Every finding on record at Hallettsville Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to ensure the resident's right to formulate an advance directive for one (Resident #12) of twenty-five residents reviewed, in that:Resident #12's OOH-DNR was witnessed by two unqualified witnesses and was therefore invalid. This deficient practice could place residents at risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.The findings were:Record review of Resident #12's facesheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including: unspecified dementia, acute kidney failure, and generalized anxiety disorder.Record review of Resident #12's Quarterly MDS, dated [DATE], revealed a BIMS score of 3 which indicated severe cognitive impairment.Record review of Resident #12's care plan, dated [DATE], revealed, Resident is a DNR.Record review of Resident #12's OOH-DNR, dated [DATE], revealed Witness #1 was the facility's Director of Human Resources and Witness #2 was the facility's Business Office Director.During an interview with DON and Administrator on [DATE] at 10:25 a.m., the DON and Administrator confirmed the witnesses for Resident #12's OOH-DNR form were the facility's Director of Human Resources and the facility's Business Office Director, and acknowledged neither were considered qualified witnesses. Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], revealed, Completing the Texas Out of Hospital Do Not Resuscitate Form: When Using Two Witnesses. Witness one is a qualified witness and may not be:. An officer, director, partner, or business office employee of a health care facility in which the patient is being cared for or any parent organization of the health care facility. Further review revealed, Frequently Asked Questions for DNR: What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly.Record review of the Texas Health and Safety Code Title 2 Health, Subtitle H Public Health Provisions, Chapter 166 Advance Directives, Section 166.083 Form of Out-Of-Hospital DNR order, effective [DATE], revealed, (a) A written out-of-hospital DNR order shall be in the standard form specified by department rule as recommended by the department. (b) The standard form of an out-of-hospital DNR order specified by department rule must, at a minimum, contain the following: . (13) a statement at the bottom of the document, with places for the signature of each person executing the document, that the document has been properly completed.

Based on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater. A total of 6 errors out of 36 opportunities were observed, resulting in a 16.67% error rate for 1 of 3 residents (Resident #33) reviewed during medication pass, in that: Medication Aide E failed to administer Resident #33's medications at the correct time. These deficient practices could place residents at risk for not receiving the intended therapeutic benefits of their medications and exacerbation of their medical conditions.The findings were: Record review of Resident #33's face sheet, dated 01/15/2026, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included: Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Dementia (decline in cognitive abilities), Chronic kidney disease (gradual loss of kidney function), Hypertension (High blood pressure), Hemiplegia (Paralysis of one side of the body). Record review of Resident #33's consolidated physicians' orders for January 2026 revealed orders for Carvedilol Oral Tablet 3.125 MG (Carvedilol) Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) hold if systolic bp is less than 100, Docusate Sodium Capsule 100 MG Give 1 capsule by mouth two times a day for constipation, metFORMIN HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth two times a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS, Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) Give 1 tablet by mouth two times a day for depression, busPIRone HCl Oral Tablet 10 MG (Buspirone HCl) Give 1 tablet by mouth three times a day for anxiety and HydrOXYzine HCl Tablet 10 MG Give 2 tablet by mouth four times a day for anxiety give two 10 mg tablets to equal 20 mg. Record review of the MAR dated January 2026, indicated Carvedilol Oral Tablet 3.125 MG (Carvedilol) Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) hold if systolic bp is less than 100, Docusate Sodium Capsule 100 MG Give 1 capsule by mouth two times a day for constipation, metFORMIN HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth two times a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS, Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) Give 1 tablet by mouth two times a day for depression, busPIRone HCl Oral Tablet 10 MG (Buspirone HCl) Give 1 tablet by mouth three times a day for anxiety and HydrOXYzine HCl Tablet 10 MG Give 2 tablet by mouth four times a day for anxiety give two 10 mg tablets to equal 20 mg. All medications were to be administered at 8:30 a.m. for the first dose in the morning. Observation on 01/15/2026 at 11:50 a.m. revealed Medication Aide E administered Carvedilol, Docusate sodium, Metformin, Sertraline, Buspirone, and Hydroxyzine to Resident #33. The 6 medications were scheduled for 8:30 a.m., the medications were given more than 2 hours late. During an interview on 01/15/2026 at 12:15 p.m., the Medication Aide E confirmed she had administered the 6 medications scheduled for 8:30 a.m. at 11:50 a.m. to Resident #33. She stated the medications were 2 hours late and out of the one hour before or after time frame. During an interview on 01/15/2026 at 3:30 p.m., the DON stated medications must be administered within one hour before or after their prescribed times. Review of facility's policy, titled Medication Administration, dated 10/24/2022, revealed Administer with 60 minutes prior to or after scheduled time unless otherwise ordered by physician.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for sanitation. 1. The facility failed to clean an approximate 2x2 ft ceiling vent in the main kitchen area. 2. The facility failed to replace a light bulb in the main kitchen area. 3. The facility failed to clean an approximate 6x5 inch ceiling vent and paint several areas of missing paint in the food storage room. 4. The facility failed to clean an approximate 1x1 ft ceiling vent in the dish-room. 5. The facility failed to clean an approximate 6x6 inch ceiling vent in the employee's bathroom. 6.-The facility failed to clean an approximate 1 ft in parameter size ceiling vent in the Dietary Manager's office. These failures could place residents at risk for food borne illness. The findings included: 1-Observation on 1/13/26 from 9:9:55-10:25 a.m., with the Dietary Manager revealed:a-there was an approximate 2x2ft ceiling air vent in the main kitchen area that had dust and dirt in the vent slots.b-there was an overhead light in the main kitchen area that did not turn on.c-there was an approximate 6x5 inch ceiling air vent that had dust and dirt in the vent slots in the food storage room.d-there were several areas of missing paint on the ceiling in the food storage room. e-there was an approximate 1x1 ft ceiling air vent that had dust and dirt in the vent slots in the employee bathroom andf-there was an approximate 1 ft in parameter ceiling air vent in the Dietary Manager's office that had dust and dirt in the vent slots. During an interview on 1/13/26 at 10:20 a.m., with the Dietary Manager and Administrator, the Dietary Manager stated she had not placed a work order for the observed areas that needed cleaning or repair. The Administrator stated that dust and dirt could affect the food preparation surfaces in the kitchen. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Record review of the facility policy, Sanitation, revised January 2024, revealed, The food service area shall be maintained in a clean and sanitary manner. I. Ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.Record review of the facility's policy titled-Cleaning-Keeping the Floors, Walls, and Ceilings Clean dated 7/10/20 revealed Floors, walls, and ceiling must be free of dirt, letter, and moisture. Record review of the facility policy titled General Kitchen Sanitation dated 10/1/18 revealed Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition. Record review of the facility policy titled General Kitchen Safety Guidelines dated 10/2018 revealed Keep all equipment in working order and report any malfunctioning to the Maintenance Department.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 of 6 resident hallways (Hallway 500) and 2 of 5 shower rooms (Hallways 100 and 200), and the laundry room reviewed for environmental concerns. The facility failed to:1-replace a light bulb in room [ROOM NUMBER]'s bathroom.2-clean a ceiling vent and repair missing ceiling paint in hallway 100's shower room.3-replace a bathroom sink light bulb in hallway 200's shower room.4-clean a ceiling vent and replace an overhead light bulb in the laundry room. These failures could place residents and staff at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included: Observation rounds on 1/15/26 from 7:40-7:50am with the Administrator and Maintenance Director revealed the following: a-A bath-room sink light did not turn on in room [ROOM NUMBER] on Hallway 500. b-A 6 inch ceiling vent had dust and dirt on the vents and there was an approximate 6x2 inch section of missing ceiling paint in the shower room on hallway# 100. c- A sink overhead light that did not turn on in the shower room on Hallway# 200.d-An approximate 10 inch ceiling vent had dust and dirt on the vents and an approximate 10x2 inch ceiling light that did not turn on in the laundry room. During an interview on 1/15/26 at 7:55am with the Administrator and Maintenance Director the Maintenance Director stated that the facility used the TELS work order system to notify him of needed repairs. The Maintenance Director stated that he had not been notified of the observed areas that needed repair. The Administrator stated that completing the repairs of the observed areas would be necessary for general maintenance of the facility. Record review of facility work orders dated 12/15/25-1/15/25 revealed that the observed areas that needed repair were not included. Record review of the undated facility document titled What is TELS revealed the facility had a protocol for staff to create work orders for facility maintenance purposes.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 25 (Residents #8 and #64) residents reviewed for comprehensive care plans, in that: 1.Resident #8's care plan did not include his diet. 2.The facility failed to revise a care plan to address Resident #64's insulin usage. These deficient practices could result in residents' needs not being identified and addressed. The findings were: 1.Record review of Resident #8's face sheet, dated 01/15/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses including: unspecified fracture of right femur, unspecified atrial fibrillation, and essential primary hypertension. Record review of Resident #8's admission MDS, dated [DATE], revealed a BIMS score of 11 which indicated moderate cognitive impairment. Further review revealed Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids). Record review of Resident #8's clinical record as of 01/15/2026, revealed a diet order, dated 12/10/2025, Regular diet, Pureed texture, Regular Liquids. Record review of Resident #8's care plan, as of 01/15/2026, revealed his diet was not addressed in the care plan. During an interview with LVN MDS A on 01/15/26 at 4:00 pm MDS LVN A confirmed Resident #8's diet order should have been addressed in his care plan so that he received the correct diet as ordered by his physician. 2.Record review of Resident #64's face sheet, dated 1/15/26, revealed an [AGE] year old male with an admission date of 5/16/25 with diagnoses that included: unspecified dementia (a condition of cognitive decline that impairs daily life), primary hypertension (a condition of high blood pressure) and type 2 diabetes (a condition in which the body has trouble controlling the blood sugar). Record review of Resident's #64's quarterly MDS assessment, dated 11/2/25, revealed a BIMS score of 8 which indicated moderate cognitive impairment. Record review of Resident #64's Physician's orders initiated on 9/22/25 and revised on 11/14/25 revealed an order for Lantus subcutaneous solution-100 unit ML - inject 25 unit subcutaneous. Record review of Resident #64's ongoing care plan initiated on 5/16/25 revealed that the Resident's insulin's use was not documented in the care plan. During an interview on 1/15/26 at 3:50pm MDS LVN A and RN B stated Resident #64's insulin's use was not documented on his current care plan. MDS LVN A and RN B stated having the insulin use on the care plan was important for care staff to be aware of the resident's care needs so that the needs are met. Record review of the facility policy, Comprehensive Care Plans, dated 10/24/2022, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident.

Based on interviews and record reviews the facility failed to review and revise a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 24 residents (Resident #4) reviewed for care plans, in that:Resident #4's care plan incorrected noted that the resident received tube feeding as well as food by mouth.This failure could have placed residents at risk of not having their needs identified and met.The findings were:Record review of Resident #4's face sheet, dated 01/16/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses including: dysphagia, unspecified convulsions, and unspecified intellectual disabilities.Record review of Resident #4's Significant Change MDS, dated [DATE], revealed the resident was rarely/never understood and a staff assessment for mental status was conducted which indicated both long and short term memory problems. Further review revealed the resident had a feeding tube.Record review of Resident #4's order summary, dated 01/16/2026, revealed aa active diet order, dated 12/02/2025, NPO diet NPO texture, NPO (Nothing by Mouth).Record review of Resident #4's clinical record as of 01/16/2026, revealed a discontinued diet order, food in bowls. was in place from 02/20/2025 to 11/19/2025.Record review of Resident #4's care plan, revised 12/04/2025, revealed, The resident requires tube feeding.[related to] Dysphagia. Further review revealed a revision dated 09/29/2025, Diet: Regular diet, Pureed texture, Nectar Thickened Liquids consistency- food in bowls, maroon spoon-1/2 teaspoon/no straws, double handled cup with lid for all liquids. Resident prefers her plate to be left on the serving tray while eating her meal.During an interview with LVN MDS A on 01/15/26 at 4:00 pm MDS LVN A confirmed Resident #4's current diet order was nothing by mouth, the resident received all liquids and nutrition via tube feeding, and that Resident #4's discontinued order from 09/29/2025 should not have continued to be included in the resident's care plan.Record review of the facility's policy titled Care Plan Revisions Upon Status Change dated 10/24/22 revealed that The care plan will be updated with the new or modified interventions.

Based on observation, interview, and record review, the facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #22) reviewed for incontinent care, in that: The facility failed to ensure, while providing incontinent care for Resident #22, CNA C used a front to back motion to clean Resident #22's buttocks. These deficient practices could place residents at-risk for infection and skin break down due to improper care practices.The findings were: Record review of Resident #22's face sheet, dated 01/15/2026, revealed an admission date of 09/16/2025, and a readmission date of 01/02/2026, with diagnoses that included: Dementia (decline in cognitive abilities), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), and Hypertension (High blood pressure). Record review of Resident #22's Quarterly MDS assessment, dated 01/06/2026, revealed a BIMS score of 0, which indicated the resident was severely impaired cognitively, and was indicated to be frequently incontinent of bowel and bladder. Observation on 01/15/2026 at 10:10 a.m. revealed while providing incontinent care for Resident #22, CNA C used a back to front motion to wipe Resident #22's buttocks. During an interview with CNA C on 10/15/2019 at 10:24 a.m., CNA C stated she used a back to front motion to wipe Resident #22's buttocks. She stated she thought she was using the right motion. She stated she received incontinent care and infection control training within the year. During an interview with the DON on 01/15/2026 at 3:30 p.m., the DON confirmed that during incontinent care the staff must use a front to back motion to clean the resident to precent fecal matter entering the urinary stream and prevent urinary infection. Review of facility's CNA/NA competency skills checklist, dated 02/04/2025, revealed CNA C met competency for infection control and incontinent care. Record review of facility's policy titled Perineal care dated 10/24/2022, revealed, Cleanse buttocks and anus, front to back.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #22) observed for infection control, in that: The facility failed to ensure, while providing incontinent care for Resident #22, CNA D sanitized her hands after touching part of the resident's environment. This deficient practice could place residents who receive assistance with personal care at risk for infection due to improper care practices.The findings were: Record review of Resident #22's face sheet, dated 01/15/2026, revealed an admission date of 09/16/2025, and a readmission date of 01/02/2026, with diagnoses that included: Dementia (decline in cognitive abilities), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), and Hypertension (High blood pressure). Record review of Resident #22's Quarterly MDS assessment, dated 01/06/2026, revealed a BIMS score of 0, which indicated the resident was severely impaired cognitively, required extensive assistance with her activities of daily living, and was indicated to be frequently incontinent of bowel and bladder. Record review of Resident #22's care plan, dated 10/27/2025, revealed a problem of The resident has bowel incontinence r/t immobility, and an intervention of Provide pericare after each incontinent episode. Observation on 01/15/2026 at 10:10 a.m., revealed while providing incontinent care for Resident #22, CNA D washed her hands, then with her bare hands touched Resident #22's bed and the bed remote. CNA D put her gloves on but did not sanitize her hands before she started providing care for Resident #22. During an interview on 01/15/2026 at 10:24 a.m., CNA D stated she did not sanitize her hands before putting her gloves on and did not think about the bed and bed remote being possibly contaminated. She stated she should have washed or sanitize her hands prior to putting her gloves on and before she stated the care for the resident, CNA D stated she received infection control training within a year. During an interview on 01/15/2026 at 3:30 p.m., the DON, she stated the environment around a resident was considered contaminated and staff should wash or sanitize their hands prior to provide care to a resident, to prevent cross contamination and prevent infection for the resident. She stated the staff was trained at least once a year on infection control Review of facility's policy, titled Hand hygiene, dated 10/24/2022, revealed The use of glove does not replace hand hygiene. If your task require gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on observation, interview, and record review the facility failed to establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the state plan for all residents regardless of payment source for 1 of 6 residents (Resident #1) reviewed for resident discharge rights in that: The facility failed to allow Resident #1 the ability to discharge with FM A and follow their internal policies for discharge and decision making when no POA or guardianship was available. The failure placed residents at risk of decline in their satisfaction with life and feeling of self-worth. Findings include: Review of Resident #1's face sheet dated 12/18/25 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (group of symptoms affecting memory, thinking, and social abilities)-unspecified severity without behavioral disturbance-psychotic disturbance-mood disturbance-and anxiety, major depressive disorder, unsteadiness on feet, and acute kidney failure. The face sheet reflected Resident #1 was his own responsible party and listed FM B only as an EC with no other granted authority. FM A was not listed. Review of Resident #1's EMR reflected there were no documents that established a POA, guardianship, or other advance directive that named anyone with legal authority to make decisions for Resident #1. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 05 indicating severe cognitive impairment. Review of Resident #1's care plan last revised 06/19/25 reflected a focus on discharge planning has been discussed with [Resident #1] and [FM B]; discharge to the community is not expected with intervention encourage family to visit as often as possible and follow up as needed to see if there are changes to the discharge plan. Review of Resident #1's progress notes reflected:- A note from social services dated 10/15/25, On October 14, 2025, SW spoke with resident after receiving a call from [Ombudsman]. The call was prompted by FM A [Resident #1's family member], who expressed her desire to have Resident #1 removed from the facility. SW spoke with both resident and FM B, the emergency contact. During the conversation, resident mentioned that he did not want to go back down that road referring to living with [FM A]. On October 15, 2025, resident asked SW to participated in a phone conversation with [FM A]. During the call, [FM A] expressed her concerns, stating that [Resident #1] was being held in the facility against his will and the facility did not have authority to manage his finances, she added that she will be coming to the facility with the police to remove [Resident #1]. Resident appears to be conflicted between making a decision that is in his best interest and considering [FM A's] wishes. SW will speak to [FM B] and consult with the Ombudsman as resident is now stating he wants to live with [FM A].- Another social services progress note dated 10/17/25, SW was conducting an assessment with the resident when his FM A arrived. She asked what was happening and proceeded to pull out some forms for his signature. SW was unaware resident family member [FM A] was in the building. SW ended the assessment session and consulted with the DON. The interim administrator (ADM D) was contacted, and he took over the situation. Review of email dated 12/18/25 at 04:40 PM from HSA, an attorney for an out of state Human Services agency reflecting a request for records made by ADM C on 12/18/25, I have attached a screenshot of the summary of findings from the APS investigation that was completed by the agency in 2021. The summary of findings reflected allegations made between Resident #1 and FM A:- Caretaker Maltreatment: Neglect- Unsubstantiated - Caretaker Maltreatment: Abuse- Unsubstantiated- Caretaker Maltreatment: Verbal Abuse- Inconclusive- Caretaker Maltreatment: Exploitation- Unsubstantiated In an interview on 12/18/25 at 11:51 AM with SW, she stated that based on what she could see from Resident #1's chart, there was nothing restricting Resident #1 from being pulled from the facility or giving one family member more power or authorization than another. She stated Resident #1 did not have an active POA or guardianship granting anyone control over medical decisions. SW stated that she did not have additional information on the events that occurred on 10/17/25 since she was not the social worker at that time and only recently started 12/10/25. In an interview on 12/18/25 at 12:00 PM with Resident #1 in the company of SW, Resident #1 stated that he recalled FM A had spoken to him about his wishes to leave the facility and to live with her. Resident #1 stated he wanted to be able to leave and to live with his family member FM A. Resident #1 stated that he recalled the last time FM A visited the facility and stated that the facility did not treat her respectfully. Resident #1 stated that the facility told her to leave and it really upset him as he believed she did not give them a reason to be that way and kick her out. Resident #1 acknowledged that another family member FM B had been involved while he was being cared for at the facility, but that it was his wishes that he preferred to discharge with FM A. Resident #1 stated he felt FM A would be able to provide care that met his needs outside of the facility, and stated he did not have any safety concerns with regard to living with FM A. At this time Resident #1 was observed to be oriented to self and place, he recalled the last time he had interaction with FM A, recalled questions related to his family and spoke to SW about his history and service. In an interview on 12/18/25 at 01:52 PM with DON, she stated she was at the facility on 10/17/25 and recalled the event. DON stated that at the time the social worker previously employed notified her that FM A wanted to take Resident #1 out of the facility. She stated while they did not know who FM A was initially, her relationship was verified by Resident #1 who recognized her and FM B when they spoke to him over the phone. The DON stated while she was aware guardianship paperwork was being filed there was not any active enforceable POA or guardianship in place for Resident #1. DON stated that on 10/17/25 ADM D was the one to speak to FM A and was the one who denied the removal of Resident #1. DON stated that she believed the decision was made on 10/17/25 to remove FM A because she was being loud and disruptive when she argued with ADM D about not being allowed to discharge Resident #1, so ADM D along with the police asked her to leave. DON stated that after the incident there was an in-service to staff that FM A was no longer allowed at the facility and that if she were to come that staff should contact the police; this was due to in part by FM B not wanting FM A to have contact with Resident #1. She stated FM A was also not allowed to take Resident #1 on pass. In an interview on 12/18/25 at 02:45 PM with Ombudsman, she stated that she recalled the event on 10/17/25. She stated she was contacted by FM A in early October 2025 about getting guidance to discharge Resident #1 from the facility. Ombudsman stated she had also spoken to the facility and FM B who expressed having concerns with FM A. She stated FM B made allegations against FM A of incidents of mistreatment against Resident #1 dating back to 2020/2021 in in another state. She stated she was presented with a booking detail from out of state with alleged charges (NOT conviction) against FM A on 11/02/2020. She stated on 10/17/25 she was contacted by ADM D for guidance on what to do since FM A was at the facility wanting to proceed with a discharge. ADM D did not feel comfortable proceeding with the discharge and at the time Ombudsman stated she did advise that if FM A was being disruptive that she could be asked to leave the premises in that moment. Ombudsman stated she did have concerns with the facility not having any POA or guardianship documents and that one family member did not have more authority than another to make decisions due to the lack of legal paperwork. In an interview on 12/18/25 at 03:17 PM with ADM D, he stated he was the administrator filling in on 10/17/25 when the incident occurred with FM A attempting to discharge Resident #1. ADM D stated he contacted Ombudsman to get advice on what he should do since she was there trying to take Resident #1 but at that point FM A had become disruptive by being loud and argumentative in his face. He stated that since FM A was being disruptive at the time the facility was in their right per Ombudsman to ask her (FM A) to leave. ADM D stated initially he did not feel comfortable releasing Resident #1 to FM A due to the appearance of her car. He stated she was using a spare tire, and her bumper was missing and it looked unsafe. He stated the vehicle appearance in addition to her behavior was enough for him to have her removed and not release Resident #1. He stated the facility attorney also stated she did not have valid documents to make the decision to take the resident, but also confirmed the facility at the time did not have a POA or guardianship documents which made the decision difficult to determine if Resident #1 should be released. ADM D stated that after the incident he also did an in-service with staff to advise them that FM A would not be allowed on the property and she could not take Resident #1 out with her or discharge the resident and that this decision was made due to allegations of mistreatment of FM A to Resident #1 made by FM B and the documentation of the alleged charges they had for FM A from 2020. In an interview on 12/18/25 at 04:12 PM with FM A, she stated that on 10/17/25 she arrived at the facility to attempt to take Resident #1 and requested the paperwork that needed to be completed in order to discharge him. FM A stated at this time multiple staff arrived to notify her that she was not able to take Resident #1. She stated they alleged they did not know who she was but that she explained she was family which was confirmed through Resident #1 himself and with FM B since the facility had spoken to him as well. FM A stated that she was informed that she would not be able to discharge Resident #1 and became upset. She stated that she was kicked out of the facility by staff including the Administrator at the time and was told she was no longer allowed on the property and no longer allowed to visit or call the resident as she was deemed a threat to him. She stated this upset her because she was never deemed a threat to Resident #1 before and was able to visit him until she attempted to discharge him which she believed upset the facility and another family member involved. FM A stated that to her knowledge there was no legal documentation that gave any other family member more authority to act on Resident #1's behalf such as a POA or guardianship. She stated she currently still had no access to Resident #1 and that the facility had no reason to keep her from her family member, or prevent his right to discharge. In an interview and record review on 12/18/25 at 05:22 PM with ADM C, the facility current Administrator stated that if a resident voices wanting to discharge it is the process that they would work to do a safe discharge with a resident and get the guidance of the ombudsman as needed. ADM C stated that they would also work with the resident's POA or guardianship if one was available. ADM C stated if the discharge was against the guidance of the facility it was their policy to alert the physician of a discharge AMA, follow the discharge AMA policy, and if there was concern with the resident's safety then to do an APS referral after the discharge. ADM C stated for Resident #1 there was no active POA or guardianship available. She stated she was out of the office on 10/17/25 which is why ADM D was present at the time but she was updated on the events after. She stated at the time the facility was made aware of FM A's history of alleged mistreatment of Resident #1 by FM A and that along with her behavior on 10/17/25 was enough that they did not feel comfortable allowing FM A to discharge the resident. ADM C stated that after the incident an in-service was completed to prevent FM A from returning or allowing her to take Resident #1 and that her picture and name were posted near the front desk to make staff aware. ADM C stated that at the time it was confirmed that FM A was a family member, and this was confirmed by FM B, another family member, and Resident #1 himself recognized her. She stated currently FM A was not allowed on the property because FM B did not want her to talk to Resident #1. ADM C stated right now they have followed FM B's wishes even though they do not have the legal documentation that allows him to solely make those decisions. She stated FM B had made allegations at the time against FM A of alleged abuse/ mistreatment of Resident #1 and presented them with the booking details of alleged misconduct 11/02/20; charges which ADM C also acknowledged were dropped based on her knowledge. ADM C confirmed that prior to FM A attempting to discharge Resident #1 on 10/17/25 there were no notes or allegations of misconduct by FM A notated or alleged by FM B, and it was only after the attempted discharge this was coming out. ADM C also acknowledged that the alleged abuse/neglect investigated out of state by Human Services between Resident #1 and FM A was unsubstantiated based on the report received 12/18/25; something that was not requested or looked into prior to that day. Review of the booking detail (arrest record- out of state) dated 11/02/20 presented by ADM C at this time that had been used to make the decision of determining FM A to be unsafe for Resident #1 included 2 charges of pending allegations and a disclaimer An arrest does not mean that the inmate has been convicted of the crime. The information on this website should not be relied upon for any type of legal action. ADM C stated she was not able to provide anything that was substantiated that would indicate FM A was a threat to Resident #1 or a legal document such as an active POA or guardianship paperwork granting one family member the sole authorized decision maker. Review of the facility undated resident rights policy included as part of the admission packet Rights and Obligations of the Resident reflected: Resident Rights: As a resident of facility, resident is entitled to various rights that facility encourages resident to exercise. A statement of rights is available on the Texas Secretary of State website and is attached hereto including: Rights upon room change, transfer, and discharge. Review of the facility Transfer and Discharge (including AMA) policy dated 03/05/25 reflected:Discharge Against Medical Advice (AMA)- AMA only applies when a resident expresses their wishes to be discharged earlier than outlined in the care plan. These situations do not apply if the facility offers to discharge a resident to a location which does not meet their health and/or safety needs, and the resident agrees. - The resident and family/ legal representative should be informed of the risks involved, the benefits of staying at the facility, and the alternatives to both. Under no circumstances will the facility force, pressure, or intimidate a resident into leaving AMA. - The physician should be notified of the intent AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. - Documentation of this notification should be entered in the nurses notes by the nursing department. The social services designee should document any discussions held with the resident/ family in the social service progress notes if present. - Notify adult protective services, or other entity as appropriate, if self-neglect is suspected. Document accordingly.

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 to help prevent the development and transmission of communicable diseases and infections for 5 of 7 residents (Residents #22, #26, #42, #61 and #71) reviewed for infection control in that: 1. The facility failed to ensure CNA-B sanitized her hands after blowing her nose, wiping her runny nose with her finger, and coughing into her hand while feeding Resident #26 during the noon meal. 2. The facility failed to ensure CNA-C changed his gloves after going from dirty to clean while providing incontinent care to Resident #71. 3. The facility failed to ensure LVN-D followed Enhanced Barrier Precautions (EBP) by not wearing a gown while administering medications via g-tube for Resident #71. 4. The facility failed to ensure LVN-E sanitize his hands in between medication administration for Residents #42, #22 and #61 and after picking up dropped pills on the floor. These failures could place residents at risk for cross contamination and the spread of infection. Finding include: 1. Record review of Resident #26's face sheet dated 10/04/2024 revealed she was a [AGE] year-old female admitted to the facility initially on 05/05/2019 with re-admission on 08/02/2020. Diagnoses included dementia (general term for loss of memory, language, and other thinking abilities), Cerebral Infarction (stroke) Type 2 Diabetes Mellitus (a long-term condition where body has trouble controlling blood sugar and using it for energy) and Need for assistance with personal care. Record review of Resident #26's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 00, indicating severe cognitive impairment and an assessment of needing maximal assistance with eating. Record review of Resident #26's Care plan dated 10/01/2024 revealed a problem area of ADL self-care performance ., with interventions which included The resident requires limited to extensive assistance by 1 staff to eat. Observation on 10/01/2024 at 12:26 pm in the main dining room revealed CNA-B sitting in a chair adjacent to Resident #26, feeding Resident #26 her lunch meal. During the course of the meal, CNA-B was observed blowing her nose with a tissue, wiping her runny nose with her finger and coughing into her hand, without sanitizing or washing her hands afterwards, and while continuing to feed Resident #26. During interview with CNA-B on 10/01/2024 at 12:43 pm, CNA-B stated she has been having cold and allergy symptoms for about a week, but no fever, and had tested negative for COVID. When asked about observations of coughing, wiping nose with finger, blowing her nose with tissue and then returning to feed Resident #26 without sanitizing her hands, she made a scrunched up facial expression and stated yeah, I should not have done that. She stated she should have sanitized her hands after touching and blowing her nose and coughing, but that she forgot to put the sanitizer In her fanny pack that morning. CNA-B stated she worked at the facility for about 3 years, and received training in infection control, and that by not sanitizing her hands, she could have passed on any infection she may have had to Resident #26. During an interview with the DON on 10/02/2024 at 09;48 a.m , the DON revealed she was aware of the observations made during the noon meal the day before and stated that CNA-B had frequent allergies and had been tested for COVID, but also confirmed that CNA-B should have used correct hand hygiene and cough etiquette procedures after coughing and touching her nose while feeding Resident #26. The DON stated that all employees received training in hand hygiene and infection control annually and when needed, and that the Infection Preventionist made periodic observations of staff to assess compliance. The DON further stated that not following correct hand hygiene procedures could result in spread of infection. 2. Record review of Resident #71's face sheet dated 10/04/2024 revealed he was a [AGE] year-old male who was admitted on [DATE], with diagnoses that included: Unspecified Dementia (general term for loss of memory, language, and other thinking abilities); Hemiplegia and hemiparesis following Cerebral Infarction (condition that causes stiffness or paralysis on one side of body resulting from a stroke) affecting left non-dominant side. Record review of Resident #71's Optional State MDS assessment dated [DATE] revealed Resident #71 had a BIMS score of 08, indicating moderate cognitive impairment, and was assessed as total dependence in bed mobility and toileting. Record review of Resident #71's Care Plan dated 08/24/2024 revealed a problem area of Mixed bladder incontinence and bowel incontinence r/t [related to] cognitive deficit and decreased mobility, with interventions that include: provide peri care after each incontinent episode. Observation of incontinent care for Resident #71 on 10/01/2024 at 02:38 p.m. revealed that CNA-C cleaned Resident #71's penis and peri area and then without changing gloves touched Resident #71 on his shoulder and legs, to reposition Resident #71 onto his side, and proceeded to clean the buttocks area. Without changing his gloves CNA-C removed the soiled brief, obtained and placed a clean brief on Resident #71, and adjusted his clothing, During an interview with CNA-C on 10/01/2024 at 02:55 p.m., CNA-C stated he had been working at the facility since April 2024, after obtaining his CNA certification, and was not aware he needed to change gloves or sanitize his hands while performing peri-care. CNA-C stated he had received training in incontinent care during his training to become a CNA. During an interview with the DON on 10/02/2024 at 09:48 a.m., the DON was aware of the observation of peri-care performed by CNA-C and noted that CNA-C had informed her immediately after the observation. The DON stated CNA-C had just completed his CNA training a few months ago and wanted to learn. She confirmed that CNA-C should have changed gloves or sanitized hands when going from dirty to clean during peri-care and not doing so could lead to cross-contamination. 3. Record review of Resident #71's face sheet dated 10/04/2024 revealed he was a [AGE] year-old male who was admitted on [DATE], with diagnoses that included: Unspecified Dementia (general term for loss of memory, language, and other thinking abilities); Hemiplegia and hemiparesis following Cerebral Infarction (condition that causes stiffness or paralysis on one side of body resulting from a stroke) affecting left non-dominant side and dysphagia (difficulty swallowing) with gastrostomy status (a G-tube, or artificial opening into the stomach for nutrition). Record review of Resident #71's Optional State MDS assessment dated [DATE] revealed Resident #71 had a BIMS score of 08, indicating moderate cognitive impairment, and was assessed as having a feeding tube. Record review of Resident #71's Care plan dated 08/24/2024 revealed a problem area of need for Enhanced Barrier Precautions due to G-tube with interventions that included Gown and gloves only for high-contact resident care activities. Record review of Resident #71's Order Summary dated 10/04/2024 revealed an order for: a. Enteral Feed Order three times a day and use gown and gloves for high-contact resident care activities for those with . increased risk of MDRO[residents with wounds or indwelling medical devices]. Observation on 10/03/2024 at 08:25 a.m. revealed that there was an Enhanced Barrier Protection (EBP) sign resting on the handrail on the wall to the left of Resident #71's door, and a PPE supply drawer next to the wall on the opposite side of the hall from Resident #71's room. Further observation revealed LVN-D prepared Resident #71's medications on the nursing cart outside his room, then entered his room, sanitized her hands, and put on gloves, but failed to put on and wear a gown while she proceeded to administer medications via G-tube to Resident #71. During an interview with LVN-D on 10/03/2024 at 09:00 am, LVN-D stated she did not see the Enhanced Barrier Protection (EBP) sign to the left of the door, noting EBP signs were normally posted on the door. LVN-D further stated that Enhanced Barrier Protections consisted of wearing gown and gloves when working in close contact with residents who had catheters to help prevent the spread of germs. She stated she had not realized a gown should be used also when working with residents who had g-tubes. 4. Record review of Resident #42's Face Sheet dated 10/04/2024 revealed he was a [AGE] year-old male with an admitted [DATE] with diagnoses that included Dementia (loss of cognitive functioning that interferes with daily life), Cerebrovascular Accident (CVA) (stroke) and Diabetes Mellitus (a condition that affects blood sugar levels and can cause serious complications). Record review of Resident #42's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 indicating severe cognitive impairment. Record review of Resident #22's Face Sheet dated 10//04/2024 revealed he was an 84- year-old male with an admitted [DATE] with diagnoses that included: Dementia; Coronary Artery Disease (a type of heart disease) and Hypertension (high blood pressure). Record review of Resident #22's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 00, indicating severe cognitive impairment. Record review of Resident #61's Face Sheet dated 10/04?2024 revealed he was a [AGE] year old male with an admitted [DATE], and diagnoses that included: Alzheimer's Disease (a brain disorder that causes memory loss), Anemia (not having enough healthy red blood cells) and Hypertension (high blood pressure). Record review of Resident #61's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 04 indicating severe cognitive impairment. During an observation on 10/03/2024 at 07:35 a.m., LVN-E was observed to drop 2 pills onto the floor while he prepared medications for Resident #42. Further observation revealed he picked up the pills from the floor with his hand, disposed of the pills in the Sharps container, and without sanitizing his hands, dispensed 2 more pills from blister pack to replace those dropped, crushed the pills, mixed them with applesauce and proceeded with medication administration to Resident #42. Continued observation revealed that after completing medication administration to Resident #42, LVN-E then proceeded to administer medications to Resident #22 and then to Resident #61 without sanitizing his hands in between medication administration for each resident. During an interview with LVN-E on 10/03/2024 at 08:10 a.m. LVN-E stated he did not sanitize his hands in between administering medications to Residents #42, #22 and #61, and did not sanitize his hands after picking up the dropped pills from the floor, stating he had gotten nervous and forgot. LVN-C stated he had worked at the facility since 2012, had received training in hand hygiene and infection control, and stated that not sanitizing his hands in between medication administration for different residents and after touching floor could result in the spread of germs. Record review of facility policy titled Hand Hygiene dated 10/24/2022 which revealed in part: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility and 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Record review of the CDC Guideline titled Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/2024 reflects that Cleaning your hands reduces: The potential spread of deadly germs to patients . and that hands should be cleaned when moving from soiled to clean activities on the same patient or if moving from care on one patient to another patient and After touching a patient or patient's surroundings Record review of the facility's policy titled Enhanced Barrier Precautions dated 04/05/2024 revealed Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organism [MDRO] that employs targeted gown and gloves during high contact resident care activities. Further review revealed An order for enhanced barrier precautions will be obtained for residents with any of the following: indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes even if the resident is not known to be infected or colonized with a MDRO. The policy further notes High-contact resident care activities include: 6. Device care of use: central lines, urinary catheters, feeding tubes tracheostomy/ventilator tubes.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 kitchen reviewed for physical environment, in that: 1. The 8 double florescent lights in the main kitchen area and the 3 double florescent lights in the dish machine room did not have a lid cover over the light bulbs. 2. One of the 8 double florescent lights in the main kitchen area and 1 of the 3 double florescent lights in the dish machine room had light bulbs that were not operating. 3. One of the 4 panel lights in the main kitchen area did not have a light bulb that was operating. 4. The light strip inside the refrigerator in the kitchen storage room was not attached on one side and the LED bulb was not operating. 5. The overhead ceiling light in the employee bathroom was not operating. This deficient practice could result in residents, staff, and or the public exposure to a potentially dangerous substance. The findings were: Observation on 10/01/24 from 10:10 am to 10:40 am during the kitchen tour with the Dietary Manager revealed the following: a. The 8 double florescent lights (which each measured 3x2 ft) in the main kitchen area and the 3 double florescent lights in the dish machine room did not have a lid cover over the light bulbs. b. One of the 8 double florescent lights in the main kitchen area and 1 of the 3 double florescent lights in the dish machine room had light bulbs that were not operating. c. One of the 4 panel lights (which measured 1.5x 4ft) in the main kitchen area did not have a light bulb that was operating. d. The light strip (which measured 2.5 ft) inside the refrigerator in the kitchen storage room was not attached on one side and the LED bulb was not operating. e. The overhead ceiling light bulb in the kitchen employee staff room was not operating. During an interview with the Dietary Manager on 10/1/24 at 10:45 am, she stated that having functioning light bulbs with covers in the kitchen would increase the overall safety of kitchen operations. The Dietary Manager stated that she had not completed a work order request for the lights to be repaired. During an interview with the Administrator on 10/1/24 at 10:55 am, he stated that having functioning overhead lights in the kitchen would provide additional illumination for kitchen operations. Record review of the facility's policy on General Kitchen Safety Guidelines, policy number 05.001, Section 5-1, dated 2018 stated that the facility will follow basic safety guidelines to reduce the risk of accidents and ensure the safety of employees. The facility will keep all equipment in working order and report any malfunctioning to the Maintenance Dept.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible, and resident receives adequate supervision and assistance devices to prevent accidents for 1 (100 hall) of 6 hallways reviewed for accidents and hazards, in that: The shower room on 100 hall was unlocked and contained a disinfectant cleaner with a warning label, Danger, Keep Out of Reach of Children. This deficient practice could result in residents, staff, and or the public exposure to a potentially dangerous substance. The findings were: Observation on 10/01/2024 at 10:42 a.m. revealed the shower room on 100 hall was unlocked. Further observation revealed a supply cabinet was unlocked with both doors open and at the front of the cabinet was located a 16-ounce spray bottle of disinfectant labeled Danger, Keep Out of Reach of Children. During an interview with LVN A on 10/01/2024 at 10:45 a.m., LVN A confirmed the shower room on 100 hall was unlocked and contained an open supply cabinet with a 16-ounce spray bottle of disinfectant labeled Danger, Keep Out of Reach of Children. LVN A confirmed that the disinfectant was potentially accessible to residents and should not have been. During an interview with the Administrator on 10/03/2024 at 5:15 p.m., the Administrator confirmed that disinfectant cleaner should not be accessible to residents. Record review of the facility policy, General Housekeeping Policies, undated, revealed, The facility provides sufficient housekeeping and maintenance personnel, equipment, and supplies to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents reviewed for accidents (Resident #1). CNA A failed to use a gait belt while performing a sliding board transfer for Resident #1 resulting in Resident #1 being improperly lowered to the ground and receiving a fracture of the proximal tibia and fibula (a fracture or break in the shinbone just below the knee). This deficient practice could affect residents at the facility who required a gait belt while receiving sliding board transfers by contributing to injury. The findings included: Record review of Resident #1's face sheet revealed Resident #1 was an [AGE] year-old female who admitted to the facility on [DATE] and had diagnoses of anxiety, type 2 diabetes mellitus, depression, chronic kidney disease and paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease). Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident # 1 had a BIMS of 11, indicating mild cognitive impairment. The MDS revealed Resident #1 had impairment on one side of the lower extremity (hip, knee, ankle, foot) and used a wheelchair for mobility. In addition, the MDS revealed Resident #1 required substantial assistance with bed to chair transfers. Record review of Resident #1's care plan, dated 07/20/2023, revised 06/24/2024, revealed Resident #1 was a fall risk and Resident #1 required assistance with ADL self-care performance related to paralysis from the waist down. Record review of Resident #1's fall risk evaluation, dated 05/13/2024, revealed Resident #1 was categorized as low fall risk and revealed Resident #1 had a balance problem while standing/walking. Record review of Resident #1's fall risk evaluation, dated 06/24/2024, revealed Resident #1 was categorized as high fall risk and revealed Resident #1 had 1-2 falls in the past 3 months. Record Review of Resident #1's incident report completed by LVN B, dated 06/24/2024, revealed LVN B was notified of a witnessed fall by CNA A on 06/24/2024 around 2:30p.m. The incident report revealed LVN B entered Resident #1's room and observed the resident lying on her back on the floor with her feet under the bed and the wheelchair brakes locked, room well-lit and uncluttered. The report revealed CNA A stated resident pushed hard against the wheelchair and caused the wheelchair to move away from the sliding board. She started to lean so I lowered her to the floor. The report said Resident #1 was hollering call the EMS and complained of pain to lower back and hips bilaterally. The incident report revealed 911, Resident#1's physician and Resident #1's responsible party were notified. Record review of Resident #1's hospital diagnostic results revealed an x-ray was completed of the right knee, 06/24/2024 at 5:27pm. The results of the x-ray revealed a subtle fracture proximal tibia and fibula. Record review of hospital physician progress note, dated 06/25/2024 at 11:28am, stated patient was evaluated by ortho and it is recommended to remain non weight bearing to her right LE and wear a knee immobilizer for 6 weeks. Xrays are to be repeated at 6 weeks to verify healing. Record review of facility investigation document, undated, provided by the Administrator, revealed under the investigation/conclusion summary, CNA A also mentioned that the resident was beginning to fall forward and turned the resident around so that she could assist her to the floor on her buttocks. The resident's legs were twisted upon her being turned around and this potentially caused the fractures. During an interview with Resident #1's family member, 06/26/2024, the family member stated she was notified on 06/24/2024 that Resident #1 was lowered to the ground during a sliding board transfer, was complaining of pain and was being sent to the hospital. She said she was notified by the hospital on 06/26/24 that Resident #1 sustained fractures to Resident #1's tibia and fibula. Resident #1's family member stated she was aware that Resident #1 was using a sliding board for transfers and said Resident #1 told her the wheelchair was not locked and it moved away from the sliding board. Record review of a handwritten statement signed by CNA A, dated 06/24/2024, stated while setting up for the slide board transfer, check points were made to ensure the safety of the resident and employee. The wheelchair in use was locked and placed directly next to the bed, and the proper clothing and tennis shoes were being worn by both the employee and resident. After the sliding board was properly placed under the resident, they attempted to place more of their body on the board and grabbed the arm of the wheelchair for assistance and stability. This caused an imbalance leading to the resident pushing the wheelchair away from the bed. Resident started to slide down slowly; employee the lowered resident to the floor; landing them softy on their back. During an interview on 06/27/2024 at 12:10p.m., CNA A stated she received training from another CNA on using the sliding board for transfers for Resident #1 to and from the bed to the wheelchair. CNA A said on 6/24/2024, she set up the sliding board between the wheelchair and the bed and locked the wheelchair brakes. CNA A said Resident #1 was sitting on the board and CNA A bent down to move Resident #1's feet so she could slide down the board onto the wheelchair. CNA A said Resident #1 became anxious and pushed on the wheelchair causing it to move and Resident #1 begun falling forward. CNA A said she was trying to prevent Resident #1 from falling on her face so, in a quick reaction, turned Resident #1's upper torso thinking she would be able to sit her down on her buttocks. CNA A said Resident #1's legs got tangled up under the wheelchair because Resident #1 was unable to move her legs. CNA A said she realized, after the fact, that she should not have tried to turn Resident #1 while lowering her to the floor. CNA A was asked if she was using a gait belt for the transfer and she said, I'm not going to lie, no I didn't. CNA A said she was trained to use a gait belt during orientation and was aware that the facility required all staff to use a gait belt during resident transfers. During an interview on 06/27/2024 at 12:42p.m., LVN B said on 06/26/2024, she was returning from break and CNA A called her and told her Resident #1 had a fall and was on the ground in her room. LVN B said when she entered the room, Resident #1 was lying on the ground on her back, the wheelchair was next to the bed, and she observed the wheelchair wheels in the locked position. LVN B said Resident #1 was complaining of pain in her lower back and hips, so LVN B reported it to the physician and called 911. LVN B said she called and notified Resident #1's family member of the fall and pending transport to the hospital. LVN B said CNA A told her that CNA A was using the sliding board and Resident #1 had her hand on the wheelchair and Resident #1 pushed on it and it caused her to launch forward and fall. During an interview on 06/27/2024 at 1:49p.m., the PT stated Resident #1 was on therapy services in March 2024, April 2024 and again on 06/17/2024. The PT stated Resident #1 was able to safely perform a sliding board transfer with one person assist. The PT stated Resident #1 was taught to use the sliding board transfer with one person when she was on therapy services from 03/16/24 through 05/15/2024. The PT stated therapy provided training to staff on using the sliding board transfer. The PT stated she would not have turned Resident #1 while lowering her to the ground and would have tried to counter the motion of Resident #1 falling forward and would lower her to the ground in the direction Resident #1 was falling. During an interview with the DON, 06/27/2024 at 2:35p.m., the DON stated Resident #1 was a one person transfer with a sliding board. The DON stated CNA A received training on using a gait belt during orientation and completed competency skills check on completing transfers with a gait belt. The DON stated the expectation was all transfers are completed with the use of a gait belt. The DON said residents are at risk for injuries if staff do not use a gait belt and stated, if the CNA was wearing her gait belt, it would have been easier for her to lower Resident #1 to the ground. The DON also stated CNA A should not have twisted Resident #1 around when she was lowering her to the floor. The DON said, the proper way to lower a person to the ground includes a gait belt and lowering the person down in the direction they are falling. The DON stated no other residents in the facility use a sliding board as a device for transfers. During an interview with the Administrator and DON, 06/28/2024 at 9:18a.m., the DON stated the facility-initiated in-services on fall prevention and completed return demonstration with direct care staff regarding the use of gait belts for transfers and how to properly lower residents to the floor during an assisted fall. The Administrator and DON stated no direct care employees would work the floor until they had received the training and performed return demonstration. Record review of facility document titled, One on One Inservice and dated 06/25/2024, revealed sliding board reenactment, sliding board reeducation with return demonstration with therapy. The return demonstration outcome stated, staff member able to properly demonstrate sliding board transfer. The document was signed by CNA A, DON, and PTA. Record review of facility document revealed CNA A completed an online training certificate of completion for a course titled, Falls, Assessment and Prevention, completed on 05/06/2024. Record review of facility document titled, C.N.A. Competency Skills Check List, revealed CNA A received a competency check off on transfer (gait belt use) on 05/08/2024. Record review of a document titled, Inservice Training Report, dated 06/25/2024, revealed staff received education on fall management and abuse and neglect and was signed by 28 employees. Record review of a document titled, Inservice Training Report, dated 06/27/2024, stated the summary of the training was resident safety during transfers and properly lowering a resident to the floor and resident safety during transfers utilizing a gait belt. The undated or titled document attached to the in-service training listed the steps for lowering a patient to the floor as 1. If a patient starts to fall and you are close by, move behind the patient and take one step back. Look and be attentive to cues if a patient is feeling dizzy of weak. 2. Support the patient around the waist or hip area or grab the gait belt. Bend your leg and place it in between the patient's legs. Hand placement allows for a solid grip on the patient to guide the fall. 3. Slowly slide the patient down your leg, lowering yourself at the same time. Always protect the headfirst. Lowering yourself with the patient prevents back injury and allows you to protect the patient's head from hitting the floor or hard objects. 4. Once the patient is on the floor, assess the patient for injuries prior to moving. Assesses patient's ability, or need for additional help, to get off the floor. 5. Provide reassurance and seek assistance if required. If required, stay with the patient, and call out for help. The in-service was signed by 52 employees. Record review of a document labeled, direct care staff and undated, had 53 employee names listed.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. There were storage containers of food in the reach in cooler that were not properly sealed. 2. Cook E wore jewelry on both hands while engaged in food preparation in the kitchen. 3. Cook E portioned food onto plates in an unsanitary manner during the lunch meal service on 08/24/2023. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 08/22/2023 at 10:20 a.m. in the reach in cooler revealed a clear, plastic 2-quart container filled with sliced American cheese. One corner of the lid on the container was not sealed, revealing a gap between the container and the lid and exposing the cheese to potential contamination. Further observation in this reach-in cooler revealed a 2-quart container filled with sliced deli ham, a 2-quart container with chicken gravy, and a 2-quart container with chopped beef. All of the containers had lids that were sealed on three sides but had one side that was not sealed onto the container, revealing a gap between the lid and container and exposing the contents of the containers to the ambient air in the cooler and potential contamination by pathogens and bacteria. Interview on 08/22/2023 at 10:22 a.m. with the DM revealed all four plastic containers of food in the reach-in cooler were not tightly sealed. The DM stated she did not know why the containers were not properly sealed and that dietary employees were trained to label, date and completely seal all food stored in the coolers. The DM further stated that the container of chopped beef had to be discarded because, I can't get the lid to stay down. The DM stated it was important to ensure food was completely sealed prior to storage to ensure the food was not subject to cross contamination and also to prevent spoilage which could lead to food borne illness. The DM stated both she and the consultant dietitian trained dietary employees on various food service and sanitation topics monthly. Food service sanitation was also a topic included in the facility's online training program. 2. Observation on 08/24/2023 at 10:32 a.m. in the kitchen revealed Cook E was preparing food for the lunch meal. Cook E had a wedding band set that included a diamond ring on the ring finger of both her left and right hands. Without donning gloves, Cook E placed a pan of ham inside the oven, dropped French fries in a pan of oil on the stove, and poured rice in a pan of water on the stove and stirred it periodically. 3. Observation on 08/24/2023 at 11:53 a.m. revealed Cook E portioned food from the steam table onto plates while assembling trays for the lunch meal. Cook E did not wear gloves. Cook E grasped the plates in a manner whereby the lip of the plate was between her thumb and forefinger and her thumb pressed down on the well of the plate where she placed the food. Interview on 08/24/2023 at 11:56 a.m. with the Consultant Dietitian revealed he observed Cook E's jewelry on her hands and her bare thumb on the plates but had been focusing on ensuring the serving sizes were correct. The Consultant Dietitian further stated Cook E should not have been wearing more than a solid wedding band on one hand and Cook E should have worn gloves while portioning food onto the plates to prevent potential cross contamination of the food. Interview on 08/24/2023 at 12:01 p.m. with the DM revealed she noted Cook E was wearing jewelry on her hands and should not have been, and also that Cook E was plating food without gloves. The DM stated she trained all her dietary staff they could not wear jewelry on their hands because the food could be contaminated by bacteria and cause food borne illness. The DM further stated Cook E always wore gloves and this was not common for her. Interview on 08/24/2023 at 12:01 p.m. with Cook E revealed she knew she could not wear bracelets or a watch while preparing food in the kitchen but she was never told she could not wear her rings in the kitchen. Cook E further stated she wore gloves on and off during her shift in the kitchen that day and had simply forgot to put them on prior to plating food for the lunch service. Record review of facility policy 03.003 Food Storage revised 06/01/2019 revealed, 2. Refrigerators. d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. Record review of facility policy 04.001 Employee Sanitation dated 10/01/2018 revealed, 3.f. No jewelry can be worn on the arms and hands while preparing food, except for a single plan ring such as a wedding band. 4. Other practices. b. Cups, glasses and bowls must be handled so that fingers or thumbs do not contact inside surfaces or lip-contact outer surfaces. 6. Use of gloves. d. Change gloves: i. Between each food preparation task. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 3-305.11, revealed: Preventing Contamination from the Premises - Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 2-303.11, revealed, Jewelry Prohibition. Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 3-301.11, revealed, Preventing Contamination from hands. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 4-904.11, revealed: Kitchenware and Tableware. (A) SINGLE-SERVICE and SINGLE-USE ARTICLES and cleaned and SANITIZED UTENSILS shall be handled, displayed, and dispensed so that contamination of FOOD-and lip-contact surfaces is prevented.

Based on observation, interviews and record reviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident for 1 of 24 residents (Resident #5) observed for dignity, in that: LVN A stood while she fed Resident #5 at lunchtime. This deficient practice could affect residents who require feeding and could result in decreased self-esteem. The findings were: Review of Resident #5's electronic face sheet dated 08/22/2023 revealed she was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's disease (progressive and irreversible condition that affects the brain and causes dementia), dementia (loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), Parkinson's disease (a chronic disorder of the nervous system that affects movement and other functions), and congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath). Review of Resident #5's quarterly MDS assessment, with an ARD of 07/17/2023, revealed the resident had scored a 00/15 on her BIMS which indicated she was severely cognitively impaired. Further review revealed the resident was totally dependent on staff for eating and required one person assist. Review of Resident #5's comprehensive care plan, with a revised date of 11/03/2022, revealed, Problem .has an ADL self-care performance deficit r/t Alzheimer's, confusion, fatigue, limited mobility and limited ROM .Interventions .Eating: The resident requires extensive assistance by one staff to eat. Review of Resident #5's Active Orders as of: 08/22/2023 revealed, Regular diet, pureed texture, pudding thickened liquids consistency, fortified meal plan all meals related to dysphagia (A condition with difficulty in swallowing food or liquid). Observation on 08/22/23 at 12:40 p.m. of Resident #5 revealed the resident was sitting at a dining table in a tall wheelchair in the dining room and LVN A stood over her and was feeding her. LVN B brought a chair over to LVN A and said to her, This chair is for you to sit down. LVN A looked at LVN B and continued to feed Resident #5 while standing. Interview on 08/24/2023 at 1:39 p.m. with LVN A who fed Resident #5 revealed she did not know she was supposed to sit to feed a residents and that she was upset to think that she might have affected Resident #5's dignity by looking down on her. Interview on 08/24/2023 at 1:50 p.m. with LVN B who brought a chair for LVN A to sit in when she fed Resident #5 revealed when she gave LVN A the chair she stated, the look LVN A gave me told me to not go any further with it. LVN B stated it was important to maintain self- esteem and respect a resident's dignity, and staff were trained to sit when they fed residents. Interview on 08/25/2023 at 11:01 a.m. with the DON revealed LVN A should have sat down in a chair to maintain eye level with Resident #5 when she fed her. The DON stated staff were trained to respect the residents who needed assistance with feeding and to sit next to them, not stand. The DON stated that standing and looking down on a resident could make them feel worthless. Review of the facility policy and procedure titled Promoting/Maintaining Resident Dignity During Mealtimes dated 01/13/2023 revealed It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner an in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident .all staff will be seated .while feeding a resident.

Based on observation, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 8 residents (Resident #12) reviewed for MDS assessments, in that: Resident #12's MDS assessment inaccurately reflected he had a stage 3 pressure ulcer. This deficient practice could affect residents who require assessments and could result in missed or inaccurate care. The findings were: Review of Resident #12's electronic face sheet dated 08/24/2023 revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cerebral infarction (refers to death of tissue, and a brain lesion in which a cluster of brain cells die when they don't get enough oxygen), peripheral vascular disease (a systemic disorder of narrowed peripheral blood vessels resulting from a buildup of plaque. Characterized by reduced circulation of blood to body part, other than the brain or heart), and chronic osteomyelitis (long-lasting or recurrent infection of the bone and its surrounding tissues). Review of Resident #12's quarterly MDS assessment, with an ARD of 07/31/2023, revealed he had 1 Stage 3 pressure ulcer. Further review revealed the resident had scored a 12/15 on his BIMS which indicated he was moderately cognitively impaired. Review of Resident #12's comprehensive care plan, with a revised date of 06/08/23, revealed, has a stage 3 pressure ulcer of the left lateral leg r/t prosthetic use .Interventions .administer treatments as ordered. Review of Resident #12's Wound Evaluation & Management Summary, dated 06/26/2023, revealed, stage 3 pressure wound to left, distal, lateral knee (Resolved on 06/26/2023). Review of the facility Weekly Pressure Injury Treatment Report, dated 06/29/2023, revealed, Resident #12 .stage 3 left lateral leg .resolved. Observation on 08/24/2023 at 1:30 p.m. of Resident #12 revealed the resident was sitting in his room with his bilateral prosthetic lower legs in place. Interview on 08/24/2023 at 1:35 p.m. with Resident #12, when asked by the surveyor if the resident had a wound still on his left leg, the resident stated no, it healed out a while ago. Interview on 08/25/2023 at 10:00 a.m. with LVN A, LVN A stated Resident #12's pressure sore should have been resolved on the MDS and the comprehensive care plan. LVN A did not know how she missed that it was healed. LVN A stated the MDS triggers areas on the care plan. Interview on 08/25/2023 at 11:01 a.m. with the DON revealed Resident #12's pressure sore healed and she did not know why it was still reflected. The DON stated it was important for both the MDS and the care plan to be accurate to communicate the type of care required for the resident. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, October 2019 revealed Section M0300C: Stage 3 Pressure Ulcers revealed Enter the number of pressure ulcers that are currently present and whose deepest anatomical stage is Stage 3. Further review revealed The RAI process increases clinical relevancy, data accuracy, clarity, and notably adds more to the resident voice in the assessment process.

Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #72) reviewed for comprehensive care plans, in that: Resident #72's wishes for DNR status was not reflected in her comprehensive care plan. This deficient practice could result in residents wishes for advanced directives to not be honored and could result in residents who do not want CPR getting CPR performed on them. The findings were: Review of Resident #72's electronic face sheet dated [DATE] revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of hypothyroidism (condition where the thyroid gland doesn't make enough thyroid hormone affecting the body's metabolism), cerebral infarction (refers to death of tissue, and a brain lesion in which a cluster of brain cells die when they don't get enough blood), and acute pain (pain that begins suddenly and does not last long). Review of Resident #72's quarterly MDS assessment, with an ARD of [DATE], revealed the resident had scored a ,d+[DATE] on her BIMS which indicated the residentwas moderately cognitively impaired. Further review revealed the resident could understand others and be understood. Review of Resident #72's comprehensive care plan, with a revised date of [DATE], revealed, Problem .is a full code .Interventions .if resident has a cardiac arrest, initiate CPR. Review of Resident #72's Active Orders As of: [DATE] revealed DNR .Order Date [DATE] .Start Date XXX[DATE]. Further review revealed the DNR order for Resident #72 was entered into the facilty's electronic medical records system by LVN C. Review of Resident #72's Out-of-Hospital DNR paperwork, dated [DATE], revealed it was completed and signed. Observation on [DATE] at 2:00 p.m. of Resident #72 in the resident's room revealed the resient was sitting in a wheelchair reading a book. Interview on [DATE] at 2:05 p.m. with Resident #72, the resident stated she was [AGE] years old and that she did not want anything extra done to her and wished to have DNR status. Interview on [DATE] at 10:00 a.m. with LVN A revealed she was one of the staff who completed the residents' care plans and she also did the MDS assessments. LVN A stated Resident #72's DNR status should have been reflected in the resident's care plan and that she did not know why it was not. LVN A stated it was important because Resident #72 did not want CPR and that needed to be communicated. Interview on [DATE] at 10:09 a.m. with LVN C revealed she put Resident #72's DNR order into the electronic medical record. LVN C stated that when a resident returned from the hospital, the comprehensive care plan needed to be revised to reflect the resident's changes and current preferences. LVN C stated she did not know how the care plan update was missed, but it could result in a resident getting CPR when they did not want to have those measures taken. Interview on [DATE] at 11:01 a.m. with the DON, the DON stated she did not know how Resident #72's DNR order was missed and not placed into a revised comprehensive care plan for the resident. The DON stated that it was important for staff to know what the resident's preferences are for advanced directives and care requirements. Review of the facility policy and procedure titled Comprehensive Care Plans dated [DATE] revealed The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment .Other factors identified by the interdisciplinary team, or in accordance with resident's preferences, will also be addressed in the plan of care.

Based on observation, interviews and record reviews, the facility failed to review and revise the comprehensive care plan by the multidisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 8 residents (Resident #12) reviewed for comprehensive care plans, in that: Resident #12's comprehensive care plan was not revised to reflect he no longer had a Stage III pressure sore. This deficient practice could affect residents with comprehensive care plans and could result in missed or unnecessary care. The findings were: Review of Resident #12's electronic face sheet dated 08/24/2023 revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cerebral infarction (refers to death of tissue, and a brain lesion in which a cluster of brain cells die when they don't get enough oxygen), peripheral vascular disease (a systemic disorder of narrowed peripheral blood vessels resulting from a buildup of plaque. Characterized by reduced circulation of blood to body part, other than the brain or heart), and chronic osteomyelitis (long-lasting or recurrent infection of the bone and its surrounding tissues). Review of Resident #12's quarterly MDS assessment, with an ARD of 07/31/2023, revealed the resident had 1 Stage 3 pressure ulcer. Further review revealed the resident had a score of 12/15 on his BIMS which indicated he was moderately cognitively impaired. Review of Resident #12's comprehensive care plan with a revised date of 06/08/23 revealed has a stage 3 pressure ulcer of the left lateral leg r/t prosthetic use .Interventions .administer treatments as ordered. Review of Resident #12's Wound Evaluation & Management Summary dated 06/26/2023 revealed stage 3 pressure wound to left, distal, lateral knee (Resolved on 06/26/2023). Review of the facility Weekly Pressure Injury Treatment Report dated 06/29/2023 revealed Resident #12 .stage 3 left lateral leg .resolved. Observation on 08/24/2023 at 1:30 p.m. of Resident #12 revealed he was sitting in his room with his bilateral prosthetic lower legs in place. Interview on 08/24/2023 at 1:35 p.m. with Resident #12, when asked by the surveyor if he had a wound still on his left leg, he stated no, it healed out a while ago. Interview on 08/25/2023 at 10:00 a.m. with LVN A, LVN A stated Resident #12's pressure sore should have been resolved on the comprehensive care plan. LVN A stated she did not know how she missed that it was healed. LVN A stated the MDS triggers areas on the care plan. Interview on 08/25/2023 at 11:01 a.m. with the DON revealed Resident #12's pressure sore healed and she did not know why it was still reflected on his care plan. The DON stated it was important for both the MDS and the care plan to be accurate to communicate the type of care required for the resident. Review of the facility policy and procedure titled Comprehensive Care Plans dated 10/24/2023 revealed The comprehensive care plan will be reviewed after each comprehensive and quarterly MDS assessment.

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 to help prevent the development and transmission of communicable diseases and infections, for 2 residents of 7 residents (Residents #34 and #183) observed for infection control, in that: LVN D failed to sanitize the blood pressure cuff between Residents #34 and #183 to prevent cross contamination. This deficient practice had the potential to affect residents in the facility by placing them at risk of contracting, spreading and/or exposing them to pathogens that could lead to the spread of communicable diseases. The findings included: In an observation on 08/23/2023 at 9:17 a.m. LVN D was observed to take Resident #183's blood pressure prior to administering her anti-hypertensive medication and did not sanitize the blood pressure cuff. In an observation on 08/23/2023 at 9:22 a.m. LVN D was observed to take Resident #34's blood pressure prior to administering her anti-hypertensive medication after Resident #183's and did not sanitize the blood pressure cuff. In an interview on 08/23/2023 at 9:22 a.m. with LVN D he stated he was not aware of any of the residents to whom she had administered medications that morning who might have a communicable illness. LVN D stated it was possible that any of the residents might be asymptomatic for a contagious illness such as COVID as it could take several days before symptoms appeared. LVN D stated he knew he was supposed to sanitize the pressure cuff or other equipment between residents to prevent cross contamination. In an interview on 08/25/2023 a.m. with the DON, she stated the facility policy was for multiuse equipment to be sanitized after each use to ensure cross contamination did not occur. The DON stated her expectation was that equipment be cleaned after each resident to prevent the spread of illness. Review of the facility policy and procedure titled Infection Prevention and Control Program dated 05/13/23, revealed Standard Precautions .All staff shall assume that all residents are potentially infected with an organism that could be transmitted during the course of providing resident care services .all reusable items and equipment shall be cleaned in accordance with our current procedures.

Based on record review and interview, the facility failed to develop and implement written policies and procedures which prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 2 residents (Residents #10 and #40) reviewed from abuse and neglect, in that: The facility did not allegations of abuse and neglect were reported to the state survey agencies (HHSC) regarding an incident involving a Resident-to-Resident altercation between Residents #10 and #40 in which one of the residents acted in a willful manner to cause an injury to another resident. This failure could place residents at risk of further abuse and neglect due to the lack to state agency reporting requirements being completed by the facility. The findings include: Record review of Resident # 10's face sheet, dated 07/08/22, revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #10's quarterly MDS, dated [DATE], revealed a BIMS score of 4 which indicated severe cognitive impairment. Record review of Resident #10's care plan, revised 06/30/22, revealed the resident had the potential to be physically aggressive with poor impulse control with a history of Resident-to-Resident altercations. Record review of Resident #40's face sheet, dated 7/7/22 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #40's quarterly MDS, dated [DATE] revealed a BIMS score of 0 which indicated severe cognitive impairment. Record review of Resident #40's care plan, revised on 1/18/22 revealed the resident had verbal aggression due to dementia. During an interview with the LVN A on 07/07/22 at 10:30 a.m., LVN A stated she directly witnessed the Resident-to-Resident interaction between Residents #10 and #40 which occurred on 06/24/22 at 1:00 p.m. in the dining room. LVN A stated Resident #40 was talking to himself and Resident #10 began laughing at Resident #40. LVN A stated Resident #40 shouted at Resident #10 to not laugh and Resident #10 then charged towards Resident #40 knocking him to the floor. LVN A stated the residents were immediately separated. LVN A stated she assessed Resident #40 who sustained a red mark of unknown description on his arm. LVN A stated she felt the red mark on the arm probably occurred whenever Resident #40 hit a chair with his arm while falling down. LVN A stated Resident #40 also had a skin abrasion on his upper back as a result of the altercation. LVN A stated Resident #10 had sustained no injuries. During an interview with the Social Worker on 07/07/22 at 4:15 p.m., the Social Worker stated she had interviewed Residents #10 and #40 about the Resident-to-Resident altercation incident. The Social Worker stated Resident #10 stated that he did,jump on, (physically strike) Resident #40 because he did not like him. The Social Worker stated she felt if Resident #10 was feeling like this again, he would probably take things into his own hands (physically strike a resident). The Social Worker stated she was not aware of any previous record of any physical interaction between Residents #10 and #40. The Social Worker stated facility staff had monitored the two residents' behavior and they stayed on opposite sides of the dining room. The Social Worker stated psychiatric services had worked with both residents. During an interview with the Administrator on 07/07/22 at 4:30 p.m. regarding the altercation incident between Residents #10 and #40, the Administrator stated she had not reported the incident. The Administrator stated it was her understanding, looking at the regulation crosswalk, a Resident-to-Resident incident of two residents with dementia, that was witnessed by staff, and resulted in only a minor injury of an abrasion on the upper back of one of the residents, did not need to be reported. The Administrator stated she did not feel there was a potential risk to the residents by not reporting this incident since the facility continued to monitor their behaviors closely. Record review of the facility's incident report of the altercation between Residents #10 and #40 which occurred on 06/24/22 revealed Resident #40 sustained an abrasion on the left shoulder as a result of the altercation. Resident #10 had sustained no injury. Record review of the facility's abuse/neglect policy included the facility notification requirement to state agency of any abuse/neglect allegations.

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accident hazards/supervision, in that: CNA A performed the 2-person mechanical lift by herself without requesting assistance from another staff member, resulting in Resident #1 slipping from the mechanical lift. Resident #1 was sent to a local ER and was diagnosed with a subdural hemorrhage (bleeding in the brain), and subarachnoid hemorrhage (bleeding in the brain). This failure could result in residents experiencing accidents, injuries and/or a diminished quality of life. The findings were: Record review of Resident #1's face sheet, dated 5/20/22, revealed an admitted [DATE] and a re-admitted [DATE] with diagnoses that included: [CONDITION(S)] (a disease of the nervous system), contracture of muscle, major depressive disorder, and need for assistance with personal care. The resident was a female age 78. RP was listed as a family member. Advanced directive was DNR (do not resuscitate). Record review of Resident #1's quarterly MDS (minimum data set), dated 4/7/22, revealed, o BIMS (brief interview of mental status) Score was 99 ( unable to answer questions) o ADLs (activities of daily living): B/B (bowel and bladder) incontinent. Transfer was total dependence two persons physical assist. Bed Mobility was extensive assistance with two-person physical assist. ROM (range of motion) contracture to both left and right hands. [Resident's history of falls triggered the assessment; interventions were found in the care plan]. Record review of Resident #1's care plan, undated, revealed: resident had a subdural hemorrhage (bleeding in the brain), subarachnoid (bleeding in the brain), hemorrhage (bleeding in the brain), and right forehead laceration, and an abrasion to right hip. Problem: The resident has had an actual fall on 5/18/22 with laceration X2 to forehead. Interventions included: [NAME]-checks Problem: (Resident #1) is at risk for falls (related to) [CONDITION(S)], weakness. Interventions included: [Mechanical] lift X 2 staff members with medium sling. Problem: (Resident #1) has an ADL self-care performance deficit (related to) [CONDITION(S)]. Interventions included: The resident required [Mechanical] lift with 2 staff assistance. Record review of Resident #1's local ER (emergency room ) report, dated 5/18/22 at 5:38 PM CT (Cat scan) scan of head revealed resident had a subdural hemorrhage (bleeding in the brain), and a subarachnoid (bleeding in the brain). Record review of Resident #1's specialized hospital ER summary, dated 5/18/22 revealed, status post fall from [Mechanical] lift and resident experienced a subdural hemorrhage (bleeding in the brain), and a subarachnoid (bleeding in the brain). [Resident went from local ER to specialized hospital and returned to facility on 5/19/22]. Record review of Resident #1's Fall Risk Evaluation, dated 11/13/2018, revealed a score of 11 (high risk for falls (a score of 10 or greater meant a high risk for falls).[Only Fall Risk assessment in the medical record] Record review of Resident #1's Nurse Note dated 5/18/22 at 3:50 PM authored by LVN M revealed that, CNA J alerted LVN M that Resident #1 had fallen from a [Mechanical] lift. LVN A entered the resident's room and was told by CNA A I transferred resident by myself without assistance from (wheelchair). The resident fell face forward. LVN M found resident on the floor lying flat on back, laceration X2 to (right) side of forehead, #1 (longest laceration), 5.30.7X0.3(centimeter); . #2 (small laceration) 1.0X0.1 .the nurse assessed NVS (neuro vital signs), first aid done .DON and Administrator (notified) .message left with MD and RP . [EMS arrived at 3:30 PM] Record review of Resident #1's Nurse Note dated 5/18/22 authored by LVN M read, Resident resting on back pressure noted to right side of forehead, VS (vital signs): 127/90 (blood pressure 9 normal), 92 (pulse-high), 18 (respiration-normal), 94% RA room air-normal), 97.0 (temperature-normal). Unable to check pupils due to Resident clenching eyes shut . Record review of Resident #1's ADL sheet for the Month of May 2022 revealed, a one person transfer on 5/18//22 by CNA A. All previous transfers in May 2022 for Resident #1 were accomplished by 2 staff assistance. [Information not available as to whether CNA A participated in any 2 person transfers with Resident #1 in May 2022.] Record review of Resident #1's weekly skin assessment, dated 5/19/22, revealed, the resident had a laceration to right side of forehead and discoloration observed around right periorbital (tissues surrounding the orbital of the eye) and right side of nose. Approximately 10 stitches to area. Observation and interview on 5/20/22 (Friday) at 10:27 AM, Resident #1 was in bed, alert and not oriented, TV on for stimulation (per DON comment). Laceration to right side of forehead with 10 stitches in place, laceration above the right eyebrow no stitches or staples, discoloration around the right eye with swelling, discoloration of the bridge of the nose, discolored left hand with palm protectors, no bruises present in areas the surveyor could view as a social worker. The resident did not reveal signs of abuse such as bruises or wounds caused by being struck by a person. Low bed and a pressure release call light was in reach; room was cleaned; there were no fall hazards; and the room was homelike. The resident was confused. Surveyor's direct questions and Resident's responses were: What happened to your forehead? Response I do not know. Have you fallen? No response given. Did someone try to pick you up: Response eight. Do you feel safe here? No .I am not [response was not complete] .No (response to whether someone is going to hurt her. Do you need help today? Response: Yes .[no further response]. Is someone going to hurt you today? Response: No. Do you remember how you fell two days ago? No response given. Are you comfortable: Response: Yes? Are you in pain? Response No. [Second observation of Resident #1 was made on 5/23/22 (Monday) at 9:45 AM] During an interview on 5/20/22 at 10:47 AM, LVN G, stated, what was reported to me (LVN G) by CNA (J) was that CNA (A) called for help on 5/18/22 because Resident (#1) slipped from the [Mechanical] lift and was on the floor bleeding from the head . LVN M went in the room and observed the resident on the floor and first aid was administered EMS called .resident was alert and crying .CNA (A) was sent home pending an investigation . During an interview on 5/20/22 at 1:14 PM, RN H stated, I was not the charge nurse on the day of the incident (5/18/22) but I was standing at the desk when the incident happened .CNA (J) stated that Resident (#1) fell from a [Mechanical] lift and was on the floor LVN I and I entered the room .we assessed the Resident and she had blood on her head and we called 911 immediately .when we got in the room, CNA (A) was present and said nothing .she did not want to explain what happened .we sent her home pending an investigation .any [Mechanical] lift is a two person procedure (as part of facility competency checklist with demonstration done by the DON or a designee) and I do not know why a one person lift was attempted after the incident, the facility started training on [Mechanical] lifts .the training stressed that there should always be two staff present so as to avoid injury and keep the resident safe .the residents today who require [Mechanical] lifts are safe .I received on 5/19/22 training on [Mechanical] lift . During an interview on 5/20/22 at 1:36 PM, CNA J stated, I did not assist with a [Mechanical] lift for Resident (#1) on 5/18/22 .but I saw CNA A coming out of the room on 5/18/22 in the evening around 4:15 PM stating she needed a nurse because the resident had fallen .I observed the room and (CNA A) was the only person with the resident on the floor with blood on the floor .(CNA A) said the resident had fallen out of the lift .in my training only 2 staff should do a lift .I cannot say why (CNA A) attempted the lift by herself .after the incident I was re-trained on abuse and neglect and [Mechanical] lifts on 5/19/22 and some of the keys points were: check safety, check that resident is comfortable and two staff present for the lift . During a telephone interview on 5/20/22 at 2:30 PM, CNA A, stated, I was never trained on doing [Mechanical] lifts .I just signed documents I was trained on [Mechanical] lifts .in the Month of May 2022, I estimate doing 20 [Mechanical] lifts without assistance because of short nurse aide staffing .I did the [Mechanical] lift alone on 5/18/22 and did not ask for help because the facility is always short on staff .as for documentation .it is just numbers and I just check off the numbers and do not know what I am checking .I was never trained on [Mechanical] lifts and I did not ask for assistance on 5/18/22 . During an interview on 5/20/22 at 2:39 PM, RN H stated, CNA A received [Mechanical] lift training on 1/27/22 and demonstrated the skill set and knew that a [Mechanical] lift required 2 persons .she did backward demonstration .training was done by me .and she signed the form and I certified that she could do the skill set of [Mechanical] lifts .and she got Reliance training on 7/15/21 on Falls, 10/20/21, 2/25/21, preventing slips and falls on 4/20/21 1/26/22 on body mechanics .in my nursing opinion she was trained not to do a [Mechanical] lift without asking for assistance the charge nurse is responsible to ensure the nurse aides attempt a [Mechanical] lift with two staff members . During an interview on 5/20/22 at 5/20/22 at 3:00 PM, the MD stated, .definitely not, a [Mechanical] lift cannot be done by one person .Day 1 at CNA school is to never attempt a [Mechanical] lift by one person .the Resident (#1) had a bad fall .it appeared to be a violent fall that resulted in a head injury .the resident had contractures and was basically bed bound .I cannot explain why the CNA (A) attempted a one person [Mechanical] lift I was notified of the incident by the ER and made contact with the Nursing Home to get details . During an interview on 5/20/22 at 3:50 PM, CNA K stated, about a month ago I completed a competency with demonstration on [Mechanical] lifts .I was told to never do a [Mechanical] lift by yourself .I have assisted (CNA A) with [Mechanical] lifts in the past and have always been available to help her .I was here on 5/18/22 and she did not ask me for help . During an interview on 5/20/22 at 4:37 PM, LVN M, who was the charge nurse on 5/18/22, stated, this was the first time I worked with CNA (A) and she did not ask for help for the mechanical lift and helped would have been provided .I was responsible for nurse aides on 5/18/22 in hall 100 .a one person [Mechanical] lift is never allowed .do not know why CNA (A) attempted the one person lift given help was available .once the incident was discovered I assessed the resident and EMS was immediately called . Observation on 5/23/22 at 9:45 AM, Resident #1 was in her room, alert but not oriented. Resident was able to say to the surveyor Good morning. No signs of pain, distress or discomfort. Wounds to the head and face were healing. Resident was cleaned and groomed. Resident could not answer any direct questions. During an interview on 5/23/22 at 9:57 AM, the DON stated, .I do not know why she (CNA A) attempted a one person on 5/18/22 .she was competent .and had been given help in the past .the charge nurse was responsible for monitoring ADL's by an CNA .we are going to do unannounced monitoring for the next 4 weeks and PRN to ensure staff adhere to the policy of two person assistance for a [Mechanical]lift . During an interview on 5/23/22 at 10:15 AM, the Administrator stated, .the employee (CNA A) was competent on [Mechanical] lifts and help was available. We cannot explain her actions .she placed residents at risk for injury .to avoid future incidents we will randomly check mechanicals lifts and we monitor often and PRN .the charge nurse was responsible to ensure the safety of residents and to check on ADL documentation and performance .we intend on re-testing for competency on transfer and re-demonstration .as of the present, we have no intention or bringing back to employment CNA A . Record review of facility's Fall Risk policy, undated, read, .the staff will identify appropriate interventions to reduce the risk of falls . Record review of facility's Safe Lifting and Movement of Residents, undated, read, . the use of mechanical lifts with residents requires the assistance of two staff members . Record review of facility's incident log for the months of March, April, and May 2022 did not reveal any incidents involving mechanical lift accidents except for the incident on 5/18/22. Record review of facility's Abuse Prevention Program policy, dated 9/2018, read, .Neglect is defined as failure to provide goods and services necessary to avoid physical, mental anguish . Record review of facility's Internal Investigation, in progress dated 5/18/22 revealed: Resident #1 slipped from a mechanical lift performed by CNA A. CNA A had mechanical lift competencies and staff was available to assist. In-service completed (started 5/18/22); 100% Record review of employee file of CNA A revealed: Date of hire was 4/19/22. Certification # NA (current). Completed mechanical lift competency on 1/27/22 with demonstration. Completed Reliance training on Reliance training on 7/15/21 on Falls, 10/20/21, 2/25/21, preventing slips and falls on 4/20/21 and 1/26/22 on body mechanics.

Based on observation, interview, and record review, the facility failed to ensure routine and emergency drugs were provided to its residents or obtain them under an agreement described in §483.70(g). The facility failed to ensure pharmaceutical services were provided, including procedures that assure the accurate acquiring, receiving, and dispensing of all drugs and biologicals, to meet the needs of each resident for 1 of 1 resident (Resident #1) reviewed for availability of routine and emergency drugs, in that: 1. Resident #1 experienced [DIAGNOSES REDACTED] (drop in blood sugar), was unresponsive and could not be revived at the facility, and the resident was sent out to the hospital. The emergency drug [MEDICATION NAME] (a medication used to treat severe low blood sugar) was not in the facility Emergency Kit (E-Kit) provided by the facility's pharmacy to deal with the resident's emergency. 2. Resident #1 did not receive the initial dose of [MEDICATION NAME] (antibiotic to treat infections) on time, as ordered by the Physician, because it was not available from Pharmacy. These deficient practices could place residents at risk of not receiving the therapeutic benefits of antibiotics, and, if an emergency drug was not available, experiencing harm during an emergency to include the possibility of death. The findings were: Record review of Resident #1's face sheet, undated, revealed the resident was admitted to the facility on [DATE], discharged on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Further review revealed the resident was listed as their own responsible party. Record review of Resident #1's Medicare 5-day MDS, dated [DATE], revealed the resident had a BIMS score of 14, which indicated the resident was cognitively intact. 1. Record review of Resident #1's care plan, undated, revealed goals and interventions for diabetes that included: fasting as ordered, monitor (blood glucose monitoring), check nutrition, and medications. (Monitoring involves complying with time frames on physician orders; and, by nursing practice, checking on a resident every two hours.) Record review of Resident #1's Order Entry Sheets (order dated [DATE]) revealed the medication ordered for diabetes were: Humalog Solution 100 Unit/ML (insulin [MEDICATION NAME]), Subcutaneously, sliding scale; [MEDICATION NAME] Solution Pen-injector 18 MG/3 ML (inject 1.8 mg one time a day); and [MEDICATION NAME] Solution Pen-injector 100 Unit /ML (Subcutaneously at bedtime). Record review of Resident #1's TAR, dated [DATE], revealed the resident received blood glucose monitoring and medication. Further review revealed there was no documentation of blood sugar level issues/concerns noted. Monitoring was based on the Order Entry Sheets described above. Record review of Resident #1's MAR for [DATE] revealed the resident the day prior to the incident, [DATE], had received his prescribed diabetes medications as ordered: Humalog Solution 100 Unit/ML, [MEDICATION NAME] Solution Pen-injector 18 MG/3 ML, and [MEDICATION NAME] Solution Pen-injector 100 Unit /ML. Record review of Resident #1's Nurse Note, dated [DATE] at 2:29 AM, that the nursing staff had conducted blood glucose monitoring. Further review revealed, Resident was un-responsive; MD contacted; nurse attempted to give glucose gel; the glucose IM-kit was not in the (medication) cart . no [MEDICATION NAME] in E-KIT . Record review of Resident #1's ER Record, dated [DATE] at 8:47 AM, revealed, patient presents with Unresponsive/low glucose. The onset was just prior to arrival . During an interview with the Interim DON and LVN A on [DATE] at 11:20 AM, LVN A stated, the purpose of the IM-Kit is to help bring back the sugar levels in the event the glucose gel is ineffective . the MD ordered D50 fluids (a commercially prepared solution of 25 g of [MEDICATION NAME] (simple sugar) in 50 ml of water) (ordered during the emergency) . but family wanted the resident sent to hospital . the IM-kit is required in the (medication) carts . The Interim DON confirmed the E-Kit at the facility on [DATE] did not contain a [MEDICATION NAME] IM-Kit. The Interim DON stated, the sealed E-Kit read on the label that an IM Kit was present . however, when the sealed E-Kit was opened there was no IM-Kit present . one should have been present to avoid harm to a resident experiencing [DIAGNOSES REDACTED] (lower than normal blood sugar) . The Interim DON further stated the, (name of the facility's previous pharmacy) services ended on [DATE] and the new pharmacy effective [DATE] is (name or the facility's new pharmacy) and they gave us another E-Kit. The Interim DON stated, . only one E-Kit was available during the incident on [DATE]. The Interim DON confirmed the facility did not have a policy for the E-kit. The Interim DON stated nursing staff used the item check list on the E-kit to determine the items in the E-kit. During an interview with LVN B on [DATE] at 11:30 AM, LVN B stated, I went into Resident # 1's room to do a glucose check prior to breakfast and found resident unresponsive . checked his sugar which read 67 . did sternal chest rub (the application of painful stimulus with knuckles of closed first to the center chest of a patient who is not alert and does not respond to verbal stimuli to assess the neurological status of an individual) . had MD called . MD ordered an IM injection . the E-kit did not have any [MEDICATION NAME] IM-Kit available . EMS was called . During an interview with LVN B on [DATE] at 11:38 AM, LVN B stated, the MD (Medical Doctor) did not say not to send the resident to the emergency room . MD was giving instructions on how to stabilize the resident . for instance, give resident glucose gel . give IV D5 ([MEDICATION NAME] 5% in water) . the family wanted the resident sent out to EMS when I made contact with them and EMS was called. Observation on [DATE] at 11:45 AM of E-Kit, provided by the facility's previous pharmacy and present during the incident on [DATE], revealed the inventory listed the presence of the IM-Kit and the [MEDICATION NAME]. Further observation of the E-Kit revealed the [MEDICATION NAME] 1 mg per ml vial was marked present by the pharmacy company. During an interview with the Administrator on [DATE] at 12:00 PM, the Administrator confirmed the [MEDICATION NAME] was not present in the facility's E-Kit during Resident #1's hypoglycemic incident on [DATE]. The Administrator stated, I was aware of the issue involving no IM-kit available to the resident that experienced [DIAGNOSES REDACTED] . 2. Record review of Resident #1's physician's orders [REDACTED]. Record review of Resident #1's Nurse Note, dated [DATE], revealed, the [MEDICATION NAME] 500 mg IV was not available from pharmacy for the initial morning dose ([DATE] at 9:00 AM); Resident received dose (on [DATE]) at 10:38 PM. During an interview with the Interim DON on [DATE] at 11:40 AM, the Interim DON confirmed Resident #1 did not receive the initial dose for [MEDICATION NAME] 500 mg IV on [DATE] at 9:00 AM or at night at 9:00 PM. The Interim DON stated, the resident did not receive the medication as ordered because, it was not available, and we had to wait on pharmacy . based on the doctor's order the initial dose should have been given in the morning (on [DATE] at 9:00 AM). The Interim DON confirmed the facility did not have a policy for following doctor's orders. The Interim DON stated the facility did not have a policy because it was, standard nursing practice to give medications as prescribed.