis/prevention/index.html, dated 04/15/2024 for prevention of conjunctivitis revealed recommendations which included: 1) Wash your hands before and after cleaning or applying eye drops or ointment to your infected eye; 2) If soap and water are not available, use an alcohol-based hand sanitizer that contains at least 60% alcohol to clean hands: 3) Avoid touching or rubbing your eyes with your fingers; 4) With clean hands, wash any discharge from around your eyes several times a day using a clean, wet washcloth or fresh cotton ball - throw away cotton balls after use and wash used washcloths with hot water and detergent then wash your hands again. Record review of facility policy titled Infection Prevention and Control revised April 2024 revealed under section titled Important facets of infection prevention include: .implementing appropriate isolation precautions when necessary. Continued review revealed Contact Precautions may be implemented for a resident known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surface or patient-care items in the resident's environment. Under section Implementation of Isolation and/or Precautions: Post clear signage .on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g. gown and gloves).

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 1 of 32 residents (Resident #50) reviewed for care plans, in that: The facility failed to update Resident #50's comprehensive care plan to remove the focus area indicating the resident smoked tobacco. This failure could affect residents who have care areas not addressed by the care plans by not having their needs met and putting them at risk of not receiving appropriate care. The findings included: Record review of Resident #50's face sheet, dated 01/10/2025, revealed an admitted [DATE] with diagnoses that included hyperlipidemia (a condition where the blood has too many fats such as cholesterol or triglycerides), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone), anxiety disorder (intense, excessive and persistent worry and fear about everyday situations) and post-traumatic stress disorder (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of Resident #50's quarterly MDS dated [DATE] revealed a BIMS of 15, which indicated the resident was cognitively intact. Record review of Resident #50's comprehensive care plan dated 11/29/2024, revealed a focus are stating, I am a smoker (vapor cigarette) and also dip tobacco. The goal was for the resident to be allowed to smoke safely and independently and interventions included several safe smoking procedures. During an interview on 01/10/2024 at 1:55, the DON stated Resident #50 had quit smoking a while ago and the focus area of smoking in the comprehensive care plan should have been updated to indicate he used dip tobacco but did not smoke or use a vape cigarette. She had seen the resident use smokeless tobacco in the smoking area of the facility. The MDS LVN was responsible for updating care plans. During an interview on 01/10/2025 at 2:07, RN H stated comprehensive care plans were updated every three months or as needed. She had received training from the facility's previous MDS coordinator and the corporate MDS coordinator. She should have removed the smoking part of the focus area of Resident #50's care plan; she had only seen the section indicating he used dip tobacco and missed it. It was important to update the comprehensive care plan to ensure it reflected all the resident's health conditions for the provision of proper care. During an interview on 01/10/2025 at 2:45 PM, RN I stated the facility used the RAI manual as their policy for MDS and Care plan updating. Staff had the manual available digitally.

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 32 residents (Resident #50) whose assessments were reviewed: Resident #50's use of tobacco was not identified on the resident's annual MDS assessment with an ARD of 02/23/2024. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings were: Record review of Resident #50's face sheet, dated 01/10/2025, revealed an admitted [DATE] with diagnoses that included hyperlipidemia (a condition where the blood has too many fats such as cholesterol or triglycerides), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone), anxiety disorder (intense, excessive and persistent worry and fear about everyday situations) and post-traumatic stress disorder (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of Resident #50's comprehensive care plan dated 11/29/2024 revealed a focus are stating, I am a smoker (vapor cigarette) and also dip tobacco. The goal was for the resident to be allowed to smoke safely and independently and interventions included several safe smoking procedures. Record review of Resident #50's Annual MDS dated [DATE] revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Section J - Health Conditions, J1300. Current Tobacco Use, revealed Code 0 was checked (0 indicated No). During an interview on 01/10/2025 at 2:15 PM, RN H stated Resident #50's annual MDS with an ARD of 02/23/2024 was coded incorrectly in Section J, as it indicated the resident did not use tobacco when Resident #50 used dip tobacco regularly. She was responsible for completing the MDS and the error was an oversight, since the resident had once used a vape cigarette and quit that method of tobacco use two years prior. She had been in the position for approximately 18 months and had been trained by her predecessor and the corporate MDS coordinator. It was important to complete the assessment accurately to ensure it captured all the resident's health conditions for the provision of proper care. During an interview on 01/10/2025 at 2:30 PM, the DON she stated she had seen Resident #50 use smokeless tobacco in the smoking area of the facility, and she was unaware his annual assessment did not reflect his use of tobacco. During an interview on 01/10/2025 at 2:45 PM, RN I stated the facility used the RAI manual as their policy for MDS and Care plan updating. Staff had the manual available digitally. Record review of the CMS RAI Version 3.0 Manual J1300 Current Tobacco Use revealed, Coding Instructions: Code 0, no: if there are no indications that the resident used any form of tobacco. Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (Resident #13) reviewed for incontinent care. The facility failed to ensure CNA A and CNA B thoroughly cleaned Resident #13 while providing incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #13's face sheet, dated 01/09/2025, revealed an admitted [DATE], with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood), Hypothyroidism (under active thyroid), Hypertension (High blood pressure), Chronic kidney disease (gradual loss of kidney function) and, Guillain-Barre syndrome (condition in which the body's immune system attacks the nerves. It can cause weakness, numbness or paralysis). Record review of Resident #13's Quarterly MDS assessment, dated 12/19/2024, revealed Resident #13 had a BIMS score of 12, which indicated mild to moderate cognitive impairment. Further review revealed Resident #13 required extensive assistance to total care with ADLs and was indicated to frequently be incontinent of bladder and bowel. Record review of Resident #13's care plan, dated 12/12/2024, revealed a problem of At risk for infection or recurrent/chronic infection related to compromised medical condition, with a goal of I will not experience any complications or adverse reactions throughout the course of treatment and the illness/infection will resolve. Observation on 01/09/25 at 10:44 a.m. revealed, while providing incontinent care for Resident #13, CNA A did not clean between the labia of the resident and did not clean the urinary meatus (urinary opening). Further observation revealed, while being turned on her side, the resident urinated and CNA A and CNA B did not clean her genital area a second time before placing a clean brief on the resident. During an interview on 01/09/2025 at 10:55 a.m. CNA A and CNA B stated she did not clean between the resident's labia because she did not want to be too invasive. CNA B stated she should have cleaned the urinary opening. The two CNAs confirmed not cleaning the resident a second time after she urinated. They had no explanation. CNA A stated she had received training for infection control and incontinent care within the last year from the RN in charge of infection control. During an interview with the DON on 01/09/2025 at 3:45 p.m., the DON stated the urinary meatus area had to be cleaned. The DON stated the staff should have cleaned the resident a second time if she had urinated after being cleaned. The DON stated the infection preventionist was responsible for training the staff in infection control and incontinent care and that performance skills checks were completed annually and as needed by the ADON, the Infection Preventionist and herself. Record review of facility policy, titled Competency Assessment Perineal Care , February 2018, revealed [ .] Separate labia and wash are downward from front to back.

Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions for 1 of 6 medication carts (Hall 500 Medication Aide carts) reviewed for medication labeling and storage. The facility failed to ensure a bottle of Ciprofloxacin 0.3% ophthalmological solution for Resident #135, which had been previously opened was labeled with an open date. This failure could place residents at risk of receiving expired medications. Findings included: Record review of Resident #135's face sheet dated 01/09/2025 revealed he was a [AGE] year old man with an admitted [DATE] and diagnosis which included: Asthma (condition where airways swell, causing extra mucus, making it difficult to breathe), abnormalities of gait and mobility, and chronic allergic conjunctivitis (infection of the outer membrane of the eyeball and inner eyelid). Record review of Resident #135's order summary dated 01/09/2025 revealed an order for Ciprofloxacin HCL Ophthalmic Solution 0.3% instill 2 drop in both eyes two times a day for conjunctivitis for 7 days supervised self-administration. Observation on 01/09/2025 at 8:13 a.m. of the Hall 500 Medication Aide cart revealed one opened bottle of Ciprofloxacin 0.3% Ophthalmological solution labeled with Resident #135's name, but without an open date written on the bottle. During an interview with MA C on 01/09/2025 at 08:32 a.m., MA C confirmed there was no open date written on the bottle of Ciprofloxacin eye drops for Resident #135, and that it had been previously opened. MA C noted the fill date on the pharmacy label showed the medication was filled on 01/07/2025, and that eye medications were good for 30 days after opening, so the eye drops could not be expired. However, MA C further stated that each medication should be marked with an open date, so that Nurse's will know when the medication does expire. MA C stated that it was the responsibility of the Nurse who opened the medication to label the medication with the open date. Interview on 01/10/2025 at 11:40 p.m. with the DON revealed that the expectation was for all Nurse's and Medication Aides to label each medication with its open date, since medications such as eye drops, were good for only 30 days past the open date, and without an open date, nurse's could not determine the expiration date of the medication. The DON noted that some eye medications could start to lose effectiveness 30 days after opening. Record review of the facility policy titled Pharmacy Services revised January 2023 revealed Medications and biologicals are labeled in accordance with currently accepted professional standards and with local and state drug-labeling regulations and The critical elements of the drug label include: .expiration dates.

Based on observation, interview and record review, the facility to ensure that the residents had the right to and that the facility promoted and facilitated resident self-determination through support of resident choice for 1 of 1 resident (Resident #61) whose care was reviewed, in that: Resident #61's preference was to have a shower on the shower bed instead of a bed bath but the resident did not receive showers because the shower bed was damaged. This deficient practice could place residents with the ability to make choices at risk of having their rights violated, diminished quality of life and unmet needs. The finding were: Record review of Resident #61's face sheet, dated 12/15/2023, revealed the resident was initially admitted on [DATE] and readmitted on [DATE], with diagnoses that included: Quadriplegia, C1-C4 incomplete, acute kidney failure, major depressive disorder, recurrent; insomnia, colostomy status, dry eye syndrome. Record review of Resident #61's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Interview on 12/13/2023 at 3:45 PM with Resident #61 stated he had received bed baths for his last 5 scheduled showers and possibly more. Resident #61 stated the shower schedule he had been given was every Tuesday, Thursday and Saturday. Resident #61 stated CNA C told him the shower bed was broken therefore the resident would be given a bed bath. The resident stated he supposed to get a shower as that was his preference and he had made that known to the facility staff. Resident #61 stated, if I do not get a shower I itch all over and the only part of my body I can really move are my hands from the neck down due to my condition, I asked [CNA C] when the shower bed was going to be fixed and she said she did not know she had reported it to the nurse but that nurse does not work here anymore; I need showers and not bed baths, I do not want to itch all over, my skin stays dry and I will get sores that I can't scratch because my condition does not allow me to scratch. Observation and interview on 12/14/2023 at 4:25 PM with CNA C stated the CNA had given Resident #61 a bed bath for the last 5 scheduled shower times as Resident #61 had stated. CNA C stated the shower bed had been broken and walked to the shower room for an observation of the shower bed. CNA C said, He does prefer a bed on the shower bed but the gurney is torn and that could hurt him if we put him on it the way it does now because it is not safe for him to use. He does have a shower chair but I cannot use that with him safely either and he prefers the shower bed. CNA C stated she had reported the shower bed as broken to her charge nurse at the time and she was sure the nurse put the information in the facility work order database. CNA C stated, CNAs do not put work orders in the facility work order database. Interview with the DON on 12/20/2023 at 4:41 PM, the DON stated they were aware Resident #61's preferred a shower and not a bed bath. The DON stated, Resident #61 should get a shower, I am not aware of any shower bed being broken. He is a reliable reporter and if he said he did not get a shower than he didn't. I don't know of any skin condition he has but I can understand him not being able to scratch himself being frustrating. The DON further stated Resident #61 should have gotten a shower if that was what he wanted because it was his preference. Interview with the MS on 12/14/2023 at 5:05 PM, the MS stated he did not have any reports of a shower bed in the facility being broken currently through the facility work order database or through verbal report. The MS stated if he would have known he would have purchased a new one. The MS stated in this case the equipment was not working so the resident did not get what they wanted and the residents should. Interview with the Administrator on 12/14/2023 at 5:30 PM, the Administrator stated she was unaware of any shower beds in the facility being broken or any resident not receiving their preferred method of a bath or shower. The Administrator stated all work orders or requests were put in through the facility work order database, there was no policy for the use of the facility work order database, it was the system they used to track needed services and/or equipment. The Administrator further stated the, Maintenance Supervisor and I have run reports to see if the broken shower bed had been reported by any nurse and we could not find where it had been, in this case I think the nurse who no longer works here may have just forgotten to put it in, she could have told someone but we have not been able to identify any maintenance staff that were aware of a broken shower bed in the facility at this time. The Administrator further stated that in this case Resident #61 did not receive his preferred method of bathing and should have because it was his right. Record review of the facility's policy titled, Statement of Resident Rights, revised 10/2022, revealed, Resident/Patient Rights include: 1. To all care necessary for them to have the highest possible level of health; 4. To be treated with courtesy, consideration and respect.

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 15 of 143 Residents ( Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 11, 13, 16, 19, 20 and 31) observed for infection control, in that: 1. The facility failed to have structures in place which included an infection control and prevention program to prevent the transmission of COVID-19 for 15 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #13, #16, #20) and nine staff members (CNA A, CNA B, CNA C, CNA D, LVN E, Dietary Aide F, LVN G, CNA OO and LVN XX). 2. The facility failed to separate residents who were identified as being positive for COVID-19 from the rest of the resident population and were using the same staff to provide direct patient care. 3. The facility failed to follow CDC guidelines on screening for COVID-19 and restrict visitors into the facility. 4. Staff did not wear appropriate PPE when entering a positive COVID-19 resident room or a presumptive positive room under isolation precautions. 5. The facility failed to establish infection control precautions for laundry services. 6. The facility stored new PPE including masks and gowns in the same closet as COVID-19 positive residents personal belongings. 7. The facility failed to implement CDC guidelines for social distancing residents in the memory care unit. 8. LVN VV assessed Resident #31 (quarantined resident) vital sign and failed to clean the stethoscope, blood pressure cuff or thermometer afterwards. LVN cleaned the pulse oximeter with an alcohol wipe instead of a disinfectant wipe. 9. ST FFF did not sanitize her hands or change her gloves after having contact with her own facemask and contact between two residents. 10. CNA TT touched residents food with bare hands and did not sanitize hands between resident contact. These failures resulted in identification of Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place to ensure residents were being monitored and assessed for signs and symptoms of COVID-19. These deficient practices could affect residents at the facility and place them at risk of infection from transmission of communicable diseases and result in a decline in health and/or death. The findings were: Record review of facility's policy (undated) titled Plan for Residents admitted or readmitted and Existing Resident during COVID 19 Pandemic read Planning: The COVID -19 infection control guidance developed by the Centers for Disease Control and Prevention (CDC) recommends the use of standard, contract and airborne precautions, including eye protection. The intent of the community plan should be able to maintain infection control practices to prevent the spread of infection .3. Isolate and evaluate admitted , readmitted or Existing residents who present with signs symptoms: e. restrict the number of team members permitted to enter the room, ALL team members who enter the room must adhere to the following: i. Standard precautions (gloves) ii. Contact precautions (gowns) iii. (goggles or face shield) iv. Airborne precautions (e.g. N95 mask or face mask) Evaluate and assess the resident: i. every shift temperature checks. ii. every shift pulse ox and record. iii every shift heart rate and record. iv. every shift evaluation of respiratory signs and symptoms. v. daily physical and respiratory assessment by a licensed nurse. Record review of facility's policy on Infection Control, Standard Precautions dated 2011 read Standard Precautions will be used in the care of all residents regardless of their [DIAGNOSES REDACTED]. Record review of a CMS letter titled, COVID-19 Long-Term Care Facility Guidance, dated [DATE], revealed: To provide critical, needed leadership for the Nation's long-term care facilities to prevent further spread of COVID-19, CMS and CDC are now recommending the following immediate actions to keep patients and residents safe: 1. Nursing Homes should immediately ensure they are complying with all CMS and CDC guidance related to Infection Control. 3. Long-term care facilities should immediately implement symptom screening for all. In accordance with previous CMS guidance, every individual regardless of reason entering a long-term care facility (including residents, staff, visitors, outside healthcare workers, vendors, etc) should be asked about COVID-19 symptoms and they must also have their temperature checked. 4. Long-term care facilities should ensure all staff are using appropriate PPE when they are interacting with patients and residents, to the extent PPE is available and per CDC guidance on conservation of PPE. For the duration of the state of emergency in their state, all long-term care facility personnel should wear a facemask while they are in the facility. Full PPE should be worn per per CDC guidelines for the care of any resident with known or suspected COVID-19 .If COVID-19 transmission occurs in the facility, healthcare personnel should wear full PPE for the care of all residents irrespective of COVID-19 [DIAGNOSES REDACTED]. 5. To avoid transmission within long-term care facilities, facilities should use separate staffing teams for COVID-19 positive residents to the best of their ability and work with State and local leaders to designate separate facilities or units within a facility to separate COVID-19 negative residents from COVID-19 positive residents and individuals with unknown COVID-19 status. 1. Record review of Resident #1- #11, #13, #16 and #20 clinical records revealed: Record review of a Provider Investigative Report, dated [DATE], revealed eight residents (Residents #1, 2, 3, 4, 5, 6, 7, and 8) had tested positive for COVID-19. Resident #1 had expired at the hospital on [DATE] and Resident's #2, 3, 4, and 6 were hospitalized . Residents #5, 7, and 8 were asymptomatic and remained at the facility. The facility reported 2 staff members had tested positive and the facility was working with the health department to identify an exposure point. Further review revealed 100% of the residents were tested for COVID-19 with testing pending and the facility was working with the health department for testing for staff members. Record review of Resident #1's face sheet dated [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review of the face sheet revealed Resident #1 was discharged from the facility on [DATE] and expired at the hospital on [DATE]. Record review of Resident #1's COVID-19 laboratory test,0 dated [DATE] and reported to the facility on [DATE] revealed the test was positive for [DIAGNOSES REDACTED]-CoV-2. Record review of Resident #1's Annual MDS dated [DATE] revealed a BIMS of 15 which indicated the resident was cognitively intact. Record review of Resident #1's Care Plan revealed Potential for alterations in well-being: Resident is at risk for infection and emotional distress related to measures in place to minimize exposure and associated risks COVID-19 and Influenza started on [DATE] with interventions which included: monitor vital signs and health condition, notify PCP and RP of any change of condition as clinically indicated and observe isolation precautions as clinically indicated. On [DATE] HHSC received a facility self-report from the facility Administrator which revealed the facility had been notified by a local hospital that Resident #1 had tested positive for COVID-19. Further review of the self-report revealed the facility had increased monitoring of resident vital signs and increased team surveillance checks. Staff was re-educated on infection control and use of masks. The facility reported an increase in sanitization of areas to every 2 hours. Record review of Resident #2's face sheet, dated [DATE] revealed an admission date of [DATE] with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Further review revealed Resident #2 was discharged to the hospital on [DATE]. Record review of Resident #2's Annual MDS dated [DATE] revealed a BIMS score of 14 which indicated the resident was cognitively intact. Record review of Resident #2's Care Plan revealed Potential for alterations in well-being: Resident is at risk for infection and emotional distress related to measures in place to minimize exposure and associated risks COVID-19 and Influenza started on [DATE] with interventions which included: monitor vital signs and health condition, notify PCP and RP of any change of condition as clinically indicated and observe isolation precautions as clinically indicated. Record review of Resident #2's progress note dated [DATE] revealed family notified facility Resident #2 was diagnosed with [REDACTED]. Record review of Resident #3's face sheet dated [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review of Resident #3's face sheet revealed the resident was discharged to the hospital on [DATE]. Record review of Resident #3's COVID-19 laboratory test dated [DATE] and reported to the facility on [DATE] was positive for COVID-19. Record review of Resident #3's Quarterly MDS dated [DATE] revealed a BIMS of 7, which indicated a severe cognitive impairment. Record review of Resident #3's Care Plan revealed Potential for alterations in well-being: Resident is at risk for infection and emotional distress related to measures in place to minimize exposure and associated risks COVID-19 and Influenza started on [DATE] with interventions which included: monitor vital signs and health condition, notify PCP and RP of any change of condition as clinically indicated and observe isolation precautions as clinically indicated. Record review of Resident #4's face sheet dated [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review revealed Resident #4 was discharged to the hospital on [DATE] and later expired at the hospital. Record review of Resident #4's Admission MDS dated [DATE] revealed a BIMS score of 12, which indicated a moderate cognitive impairment. Record review of Resident #4's Care Plan revealed Potential for alterations in well-being: Resident is at risk for infection and emotional distress related to measures in place to minimize exposure and associated risks COVID-19 and Influenza started on [DATE] with interventions which included: monitor vital signs and health condition, notify PCP and RP of any change of condition as clinically indicated and observe isolation precautions as clinically indicated. Record review of Resident #5's face sheet dated [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's COVID-19 laboratory test dated [DATE] and reported to the facility on [DATE] revealed the Resident was positive for COVID-19. Record review of Resident #5's Quarterly MDS dated [DATE] revealed a BIMS score of 9, which indicated a moderate cognitive impairment. Record review of Resident #5's Care Plan revealed Potential for alterations in well-being: Resident is at risk for infection and emotional distress related to measures in place to minimize exposure and associated risks COVID-19 and Influenza started on [DATE] with interventions which included: monitor vital signs and health condition, notify PCP and RP of any change of condition as clinically indicated and observe isolation precautions as clinically indicated. Record review of Resident #6's face sheet dated [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review revealed Resident #6 was discharged to the hospital on [DATE]. Record review of Resident #6's COVID-19 laboratory test dated [DATE] and reported to the facility on [DATE] revealed the resident was positive for COVID-19. Record review of Resident #6's Annual MDS dated [DATE] revealed a BIMS of 15, which indicated the resident was cognitively intact. Record review of Resident #6's Care Plan revealed Potential for alterations in well-being: Resident is at risk for infection and emotional distress related to measures in place to minimize exposure and associated risks COVID-19 and Influenza started on [DATE] with interventions which included: monitor vital signs and health condition, notify PCP and RP of any change of condition as clinically indicated and observe isolation precautions as clinically indicated. Record review of Resident #7's face sheet, dated [DATE], revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #7's COVID-19 laboratory results dated [DATE] and reported to the facility on [DATE] revealed the resident was positive for COVID-19. Record review of Resident #7's Quarterly MDS dated [DATE] revealed the residents BIMS score was 99, which indicated a severe cognitive impairment. Record review of Resident #7's Care Plan revealed Potential for alterations in well-being: Resident is at risk for infection and emotional distress related to measures in place to minimize exposure and associated risks COVID-19 and Influenza started on [DATE] with interventions which included: monitor vital signs and health condition, notify PCP and RP of any change of condition as clinically indicated and observe isolation precautions as clinically indicated. Record review of Resident #8's face sheet, dated [DATE], revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #8's lab results dated [DATE] revealed the resident was positive for COVID-19. Record review of Resident #8's Quarterly MDS, dated [DATE], revealed a BIMS' of 15, which indicated the resident was cognitively intact. Record review of Resident #8's Care Plan revealed Potential for alterations in well-being: Resident is at risk for infection and emotional distress related to measures in place to minimize exposure and associated risks COVID-19 and Influenza started on [DATE] with interventions which included: monitor vital signs and health condition, notify PCP and RP of any change of condition as clinically indicated and observe isolation precautions as clinically indicated. Record review of Resident #9's face sheet, dated [DATE], revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review revealed the resident was discharged to the hospital on [DATE]. Record review of Resident #9's COVID-19 laboratory test dated [DATE] and reported to the facility on [DATE] revealed the resident was negative for COVID-19 at this time. Record review of Resident #9's Quarterly MDS dated [DATE] revealed a BIMS score of 12, which indicated a moderate cognitive impairment. Record review of Resident #9's Care Plan revealed Potential for alterations in well-being: Resident is at risk for infection and emotional distress related to measures in place to minimize exposure and associated risks COVID-19 and Influenza started on [DATE] with interventions which included: monitor vital signs and health condition, notify PCP and RP of any change of condition as clinically indicated and observe isolation precautions as clinically indicated. During an interview with the Administrator on [DATE] at 11:20 AM, the Administrator confirmed Resident #9 had tested positive for COVID-19 in a second round of testing which wasn't reported to the facility until the resident was in the hospital. Record review of Resident #10's face sheet dated [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review revealed Resident #10 was discharged to the hospital on [DATE] and expired on [DATE]. Record review of Resident #10's Quarterly MDS dated [DATE] revealed a BIMS score of 4, which indicated a severe cognitive impairment. Record review of Resident #10's Care Plan for revealed Potential for alterations in well-being: Resident is at risk for infection and emotional distress related to measures in place to minimize exposure and associated risks COVID-19 and Influenza started on [DATE] with interventions which included: monitor vital signs and health condition, notify PCP and RP of any change of condition as clinically indicated and observe isolation precautions as clinically indicated. Record review of Resident #10's hospital medical records dated [DATE] revealed the resident was admitted to the hospital with [REDACTED]. Record review of Resident #11's face sheet dated [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #11's lab results, dated [DATE], revealed the resident was negative for COVID-19. Record review of Resident #11's lab results dated [DATE] revealed the resident was positive for COVID-19. Record review of Resident #11's Quarterly MDS dated [DATE] revealed a BIMS score of 10, which indicated the resident had a moderate cognitive impairment. Record review of Resident #11's Care Plan revealed Potential for alterations in well-being: Resident is at risk for infection and emotional distress related to measures in place to minimize exposure and associated risks COVID-19 and Influenza started on [DATE] with interventions which included: monitor vital signs and health condition, notify PCP and RP of any change of condition as clinically indicated and observe isolation precautions as clinically indicated. Record review of Resident #13 face sheet dated [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review revealed Resident #13 was discharged to the hospital on [DATE] and expired at the hospital on [DATE]. Record review of Resident #13's 2nd COVID-19 laboratory test dated [DATE] revealed the resident was positive for COVID-19. Record review of Resident #13's Quarterly MDS dated [DATE] revealed a BIMS score of 5, which indicated a severe cognitive impairment. Record review of Resident #13's Care Plan revealed Potential for alterations in well-being: Resident is at risk for infection and emotional distress related to measures in place to minimize exposure and associated risks COVID-19 and Influenza started on [DATE] with interventions which included: monitor vital signs and health condition, notify PCP and RP of any change of condition as clinically indicated and observe isolation precautions as clinically indicated. Record review of Resident #16's face sheet dated [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #16 was discharged to the hospital on [DATE] and expired on [DATE]. Record review of Resident #16's 2nd laboratory test results for COVID-19 dated [DATE] revealed the resident was positive for COVID-19. Record review of Resident #16's Quarterly MDS dated [DATE] revealed a BIMS score of 13, which indicated the resident was cognitively intact. Record review of Resident #16's Care Plan revealed Potential for alterations in well-being: Resident is at risk for infection and emotional distress related to measures in place to minimize exposure and associated risks COVID-19 and Influenza started on [DATE] with interventions which included: monitor vital signs and health condition, notify PCP and RP of any change of condition as clinically indicated and observe isolation precautions as clinically indicated. Record review of Resident #16's Care Plan initiated on [DATE] revealed the resident was at risk for COVID-19 with interventions which included observe isolation precautions as clinically indicated. Further review of the Care Plan revealed the Resident was positive for COVID-19 with a start date of [DATE] with interventions which included observe droplet isolation precautions. Record review of Resident #20's face sheet dated [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #20's 2nd laboratory test results for COVID 19 dated [DATE] revealed the resident was positive for COVID-19. Record review of Resident #20's Significant Change MDS dated [DATE] revealed a BIMS score of 99, which indicated a severe cognitive impairment. Record review of Resident #20's Care Plan for Potential for alterations in well-being: Resident is at risk for infection and emotional distress related to measures in place to minimize exposure and associated risks COVID-19 and Influenza started on [DATE] with interventions which included: monitor vital signs and health condition, notify PCP and RP of any change of condition as clinically indicated and observe isolation precautions as clinically indicated. Record review of Resident #20's progress notes dated [DATE] revealed resident was positive for COVID-19. Record review of a Staff Spreadsheet for COVID-19 testing provided by the Administrator revealed: -CNA A risk for exposure was not documented and tested positive for COVID-19 on an unknown date -CNA B was listed at high risk for exposure and tested positive for COVID-19 on [DATE] -CNA C was listed at high risk for exposure and tested positive for COVID-19 on [DATE]. -CNA D was listed as high risk for exposure and tested positive for COVID-19 on [DATE]. -LVN E was listed at high risk for exposure and tested positive on an unknown date -Dietary Aide F was listed as low risk for exposure and tested positive on [DATE]. -LVN G was listed as a medium risk for exposure and tested positive on [DATE]. -CNA OO was listed as high risk for exposure and tested positive for COVID-19 on [DATE] -LVN XX risk for exposure was not documented, tested negative for COVID-19, later developed symptoms and tested positive on an unknown date. 2. Observation on [DATE] at 1:30 PM of the 400-Hall revealed the positive COVID-19 residents were intermingled in the same hall with negative residents and were using the same staff to provide care. During an interview on [DATE] at 4:55 AM LVN RR confirmed COVID-19 positive residents resided on the same hallway as negative residents. During an interview on [DATE] at 5:35 AM LVN RR stated, I can't believe they have both positive and negative resident on the same hall way and they are using the same staff for both halls. We are trying to be careful not to cross contaminate, but it's going to happened. Especially with staff coming in and out of the resident rooms. During an interview on [DATE] at 12:51 PM ADON AAA confirmed positive and negative residents were intermingled on the same hall. ADON AAA stated it was hard to separate the residents because the night shift had less staff to take care of all the residents on both sides, so they had to share staff. ADON AAA further stated she did not give staff instructions or direction on keeping the negative residents separate from the positive residents. During an interview on [DATE] at 11:22 AM ADON K (Infection Control Preventionist) confirmed residents who had tested negative for COVID-19 were still on the same unit as residents who had tested positive. ADON K further confirmed they did not have dedicated staff to care for the COVID positive residents. During an interview on [DATE] at 8:58 AM the DON confirmed negative residents had not been separated from positive residents on the COVID-19 designated hall. Record review of the facility's policy titled Pandemics, undated, revealed, 1. The Administrator and DON has been designated as the staff persons responsible for assessing and coordinating staffing needs during a pandemic outbreak in the community. Tier 1-Containment isolated to a hall/unit: If the community has the ability to place [MEDICAL CONDITION] residents in separate rooms on the identified hall/unit the plan will be implemented. The isolating/containment of al hall/unit with consistent assignment by specific team members further educated for the [MEDICAL CONDITION]/pandemic situation. 3. Record review of visitor screening questionnaires, dated [DATE]-[DATE], revealed some of the questionnaires were incomplete and screening questions were left blank. Further review revealed some of the questionnaires did not have the name of the person completing the questionnaire and the date was not always filled in. Observation on [DATE] at 12:15 PM upon entrance to the facility revealed visitors' temperature and oxygen saturation were obtained by Receptionist UU instructed the visitors to fill out a questionnaire on a bedside table (that was placed away from the immediate screening area and across from the desk where the actual screening occurred). The questionnaire was completed by the visitor and was not monitored or reviewed by a staff member before entrance into the facility. Further observation revealed no instructions were given to visitors for social distancing, hand hygiene or cough etiquette before entrance into the facility occurred. Observation on [DATE] at 12:17 PM revealed a delivery driver entered the lobby area to deliver packages after being allowed in by facility staff through locked entrance doors. The Delivery driver was not asked to leave the packages outside of the facility for disinfection prior to entrance into the facility and was not asked by staff to answer any screening questions or have his temperature and oxygen saturation measured prior to entrance into the facility. Observation on [DATE] at 5:45 PM in the main entrance with the Corporate Nurse revealed an (unidentified) agency nurse member entered the facility without wearing a mask. The agency nurse rang the doorbell and a staff member from inside the facility opened the front entrance door and allowed the agency nurse to enter into the facility without wearing a mask. Following the observation, the Corporate Nurse acknowledged the agency nurse had entered the facility without wearing a mask. Observation on [DATE] at 10:49 AM revealed a contracted phlebotomist was not asked any health questions regarding symptoms of COVID-19 and was allowed to enter the facility. Observation on [DATE] at 8:30 AM revealed a food service delivery driver was allowed into the facility to deliver packages. The delivery driver was observed walking from the maintenance entrance thru the facility corridors to the front Receptionist desk for screening. Following a temperature and pulse oximeter check the food service delivery driver was allowed back thru the facility for delivery services. Interview on [DATE] at 9:15 AM, Receptionist UU confirmed she had not been providing instructions on social distancing, hand hygiene and cough etiquette and had allowed visitors to self-fill out the form questionnaire regarding COVID-19 exposure and symptoms without reviewing the forms. Interview on [DATE] at 9:51 AM, the Corporate Nurse revealed the staff member who entered the facility was an agency nurse. The Corporate Nurse confirmed that a facility staff member who was already at the facility had to unlock both set of double locked doors to let the agency nurse into the facility without a mask. Interview on [DATE] at 11:22 AM, ADON K (Infection Control Preventionist) stated: For visitor screening: Employees are screened by a nurse, visitors are screened by the receptionist. The facility received Corporate guidance that no one over 99.7 or oxygen saturation in low 90's or whom had answered yes to travel screening questions could be allowed in to the facility. The ADON RN K further stated, a person with symptoms and low-grade fever should not have been allowed in to the facility but a visitor with a temp of 99.6 would be allowed into facility. Interview on [DATE] at 4:30 AM with Night Shift Supervisor RN JJ stated she had received guidance from the Corporate RN this week, (after State entrance) to use the questionnaire to ask the screening questions. Screening also including a temperature check and oxygen saturation reading for anyone coming into the facility. RN JJ stated a temperature of 99.7 or greater required a recheck for temperature accuracy and may require further questioning. RN JJ stated that prior to surveyor entrance, the questionnaire was filled out by the visitor or staff member entering facility and placed in a file that was given to the Administrator. Interview on [DATE] at 8:58 AM with the DON revealed the House Supervisor screens staff and visitors at night and the Receptionist screens staff and visitors during the day. The DON stated she did not know who reviewed the answers to the questionnaire, but indicated the forms go directly to the Administrator. The DON confirmed delivery drivers should not be allowed into the facility and should drop their packages outside. The DON stated service providers such as lab, x-ray, etc. should be allowed into the facility after a proper screening. Interview with Administrator on [DATE] at 11:26 AM, the Administrator stated staff who were considered high risk for exposure were still allowed to work pending testing because they were not symptomatic, and they were screened with the screening process. The Administrator stated she reviewed the questionnaires and the log sheets and followed up with any employee who had symptoms in illness to make sure they had been sent home and had not clocked in to work. The Administer further stated, visitors with symptoms should not be allowed into the facility. Record review of the facility's policy titled Prevent COVID-19 Screening Checklist-Recommendations for Visitors/Service Providers, dated [DATE], revealed: All individuals entering the building should be asked the following questions: 1. Has the individual washed their hands or used alcohol-based hand rub on entry? 2. Ask the individual if they have any of the following symptoms? Fever in last 4 hours, sore throat, runny nose, nausea or vomiting, cough, abdominal pain, diarrhea, shortness of breath. 3. Ask the individual if they have: been recently tested for COVID-19, have you or a family member traveled outside of your city or town in the last 14 days? Worked in another health care setting with confirmed COVID-19 cases? Ask the purpose of v (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure a resident who displayed or was diagnosed with [REDACTED].#28) reviewed for treatment and services, in that: The facility did not develop and implement interventions to address Resident #28's behaviors and emotional distress prior to being discharged to the hospital and discharged from the facility. This deficient practice could place residents with dementia at risk for their medical, physical, and psychological needs not being met and result in a decline in health. The findings were: Record review of Resident #28's face sheet, dated 5/14/20 revealed, an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review revealed Resident #28 was discharged to the hospital on [DATE] and discharged from the facility on 5/14/20. Record review of Resident #28's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 4, which indicated the resident was severely cognitively impaired. Further review revealed Resident #28 had no symptoms of [MEDICAL CONDITION], no symptoms of [MEDICAL CONDITION], and no behavioral symptoms including no rejection of care behaviors. Record review of a Resident #28's Quarterly IDT meeting, dated 3/5/20, revealed there were, no significant changes in the past 3 months. (Resident #28) has a good appetite. He eats all meals in the dining room. He occasionally participates in activities and his son visits often. There are no concerns/preferences at this time. The team will monitor for changes. Record review of Resident #28's physician orders, dated 4/29/20, revealed orders for [MEDICATION NAME] tablet 0.5 mg, give 1 tablet every 12 hours as needed for anxiety for 14 days, and [MEDICATION NAME] tablet 2 mg/ml, inject 1 mg intramuscularly every 12 hours as needed for anxiety and agitation. Record review of Resident #28's MARs for April and May of 2020 revealed [MEDICATION NAME] tablets and [MEDICATION NAME] IM injection were not documented as administered and there were no documented attempts to administer the medications. Record review of Resident #28's Rehab screening tool, dated 5/5/20, revealed the resident had a witnessed fall where, he had gotten up to close the door to his room, became upset at a staff member walking by in the hallway and attempted to throw his milk carton at her. Patient fell backward onto his bottom. Record review of Resident #28's ABC Tool related to behavior, dated 5/8/20, revealed the resident was, yelling, name calling, calling team members prostitutes, throwing water and throwing urine at team members. Further review revealed the rest of the form was incomplete. The areas of the form titled, context of behavior including relevant history, diagnoses, psychotic symptoms, vitals signs, etc., and activators including, what happened just before the problem behavior, interpersonal, environmental, psychological, and medical factors, contributing were all left blank. Interventions included, try to redirect. Record review of Resident #28's Transfer Form, dated 5/8/20, revealed the resident was sent to the hospital for chest pain. Further review revealed the form did not indicate the resident's behaviors. Record review of Resident #28's Care Plan revealed on 9/9/19 a plan of care was created and last revised on 11/4/19 for, memory problems with impaired cognitive function/impaired thought process, with interventions that included, cue, reorient and supervise as needed, notify MD for any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness and mental status and present just one thought, idea, question or command at a time. Further review revealed a plan of care created on 11/4/19 and last revised on 12/2/19 for potential to demonstrate verbally: yelling out loud, cursing and physically abuse behaviors. Related to: dementia, poor impulse control. Interventions included: Assess and anticipate my needs for food, thirst, toileting, comfort level, body, position, pain, etc., assess my understanding of the situation, psychiatric/psychogeriatric consult as indicated, redirect. Further review of the Care Plan revealed on a plan of care titled, Potential for alterations in well-being: resident is at risk for infection and emotional distress related to measures in place to minimize exposure and risk associated with COVID-19 and Influenza. Interventions included: notify MD and RP of any change in condition as clinically indicated, monitor for psycho-social changes, observe and report any changes in mental status caused by situational stressors. Record review of Resident #28's progress notes revealed: -3/2/20: Resident #28 is up and dressed daily and is not in bed most of the day. The resident spends most of the time out of his room. The Resident had no problems socializing with others . -4/27/20: The resident's RP was notified that as a precaution the residents room would be moved due to COVID-19 precautions. -4/29/20: . received consent to give PRN [MEDICATION NAME] agitated/anxiety. -5/1/20: continue with confusion, UA collected-pending pick up, will continue to monitor. antibiotics started. -5/3/20: activities notified nurse she witnessed Resident #28 fall in his room, I closed his door because it was open. He then started yelling . threw a milk carton with milk in the hallway aiming at staff . fell backwards landing on his buttocks . no injuries noted. -resident refused vitals. Resident name calling, saying get out of my room, refused meds . will continue to monitor. RN/DON made aware of behaviors. -5/4/20: Resident name calling, yelling, grabbing. RN/DON made aware. -5/4/20: Resident had been calling out for his family member and yelling obscenities to the staff when trying to attend to resident. -5/4/20: refusing medication this am will continue to monitor, MD notified. -5/5/20: resident upset tonight at staff, stated, we are the ones who came in and held him down and poked his nose, dumb b*****, p**********, I will call you when I need you. Resident hollered out a lot, call light on a lot, able to medicate after several attempts. -5/6/20: Resident #28 was, continued foul in mood, yelling at staff, will continue to monitor. -5/6/20: Resident #28 came out of room to back exit door setting alarm off. CNA attempted to redirect patient back to room. Resident noted very agitated and yelling at CNA. Resident ripped isolation signs off his door and tore them to pieces and started to push isolation barrel and trash box out of his room. This nurse went to assess who started yelling, oh you get the hell out of here you damn prostitute. RN notified of residents increased behaviors. -5/8/20: Spoke to med/management this morning to discuss Resident #28's refusal of meds and agitated behavior. Order received for [MEDICATION NAME] Q12 hours IM PRN. RP does not consent to [MEDICATION NAME] IM injection. -5/8/20: ADON RN made aware of behaviors, will continue to monitor -5/8/20: staff report Resident #28 throwing urine at them, throwing water in cup at staff, name calling, Resident is yelling for his family member, attempted to redirect the resident . becomes verbally upset. Resident complains of painful urination, will continue to monitor. -5/8/20: social worker noted: spoke with the resident's RP about the medication ([MEDICATION NAME] IM injection) proposed . RP consented to allow Resident #28 to receive the medication. LMSW communicated this to the ADON. -5/8/20: Resident #28 complains of left sided chest pain in the epigastric area, stated for the week or two he had chest pains reflux. Resident yelling out, resident stated it hurts all over. ADON (name) notified and assessed the resident, ADON (name) suggested [MEDICATION NAME] and Tylenol, ADON advises notify MD. MD called, waiting for call back. PRN Tylenol and [MEDICATION NAME] given per suggestion. -5/8/20: No further complaints of chest pain. Report given to MD, MD stated send to ER with chest pain ADON notified of orders who stated, if he goes he will not be able to take him back, suggested calling MD back and letting him know that. MD made aware the resident reported no further pain and made the resident that the resident could not come back to the facility if sent out. Will continue to monitor. -5/8/20 at 6:30 PM: Resident had chest pain during day shift which resolved with [MEDICATION NAME] and Tylenol. Resident #28 asked staff to call his son because he would know what to do for him since he felt as if nothing was being done to help him. MD informed of continued chest pain. Order to send to ER. During an interview on 5/21/20 with MDS Coordinator OOO, stated Resident #28 would constantly turn on his call light and call out verbally. MDS Coordinator OOO stated Resident #28 would go into the room and the resident would become verbally aggressive and tell staff to get out of his room. MDS Coordinator OOO stated the resident had a recent room change and that was what started with the increased aggression. MDS Coordinator OOO stated the situation was, non-stop, and, sad, and, very bad because other residents were becoming upset. MDS Coordinator OOO stated there was no pleasing Resident #28. The resident had racial prejudice and stated, I think he knows what he is saying and it's derogatory. MDS Coordinator OOO stated she had spoken with the RP a couple of times but did not document the discussions. MDS Coordinator OOO confirmed she not notified the resident's physician. MDS Coordinator OOO stated the staff had discussed interventions in morning meeting but there was no pleasing the resident. MDS Coordinator OOO confirmed she had not updated Resident #28's care plan to reflect the change of condition or increased behaviors. During an interview on 5/21/20 at 1:59 PM with LVN PPP stated Resident #28 was belligerent when staff tried to administer the resident his medications. LVN PPP confirmed the resident refused medications and care. LVN PPP stated she was supposed to notify the ADON, the DON, and the resident's physician for a change of behaviors. The LVN stated because she worked on night shift she did not notify the ADON, the DON, or the resident's physician. During an interview on 5/21/20 at 2:12 PM with LVN VV, stated Resident #28 called staff, racially negative words, and used profanity towards staff members. LVN VV stated the resident was throwing water and urine out of his door and in her opinion seemed to be aware of what he was doing. LVN VV stated she did not attempt to give Resident #28 [MEDICATION NAME] that she remembered and stated, if she had given it she would have documented it. LVN VV stated she had notified the ADON and social services of the resident's behaviors and indicated the ADON indicated that psychological services was going to be called. LVN VV confirmed she did not notify the residents physician or psychological services about the residents increase in behaviors. During an interview on 5/21/20 at 3:27 PM with LVN NNN, confirmed Resident #28 had a change of condition with an increase in behaviors. LVN NNN stated the resident was calling staff, p********** and w*******, and further stated the resident was very confused. LVN NNN confirmed the resident was refused care, did not understand what was going on with COVID-19 Infection Control, and did not understand why the room doors had to stay closed or why his family member was not visiting. LVN NNN stated the resident was yelling, get the hell out of my room, and refused medications. When LVN NNN was asked why there were no documented attempts to administer Resident #28 [MEDICATION NAME] for anxiety, LVN NNN stated, I do not remember an event or any aggressive behavior in which he would have needed [MEDICATION NAME]. LVN NNN further stated the staff interventions for the behavior were attempts at redirection. During an interview on 5/21/20 at 3:48 PM with ADON K, confirmed Resident #28 had behaviors which consisted of yelling, resisting care and, throwing stuff. ADON K stated Resident #28 had been transferred from another hallway because of positive COVID-19 cases, and confirmed Resident #28 had a difficult time adjusting to the move. ADON K confirmed [MEDICATION NAME] for anxiety was not documented as administered although she remembered a nurse administered the resident a dose of the medication right before his discharge to the hospital. ADON K confirmed she did not notify the resident's physician or psychological services of an increase in behaviors or of the resident's refusals to take his medication. ADON K further confirmed she was aware that the resident's RP had consented to an IM [MEDICATION NAME] injection after the RP initial refusal. ADON K stated, I was not about to give that man an IM injection of [MEDICATION NAME] after he (RP) screamed at me. ADON K stated the facility was not equipped to handle Resident #28's behaviors, and confirmed the Administrator was aware of the resident's behaviors prior to discharge. During an interview on 5/21/20 at 3:56 PM with the DON, stated she first became aware of Resident #28's significant change in behavior approximately 1-2 days prior to his discharge to the hospital. The DON confirmed Resident #28 had behaviors when he first came to the facility due to dementia but the resident had adjusted and the move to a new room due to COVID-19 had triggered the change in behaviors. The DON stated the resident did not object to the recent move. The DON confirmed she had not notified the residents physician or psychosocial services. The DON stated she had reached out to med-management group to adjust the resident's medications and they performed a tele-visit on the day of Resident #28's discharge from the facility. The DON confirmed staff was expected to monitor resident behaviors and for a change of condition was expected to fill out a SBAR report, notify the resident's physician and psychological services physician to get a psych consulted, notify the social worker and the DON. The DON further confirmed staff was expected to follow physician orders. Record review of facility's policy titled Changes in Resident Condition, dated 5/2017 revealed: 2. Changes in condition shall be communicated from shift to shift through the 24 hour report management system. 3. Changes in the resident status that affect the problem(s)/goal(s) or approach(s) on his/her care plan shalll be documented as revisions and communicated to the interdisciplinary caregivers.