Every finding on record at Harbor Valley Health and Rehabilitation

Based on record review and interview, the facility failed to permit a resident to return to the facility after being hospitalized and failed to document sufficient preparation and orientation to residents to ensure a safe and orderly transfer or discharge from the facility for 1 (Resident #1) of 3 residents reviewed for transfer and discharge rights, in that:Resident #1 was issued a 30 day discharge letter on 12/01/2025 for nonpayment. Resident #1 was transferred to the hospital on [DATE] for a CT scan and was denied readmission to the facility. The facility did not document Resident 1's medical record the reason for not accepting Resident #1 to return to the facility.This failure could place residents at risk of not receiving care and services to meet their needs upon discharge.The findings included:Record review of Resident #1's undated face sheet revealed Resident #1 was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included delusional disorder (a mental health disorder in which a person can't tell what's real from what's imagined), borderline personality disorder (a serious mental health condition characterized by intense emotional instability, impulsive behaviors and difficulties in interpersonal relationships), bipolar disorder (mental health condition characterized by significant mood swings) , dementia (syndrome characterized by a decline in cognitive function), depression (feeling of persistent sadness) and anxiety ( a feeling of worry, nervousness or unease). Date of discharge on the face sheet was 12/10/2025 and location was listed as an acute care hospital.Record review of Resident #1's annual MDS assessment dated , 11/15/2025, revealed a BIMS score of 13, indicating no cognitive impairment. Section Q - Participation in Assessment and Goal Setting revealed there was no active discharge planning occurring for Resident #1 to return to the community.Record review of Resident #1's comprehensive care plan revealed a care plan, date initiated 01/20/2026, revision 01/20/2026 and cancelled 01/20/2026, that revealed, Cancelled: [Resident #1]'s discharge planning will honor her personal wishes, The expectation, based on care plan meetings and talking with [Resident #1], is to stay in facility for LTC.Record review of Resident #1's nursing progress notes revealed a note, dated 11/24/2025 at 10:44 a.m. that read, Administrator and myself entered room to give notice to resident of discharge d/t nonpayment, Resident started yelling and cursing stating that she had a court order that says she does not owe [facility initials] anything.Record review of Resident #1's A/R payment statement, 12/01/2025, revealed Resident #1 owed the facility a total of $2017.60 and had not made a payment to the facility since April 2025.Record review of Resident #1's 30 day discharge letter, dated 12/01/2025, revealed the reason for discharge was, the resident has failed, after reasonable and appropriate notice, to pay for (or have paid under Medicare or Medicaid) stay at the facility. The letter revealed, Discharge to [address] or [Nursing facility name and address]. The effective discharge date was January 1, 2026. The letter revealed, To ensure a safe and orderly transfer or discharge from [Facility name] the facility will provide sufficient preparation and orientation. In addition, the letter revealed, You have the right to appeal the action as outline in Fair Hearing, fraud and Civile (sic) Rights Handbook of the Texas Health and Human Services Commission by submitting a written request of r a hearing to the Medicaid eligibility worker at the local Texas Department of Aging and Disability Services (DADS) office within 90 days. The facility Administrator signed the letter.Record review of Resident #1's nursing progress notes dated 12/10/2025 at 4:47 p.m. revealed a note, Resident p/u by [EMS company] x 2 EMS personnel, to be taken to [hospital] for CT and evaluation of neck and upper spine.During an interview with Resident #1 on 01/20/2026 at 11:22 a.m., Resident #1 stated the facility had attempted to discharge her 3 times in the past and she had a court order that stated the facility could not evict her. Resident #1 stated she was given a discharge letter on 12/01/2025 but told the Administrator that she would not be leaving and would appeal the discharge. Resident #1 stated she was sent to the hospital because of neck pain, and the facility did not allow her to return after her hospital visit. Resident #1 stated the hospital set up a group home for her, but she did not like it as soon as she admitted and tried to go back to the hospital and the hospital would not let her return. Resident #1 stated she went to another hospital and then was temporarily placed at another long-term care facility until she finds a facility she wants to reside in long term.During an interview with the facility Ombudsman on 01/20/2026 at 1:46 p.m., the Ombudsman stated the facility notified her that Resident #1 had been issued a discharge letter for nonpayment on 12/01/2025. The Ombudsman stated she had spoken to Resident #1 after the discharge letter was issued and stated Resident #1 expressed to the Ombudsman that Resident #1 planned to appeal the discharge. The Ombudsman stated Resident #1 was sent out to the hospital around 12/12/2025 and the facility would not let her return to the facility. The Ombudsman stated she attempted to reach out to the Administrator but received no responses back and stated she spoke to the BOM. The Ombudsman stated the BOM disclosed that the corporate office had given the directive that Resident #1 was not allowed to return. The Ombudsman stated she explained to the BOM that the facility could not do that, and Resident #1 had the right to appeal the discharge letter and the BOM stated it was a corporate decision. The Ombudsman stated Resident #1 was placed at another nursing facility in town. The Ombudsman stated Resident #1 was sent to a group home from the hospital and tried to return to the hospital the same day and the hospital refused to readmit Resident #1 so Resident #1 was sent to another hospital who found placement for Resident #1 in another long term care facility in town. The Ombudsman stated Resident #1 had been issued a 30 day discharge letter earlier in the year and the facility did not include a discharge location so Resident #1 won the appeal to that discharge letter. The Ombudsman stated she had tried to explain to Resident #1 that the appeal was not a court order, and the facility had the right to issue another discharge letter, but Resident #1 was fixated on the appeal letter from earlier in the year.During an interview with the BOM on 01/20/2026 at 2:14 p.m., the BOM stated a resident could be issued a discharge letter for nonpayment if a resident or resident representative was not paying the facility their monthly room and board payments. The BOM stated the Administrator was responsible for making the decision to issue a 30 day discharge letter to a resident and the Administrator signed the letter. The BOM stated the resident and/or representative were notified of the appeals process at the time the letter was issued. The BOM stated Resident #1 was issued a 30 day discharge notice on 05/01/2025 for nonpayment, Resident #1 appealed the letter and won the appeal because we left off a discharge address. The BOM stated Resident #1 was told that another discharge letter would be issued if Resident #1 continued to not pay her applied income payment of $257.60 a month. The BOM stated she delivered the discharge letter to Resident #1 on 12/01/2025 and Resident #1 told her that she planned to appeal the discharge. The BOM stated Resident #1 asked her twice about the last day to appeal and the BOM told her it was 01/01/2026 and Resident #1 knew she had 30 days to appeal the discharge. The BOM stated, she could have appealed anytime between 12/1 and 12/31 to stop us from discharging her. The BOM stated Resident #1 had been accepted at another long term care facility and that facility was listed as the discharge location on the discharge letter. The BOM stated she was not sure what the facility policy stated regarding resident discharges. The BOM stated Resident #1 was sent to the hospital in December and was not allowed to return to the facility and stated when the hospital began calling report for the resident to return, the Administrator told her Resident #1 was not allowed to return and all calls regarding Resident #1 were to be directed to the Administrator. The BOM stated it was important for residents to have the right to appeal and discharge and not be discharged until an organized discharge plan was in place, to make sure we are being fair, and a third party can hear both sides.During an interview with the DON, 01/21/2026 at 12:19 p.m., the DON stated Resident #1 was sent to the hospital on [DATE] for a CT scan due to Resident #1 complaining of neck pain. The DON stated the physician had given the order for the CT a week or two prior to Resident #1 going to the hospital for the CT scan but Resident #1 kept cancelling the appointment or refusing to go to the scan. The DON stated she was notified on 12/12/2025 that the hospital was calling to give report to send Resident #1 back to the facility and the DON was told by the Administrator that Resident #1 was not allowed back to the facility because the facility could not meet her needs. The DON stated she was unaware that when Resident #1 went to the hospital that the facility would not be taking her back and stated the hospital was not notified, when Resident #1, was sent to the hospital on [DATE], that the facility would not be taking her back.During an interview with the Administrator, 01/21/2026 at 1:55 p.m., the Administrator stated Resident #1 was issued a 30 day discharge letter on 12/01/2025 for nonpayment and Resident #1 had up to 30 days to appeal the discharge. The Administrator stated he did not believe the facility could discharge a resident who appealed a 30 day discharge and stated Resident #1 had appealed her previous discharge letters. The Administrator stated Resident #1 was not notified prior to her transfer to the hospital that she would not be allowed to readmit, and the Administrator stated the thought the DON informed the hospital when she was transferred that the facility was not allowing Resident #1 to readmit. The Administrator stated the corporate office made the decision that Resident #1 would not be readmitted to the facility and stated he educated the corporate office that the resident had 30 days to appeal the discharge notice and that it was against resident rights to discharge a resident without a discharge plan. The Administrator stated, it was the direction I was given, and she was in a safe place at the hospital. The administrator stated it was important for a resident to have the right to return back to the facility and to appeal the discharge, so she can be heard by the state or appeals process and it was important that the hospital send her to the right place for the right treatment because we are not a psych hospital.Record review of a facility policy titled, Notice of a Transfer and/or Discharge, policy revised date 11/28/2016 and 09/13/2017, revealed, 1. The facility will notify the resident, and/or his or her representative (sponsor) of an impending transfer or discharge from our facility for the following criteria: .e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. 2. The facility may not transfer or discharge the resident while an appeal is pending, when a resident exercised his or her right to appeal a transfer or discharge notice from the facility, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document that failure to transfer or discharge would pose 4. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.Record review of a facility policy titled, Documentation of Transfers/Discharges, revision date 09/13/2017, revealed, When a resident is transferred or discharged his or her medical record shall be documented as to the reasons why such action was taken. Policy Interpretation and Implementation revealed, 1. All documentation concerning the transfer or discharge of a resident must be recorded in the resident's medical record. The documentation must include: a. The basis for the transfer. B. If transferring/discharging for the resident's welfare and the resident needs cannot be met, or the resident's health has improved sufficiently so that the resident no longer needs the care and/or services of the facility, the following must be documented by the Resident's Physician: 1. The specific resident need(s) that cannot be met; 2. Facility attempts to meet the resident needs; and 3. The service available at the receiving facility to meet the need (s).

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 6 of 18 residents (Resident #3, 68, #71, #45, #7 and #4) reviewed for care plans: 1. The facility failed to ensure a focus area for activities was reflected in Resident #3's comprehensive care plan. 2. The facility failed to ensure a focus area for activities was reflected in Resident #68's comprehensive care plan. 3. The facility failed to ensure a focus area for activities was reflected in Resident #71's comprehensive care plan.4. The facility failed to ensure a focus area for activities was reflected in Resident #45's comprehensive care plan. 5. The facility filed to ensure a focus area for activities was reflected in Resident #7's comprehensive care plan. 6. The facility filed to ensure a focus area for hospice was reflected in Resident #4's comprehensive care plan. These deficient practices could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services. The findings included:1. Record review of Resident #3's face sheet dated 12/3/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included schizophrenia (a chronic, severe mental health disorder that affects how a person thinks, feels, and behaves), delusional disorders (a mental health condition characterized by the presence of one or more delusions that last at least one month; fixed false belief that is not based in reality and cannot be changed even with clear evidence), hallucinations (sensory experiences that appear real but are created by the mind, occurring without any external stimulus), and acquired absence of limb.Record review of Resident #3's most recent quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills.Record review of Resident #3's comprehensive care plan with initiated date 9/16/25 did not reflect a focus area dedicated to activities.Record review of Resident #3's document titled Multidisciplinary Care Conference, unsigned and dated 10/2/25 under the Activities Summary section for Evaluation/Goals reflected, engage resident in daily activity of choice as tolerated.2. Record review of Resident #68's dated 12/3/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included heart disease, multiple sclerosis (chronic autoimmune disease in which the immune system attacks myelin, the protective covering around nerves in the brain, spinal cord, and optic nerves), diabetes (chronic medical condition in which the body either does not produce enough insulin or cannot use insulin effectively), hyperlipidemia (abnormally high levels of fats in the flood, high cholesterol), and hypotension (low blood pressure).Record review of Resident #68's most recent quarterly MDS assessment dated [DATE] reflected the resident was cognitively intact for daily decision-making skills.Record review of Resident #68's comprehensive care plan with revision date 2/22/23 did not reflect a focus area dedicated to activities.Record review of Resident #68's document titled Multidisciplinary Care Conference, unsigned and dated 7/17/25 under the Activities Summary section for Evaluation/Goals reflected, engage resident in daily activity of choice as tolerated.3. Record review of Resident #71 face sheet dated 12/3/25 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] and 8/19/23 with diagnoses that included reduced mobility, major depressive disorder (a mental health condition characterized by persistent, intense feelings of sadness or loss of interest that last at least two weeks and interfere with daily functioning), and age-related osteoporosis (a medical condition in which the bones become weak, brittle, and more likely to break) with current pathological fracture.Record review of Resident #71's most recent quarterly MDS assessment dated [DATE] reflected the resident was severely cognitively impaired for daily decision-making skills.Record review of Resident #71's comprehensive care plan with initiated revision date 9/2/22 did not reflect a focus area dedicated to activities.Record review of Resident #71's document titled Multidisciplinary Care Conference, unsigned and dated 5/1/25 under the Activities Summary section for Evaluation/Goals reflected, engage resident in daily activity of choice as tolerated.4. Record review of Resident #45's admission Record dated 12/04/25 revealed a [AGE] year old woman admitted to facility on 07/16/25 with diagnoses that included cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior cerebral arteries (a stroke caused by blocked blood flow in major arteries to the brain), vascular dementia (a decline in thinking skills due to reduced blood flow to the brain often caused by stroke), aphasia (a communication disorder caused by brain damage that impairs a person's ability to speak), dysphagia, oral phase (a swallowing disorder), and encounter for attention to gastrostomy (a medical visit for care of a feeding tube). Record review of Resident #45's Significant Change MDS dated [DATE] indicated she had unclear speech, rarely/never makes self understood and rarely/never understands others. Resident #45 was unable to complete a BIMS so a staff interview indicated she was severely impaired for cognitive skills for daily decision making.Record review of Resident #45's document titled Multidisciplinary Care Conference dated 08/12/25 reflected it was blank except for the section under Activities Summary which indicated Evaluation/Goals - engage resident in activity of choice as tolerated.Record review of Resident #45's comprehensive care plan with the most current initiated revision date of 12/03/25 did not reflect a focus area dedicated to activities. 5. Record review of Resident #7's admission Record dated 12/04/25 revealed a [AGE] years old woman originally admitted to facility 10/19/22 with the most recent admission dated 11/04/25. Resident #7's diagnoses included chronic obstructive pulmonary disease (a progressive lung disease), rheumatoid arthritis (a chronic autoimmune disease where the immune system mistakenly attacks healthy tissue), dysphagia, oropharyngeal phase (difficulty starting a swallow, involving problems in the mouth or throat moving food/liquid to the esophagus), Type 2 Diabetes Mellitus (common condition where the body doesn't use insulin properly leading to high blood sugar), depression (a mood disorder affecting how you feel, think, and act, characterized by persistent sadness), anxiety disorder (mental health condition marked by excessive, persistent worry and fear) and peripheral vascular disease (a broad term for circulation problems in blood vessels).Record review of Comprehensive Care Plan for Resident #7 with the most recent revision on 10/17/25 reflected it failed to include a focus area dedicated to activities.During an interview with Resident #7 on 12/03/25 at 11:13 am, Resident #7 reported that neither she nor her family has gone to a care plan meeting. Resident #7 stated that she did go to activities as well as Resident Council. 6. Record review of Resident #4's admission Record dated 12/04/25 revealed an [AGE] year old male admitted most recently 08/28/25. Resident #4's diagnoses included infection and inflammatory reaction due to other internal joint prosthesis (mechanical complications of internal orthopedic prosthetic device), peripheral vascular disease (a broad term for circulation problems in blood vessels), atherosclerotic heart disease of native coronary artery with angina pectoris (heart disease caused by plaque buildup in arterial walls with chest pain), and presence of cardiac pacemaker (a battery powered device that regulates heartbeats). Record review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating he was cognitively intact. Section O also indicated he was on hospice services. Record review of Resident #4's Care Plan with the most recent revision of 07/09/25 did not reveal a focus for hospice services or coordination of care with hospice. The only mention of hospice was under Special Instructions at the top of the first page which listed the name and phone number of the hospice. During an interview on 12/4/25 at 2:14 p.m., the Activities Director stated activities were included in the care plan because it determined what the residents liked and the types of activities they were involved in. The Activities Director stated, if the resident chose not to participate in activities, it should be included in the care plan, but I document that in a progress note and not actually in the care plan itself. The Activities Director stated all her activities documentation was in the form of a progress note or a care plan meeting note (Multidisciplinary Care Conference document). The Activities Director stated care plans were important because they were used to follow-up on the residents, to determine if there was a decline, communication with the family, and how involved the residents were in activities. The Activity Director stated she did not enter the information into the care plan since the MDS Coordinator was responsible to enter information in that document.During an interview on 12/5/25 at 8:48 a.m., the Regional RN stated activities needed to be incorporated into the comprehensive care plan and it needs to be detailed in the care plan. The Regional RN stated there needs to be a better process in place. The Regional RN stated the comprehensive care plan was important because staff used the comprehensive care plan to give instruction on how to provide quality of care to the residents. During an interview on 12/5/25 at 3:19 p.m., the DON stated it was important to include activities in the comprehensive care plan because it contributed to the resident's quality of life because it was individualized and specific to the resident. The DON stated the MDS Coordinator retrieved information from different disciplines and incorporated it into the comprehensive care plan. The DON stated, she believed the Activities Director provided resident activities information in the progress notes, and the MDS Coordinator took that information and incorporated it into the comprehensive care plan. The DON stated it was the MDS Coordinator who was responsible for developing the care plan based on the information received from the other disciplines. The DON stated she would sign-off on the comprehensive care plans and reviewed them. Record review of the facility document titled Care Plans - Comprehensive with revision date 3/1/22 revealed in part, .An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.Each resident's Comprehensive Care Plan has been designed to.Incorporate identified problem areas.Incorporate risk factors associated with identified problems.Build on the resident's strengths.Reflect treatment goals and objectives in measurable outcomes.Identify the professional services that are responsible for each element of care.Aid in preventing or reducing declines in the resident's functional status and/or functional levels.Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed at least quarterly and any significant change in status.

Based on interview and record review the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility and demonstrate their response and rationale for such response, for 3 of 6 anonymous residents who attended resident council meetings. (Resident council meeting).The facility failed to provide residents with requested copies of the documentation of their grievances and their resolution. This failure could result in the residents feeling that their grievances are not being acted upon and could place all residents who attend the Resident Council meetings at risk for feelings of powerlessness and decreased self-worth.The Findings included:Record review of Resident Council minutes, dated 07/08/25, reflected food going to waste. Food no flavor, raw bacon being served .Record review of Resident Council minutes, dated 11/12/25, reflected talked about food not being good. No flavor.Record review of facility's grievances since 07/2025 reflected no grievances about food complaints from the resident council.Record review of facility's grievances since 07/2025 reflect out of 24 total grievances 11 of the grievances had written documentation regarding resolutions communicated to the resident or resident family. During the confidential Resident Council interview at an undisclosed date and time three residents in attendance stated they have not received copies of both their grievances filed and their resolution. The residents stated they must ask staff for a grievance form, and they know how to file grievances but once they have filed it nothing happens, and no one follows up with them regarding a resolution. The residents stated they had asked for copies of their grievance and documentation of the resolution and had not received either. The residents stated they usually give their grievance to the SW, or a staff member will take it to the SW or Administrator for the resident. The residents stated when they ask the SW for follow up on grievances, he states he is working on it and states he gave the grievance to the Administrator. During an interview with the Administrator on 12/03/25 at 2:00 pm, the Administrator was asked for the Grievance Log. He printed it off for the past 5 months since the track log (where they keep track of the number of grievances in the month) as well as the individual grievances are all placed in a computer program. The Administrator was asked if residents ever received a copy of the grievance resolution and he stated, If they ask for it, we can give them a copy. The Administrator then said that they usually just verbally tell the person filing the grievance about the outcome. During an interview with the SW on 12/04/2025 at 1:34 p.m., the SW stated if a resident comes with a grievance the SW gets with the Administrator depending on the concern. The SW stated if a resident comes to the SW wanting to change their meal the SW will connect the resident to dietary or if the resident is wanting more physical therapy the SW will connect the resident with the physical therapy department. The SW stated if it is an abuse grievance the SW refers to the Administrator as he is the abuse prevention coordinator. When asked about follow up to the concern/grievance the SW stated the follow up is usually in the moment of the concern and depending on the concern it is not documented. The SW stated if a resident wants to fill out documentation the SW shows the resident the grievance form. The SW stated the grievance forms are in his office and believes residents know where they can find the grievance forms. When asked what happens to the grievance when the SW receives a grievance form the SW stated he sends it to the Administrator who then inputs it into the computer. When asked if the resident ever receives a copy of the grievance or resolution the SW stated the resolution is verbalized to the resident, but he is unsure if they get a paper copy of documentation of the resolution. When asked if anyone has been designated to follow up with residents regarding grievances the SW stated he is unsure if anyone is designated to be the follow up person but from his experience the department in which the grievance is towards usually does the follow up. When asked if the SW ever follows up with residents the SW stated they take care of the issue right there and then and when they do rounds with the residents, they will let me know if they have any other issues.During an interview with the Activities Director on 12/04/2025 at 2:14 p.m., the Activities Director stated she did not fill out grievances for residents. The Activities Director stated she thinks residents go to the SW and he fills them out with them. When asked where residents get grievance forms the Activities Director stated she does not have grievance forms but if a resident needs one and during resident council she can get one for the resident from the SW or they can go to the SW and get one. The Activities Director stated the residents then give the filled-out grievance to the SW. When asked what the Activities Director does if they receive a filled-out grievance from a resident and the Activities Director stated she has never given the SW a grievance form on behalf of the residents.During an interview on 12/04/25 at 03:47 p.m., the CDM revealed he had not received any grievances about food since June. He revealed grievances about food would be important for him to receive so he could make improvements for the residents. He revealed the typical process for grievances should be for him to receive a grievance form, make improvements, then give this grievance form back with his corrective action. During an interview with the DON on 12/04/2025 at 3:59 p.m., the DON stated the nursing staff will assist residents with filling out grievances unless it involves the nursing department. The DON stated once the grievance is filled out it then goes to the SW. The DON stated the grievance coordinator is the Administrator. When asked what occurs next the DON stated the SW will let the Administrator know the resident talked to the SW about the grievance and that the Administrator should go talk to the resident as well. The DON stated when they are aware of a grievance, they usually ask the SW to go talk to the resident. The DON stated the SW will address the resident and if it has to do with the DON addressing an issue the DON will call the resident's family or talk to the resident themselves. When asked who is responsible for following up with grievances the DON stated the SW and Administrator but that the DON will do the follow up if it is regarding nursing and if the SW and Administrator let the DON know. When asked how the DON becomes aware of nursing grievances if they didn't previously know about it and the DON stated they do not get a paper notification but that they are just notified that a family wants to talk to the nursing department. The DON stated they know there is a paper grievance form but that the DON communicates back the results of the grievance to the Administrator or the SW or to whomever made the DON aware of the grievance. When asked if the resolutions to grievances are ever documented the DON stated not by the DON and stated if the DON is getting a grievance, it is usually orally or through a message. The DON stated the last time they filled out a grievance form the resolution was not written down.During an interview with ADON B on 12/04/2025 at 5:12 p.m., ADON B stated they file grievance forms and address the issue with the correct department. When asked where the grievance forms go once filled out ADON B stated the grievance goes to either the SW or Administrator. ADON B stated once they come up with a resolution, they inform the resident if their BIMS is high enough to understand or they inform the responsible party either in person or using the grievance form. ADON B stated the resolution is documented on the grievance form and how the parties of the grievance are notified. When asked who documents the resolution ADON B stated usually the correct department with the SW or the Administrator will write it on the grievance form. When asked who keeps the grievances ADON B stated the administrator keeps grievances together and the nurses keep copies of grievance forms at the nurse stations.During an interview with the Administrator on 12/04/2025 at 5:40 p.m., The Administrator stated that information does get relayed to the person filing the grievance regarding the resolution. When asked what the risk could be to the residents if they are not provided with a copy of their grievance or resolution of grievance when asked, the Administrator stated they have had this system in place for a while, and he was not sure why it was an issue. Record review of the facility's policy titled Filing Grievances/Complaints, dated 11/28/2016 stated the following:Policy Interpretation and Implementation8. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. The Administrator, or his or her designee, will make such reports orally within 5 working days of the filing of the grievance or complaint with the facility. A written summary of the investigation also be provided to the resident upon request.

Based on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 3 of 5 residents (Resident #68, #10 and #74) reviewed for resident assessments: 1.The facility failed to ensure Resident #68's most recent quarterly MDS assessment was updated to include the resident did not receive insulin injections. 2. The facility failed to ensure Resident #10's most recent quarterly MDS assessment, dated 11/20/25, was updated to include the resident having a significant weight gain in the last 6 months. 3. The facility failed to ensure Resident #74's admission MDS assessments dated 04/09/25 and most recent quarterly MDS assessments dated 09/01/25 04/09/25 and most recent quarterly MDS assessment dated [DATE] were updated to include the resident had difficulty with chewing. This failure could place residents at risk for inadequate care due to inaccurate assessments.The findings included:1.Record review of Resident #68's face sheet dated 12/3/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included heart disease, multiple sclerosis (chronic autoimmune disease in which the immune system attacks myelin, the protective covering around nerves in the brain, spinal cord, and optic nerves), diabetes (chronic medical condition in which the body either does not produce enough insulin or cannot use insulin effectively), hyperlipidemia (abnormally high levels of fats in the flood, high cholesterol), and hypotension (low blood pressure).Record review of Resident #68's quarterly MDS assessment dated [DATE] reflected the resident was cognitively intact for daily decision-making skills, was diagnosed with diabetes, and received insulin injections. Record review of Resident #68's most recent quarterly MDS assessment dated [DATE] reflected the resident was cognitively intact for daily decision-making skills, was diagnosed with diabetes, and received insulin injections. Record review of Resident #68's Order Summary Report for December 2025 revealed the resident received Metformin 500 mg tablets two times a day for diabetes with start date 9/25/25 and no end date.Record review of Resident #68's comprehensive care plan with revision date 6/14/23 reflected that the resident had diabetes and interventions included to provide diabetes medication as ordered by the doctor.During an interview on 12/3/25 at 1:57 p.m., Resident #68 stated she did not receive insulin injections and had never been treated with insulin injections while residing at the facility. Resident #68 stated the nursing staff checked her sugars daily.During an interview on 12/4/25 at 10:23 a.m., LVN C stated he had worked for the facility for almost a year and a half and did not recall Resident #68 ever having been treated with insulin. LVN C stated Resident #68 had her sugars checked daily but was not treated with insulin.During an interview on 12/4/25 at 3:19 p.m., the DON stated Resident #68 used to be treated with insulin back in March of 2025. The DON stated she did not know why Resident #68's MDS reflected the resident received insulin injections. The DON stated the purpose of the MDS was to populate or was used to flag patients with certain medical needs.2. Record review of Resident #10's admission Record, dated 12/02/2025, reflected a [AGE] year-old male with an initial admission date of 02/03/2025 and re-admission date of 03/21/2025. It reflected Resident #10 had diagnoses that included Type 2 Diabetes, Muscle Wasting and Atrophy (body tissue wasting away), and Dysphagia (difficulty swallowing). Record review of Resident #10's quarterly MDS Assessment, dated 11/20/2025, reflected Resident #10 had a BIMS score of 9 out of 15, indicating the resident was moderately cognitively impaired. Resident #10's MDS assessment reflected Resident #10 had no weight gain (gain of 5% or more in the last month or gain of 10% or more in the last 6 months).Record review of Resident #10's Weight Summary, undated, reflected Resident #10 gained 15.6% in the last 6 months.Record review of Resident #10's care plan, undated, reflected, [Resident #10] is at risk for nutritional and/or hydration deficits., initiated 02/05/25.During an interview on 12/05/25 at 11:42 a.m., the MDS nurse revealed she was out of town and could not access residents' MDS assessments. She revealed residents' significant weight changes needed to be documented in their respective MDS assessments. (The MDS nurse was unable to confirm weight gain for Resident #10.)3. Record review of Resident #74's admission Record, dated 12/02/2025, reflected a [AGE] year-old female with an admission date of 03/31/2025. It reflected Resident #74 had diagnoses that included Altered Mental Status.Record review of Resident #74's admission MDS Assessment, dated 04/09/2025, reflected Resident #74 had None of the above in Section L-Oral/Dental Status to include Mouth or facial pain, discomfort or difficulty with chewing and Resident #74 had a mechanically altered diet (require change in texture of food or liquids).Record review of Resident #74's Quarterly MDS Assessment, dated 09/01/2025, reflected Resident #74 had a BIMS score of 2 out of 15, indicating the resident was severely cognitively impaired. It further reflected no selection (to include mouth or facial pain, discomfort or difficulty with chewing) in Section L-Oral/Dental Status.Record review of Resident #74's care plan, undated, reflected, [Resident #74] is at risk for nutritional and/or hydration deficits r/t .dysphagia [difficulty swallowing] advanced texture., initiated 04/03/25.Record review of Resident #74's Order Summary Report, dated 12/02/25, reflected resident's diet was Dysphagia Puree [smooth, creamy substance] texture, dated 09/25/25.During an interview on 12/02/25 at 11 a.m., Resident #74 revealed the only teeth she had were a couple in the back of her mouth on each side. She revealed it caused her to have issues with chewing her food so she received meals with food that she could swallow and not need to chew.During an interview on 12/05/25 at 11:42 a.m., the MDS nurse revealed Resident #74's lack of teeth should be notated in her MDS assessment. It was important because it can influence someone's nutrition and oral hygiene. During a telephone interview on 12/5/25 at 11:53 a.m., the MDS Coordinator stated she was pretty much the only person compiling the MDS assessments. The MDS Coordinator stated she relied on information provided by the medication administration record and the physician's orders when completing an MDS assessment. The MDS Coordinator stated she could not explain why Resident #68's most recent quarterly MDS assessment reflected the resident received insulin injections and could not refer to the resident's record because she was out of town.During an interview on 12/4/25 at 5:35 p.m., the Administrator revealed it was important for the MDS nurse to note significant weight changes in residents' MDS assessments. He stated it was important that the MDS was accurate because it captured all of the care areas and services provided for the residents and it makes sure the services provided were appropriate. The Administrator stated it was his expectation that the MDS Coordinator would be auditing the accuracy of the MDS assessments.The facility did not provide a policy for the accuracy of MDS assessments requested on 12/4/25 at 3:19 p.m.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 5 residents (Resident #10) reviewed for infection control:The facility failed to ensure LVN K cleaned an insulin pen's rubber seal with an alcohol swab prior to insulin administration for Resident #10.This failure could place residents at risk for cross contamination and infection due to improper care practices. The findings included: Record review of Resident #10's face sheet dated 12/4/25 revealed a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes (a chronic medical condition in which the body does not use insulin effectively and over time may also not produce enough insulin causing blood glucose levels to become too high), metabolic encephalopathy (a temporary or permanent disturbance of brain function caused by an imbalance in the body's chemistry), and gout (a form of inflammatory arthritis caused by a buildup of uric acid crystals in the joints leading to sudden, severe pain and swelling). Record review of Resident #10's Order Summary Report dated 12/4/25 revealed the following:- Insulin Lispro injection 100 unit/ml, inject as per sliding scale subcutaneously three times a day for diabetes, with order date 2/3/25 and no end date. During the observation of the medication pass on 12/4/25 at 11:48 a.m., LVN K prepared Resident #10's insulin Lispro and placed an insulin needle through the insulin pen's rubber seal without cleaning the rubber seal with an alcohol wipe prior to administering the insulin. During an interview on 12/4/25 at 12:04 p.m., LVN K stated he was unsure if the rubber seal on Resident #10 insulin pen was supposed to be cleaned with an alcohol wipe. LVN K stated, I probably should have cleaned the rubber seal first before piercing it with a needle because it was a break in infection control and could result in cross contamination. LVN K stated the risk of cross contamination could result in the resident getting an infection. During an interview on 12/4/25 at 3:19 p.m., the DON stated it was her expectation for nursing to clean the rubber seal from an insulin pen with an alcohol wipe because it needs to be clean. The DON stated it was important to make sure it's (rubber seal on the insulin pen) not dirty before the needle is inserted because the resident could get an infection and it was considered an infection control issue. Record review of the document titled INSTRUCTIONS FOR USE Insulin Lispro KwikPen injection for subcutaneous use with revision date July 2023 revealed in part, .Always use a new needle for each injection to help prevent infections.Pull the Pen Cap straight off.Wipe the Rubber Seal with an alcohol swab.

Based on interview and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to maintain the temperature of walk-in refrigerator at or below 41 degrees F in November 2025.2. The facility failed to maintain the temperature of the milk refrigerator at or below 41 degrees F in December 2025.3. The facility failed to take temperatures for the cold foods (to include tossed salad on 12/03/25, milk and orange juice on 12/01/25, 12/02/25 and 12/04/25). These failures could place residents at risk for food borne illness.The findings included: Record review of Refrigerator Temperature-walk in, dated November 2025, reflected the following days had temperatures that were above 41 degrees Fahrenheit:(day: degrees Fahrenheit for morning and/or evening)6: evening 42 (signature unknown)7: evening 43 (signature unknown)15: evening 43 (signed by [NAME] I)19: morning 42 (signature unknown), evening 43 (signature unknown) Record review of Refrigerator Temperature-milk, dated December 2025, reflected the refrigerator was 42 degrees Fahrenheit (signed by Dietary Aide J) for the night shift on 12/02/25. Record review of Week at a Glance, dated 12/02/25, reflected Tossed Salad was served on Wednesday (12/03) with no temperature taken for tossed salad on Service Line Checklist, dated 12/03/25 and unauthored. Record review of Week at a Glance further reflected milk and orange juice were served for breakfast on 12/01/25, 12/02/25 and 12/04/25 with no temperature documented on the Service Line Checklist for milk and orange juice on 12/01/25, 12/02/25, and 12/04/25. Interview on 12/04/2025 at 6:11 PM, [NAME] I revealed he took temperatures of cold foods and knew if the temperature was above 41 degrees Fahrenheit he had to close the door, tell someone, and take the temperature again. He revealed it was important for food to be at the right temperature because people could get sick and food could spoil. He revealed he did not take temperatures of cold foods/drinks before meal service, and the dietary aide would do this. Interview on 12/04/25 at 06:14 PM, Dietary Aide J revealed she had not had any temperatures for cold foods that were above 41. She revealed if cold foods were above 41, then she would tell the dietary manager. She revealed it was important for food to be at the appropriate temperature, so the food did not spoil. She further revealed she assumed that residents could get sick if food wasn't at the appropriate temperature. She revealed she did not take temperatures of cold items right before meal service and the line cook took these temperatures. Interview on 12/05/25 at 02:18 PM, the CDM and Corporate Dietary Manager revealed it was important to ensure temperatures were within appropriate range to prevent food borne illnesses. They revealed they would communicate with the team on having foods within appropriate temperature and who needed to take temperatures at meal service. Interview on 12/05/25 at 05:34 PM, the DON revealed there had not been any foodborne illness outbreaks in the facility this year. Record review of the FDA Food Code 2022, U.S. Department of H&HS, revealed 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (2) At 5 C (41 F) or less. Record review of the facility's policy Food: Preparation, revised 02/2025, reflected 14. All foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit for hot holding, and less than 41 degrees Fahrenheit for cold food holding. Record review of the facility's policy Food Storage: Cold Foods, revised 02/2023, reflected 2. All perishable foods will be maintained at a temperature of 41 degrees of Fahrenheit or below, except during necessary periods of preparation and service.

Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 8 residents (Resident #10) reviewed for personal hygiene. The facility failed to keep Resident #10's toenails and fingernails trimmed. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections. Record review of Resident #10's admission Record, dated 12/02/2025, reflected a [AGE] year-old resident with an initial admission date of 02/03/2025 and re-admission date of 03/21/2025. It reflected Resident #10 had diagnoses that included Type 2 Diabetes, Major Depressive Disorder, and Polyneuropathy (nerve disease caused by damage to nerves). Record review of Resident #10's Quarterly MDS Assessment, dated 11/20/2025, reflected Resident #10 had a BIMS score of 9 out of 15, indicating the resident was moderately cognitively impaired. Resident #10's MDS assessment indicated that Resident #10 was Dependent (helper does ALL of the effort) for personal hygiene. Record review of Resident #10's care plan, undated, reflected, [Resident #10] is at risk for skin impairment and/or [pressure ulcer] development r/t fragile skin. with intervention Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short., initiated 02/11/2025. Record review of Incidents for the last 6 months reflected Resident #10 had no incidents of skin tears or injury of unknown origin. Interview and observation on 12/02/2025 at 10:30 AM, Resident #10 revealed he had long nails and had told the facility he needed a podiatrist about a month or two ago. (He could not recall the name of the person he told.) He revealed it was important for his nails to be trimmed because he could scratch himself. He revealed he could feel his toenails were long because they brushed up against each other. Observation revealed his fingernails were past his fingertips (length unknown). Interview and observation on 12/05/25 at 02:15 PM, CNA H observed and revealed Resident #10 needed his fingernails trimmed. She revealed she had the ability to trim his fingernails, but the nurse would help with trimming his toenails. She revealed it was important to have his nails trimmed to prevent injury. Interview and observation on 12/05/25 at 02:20 PM, LVN G revealed nurses typically made sure to cut residents' nails once a week. LVN G observed and revealed Resident #10's fingernails and toenails needed to be trimmed. She revealed Resident #10 should be on the list to be seen by podiatry. She revealed any nursing staff member had the ability to report the Resident #10's nails needed to be trimmed. She revealed it was important for Resident #10's nails to prevent injury and because he was diabetic. Interview on 12/04/25 at 01:44 PM, the SW revealed he kept up with residents' ancillary services (supplementary services like podiatry (treatment of the feet) and vision). He revealed he would keep a list of residents who needed ancillary services, and he would speak with nursing staff to see if any other resident needed to be added to the list. The SW revealed he could not find records that showed Resident #10 had been on the list to see the podiatrist for the last 3 months so Resident #10 was probably not seen by the podiatrist. Interview and observation on 12/04/25 at 04:07 PM, the DON revealed it was important to cut residents' nails, especially their feet because having long nails could cause injury to themselves, especially for diabetics because they were more prone to amputations. She revealed the nurses were able to cut fingernails and not toenails. The DON observed Resident #10's toenails and said he needed to be on the list to see the podiatrists. She revealed she could not say how long Resident #10 had not had his toenails or fingernails trimmed but it was possible that Resident #10 had not been seen by the podiatrist in November at least. Record review of facility's policy, Resident Rights, dated April 2019, reflected You have the right to: Receive all care necessary to have the highest possible level of health. Record review of facility's policy, Coordination of Medical Care, revised April 2008, reflected 2. Coordination of medical care includes, but is not limited to: a. Ensuring that residents have appropriate physician coverage and services, including emergency care. (This was the policy given after requesting a policy about podiatry.)

Based on observation, interview and record review the facility failed to ensure the resident's environment remains as free of accident hazards as is possible, for 2 of 2 resident (Resident #41, Resident #90), in the facility reviewed for accidents, in that: 1.The facility failed to ensure Resident #41 did not have a razor in his room. 2.The facility failed to ensure Resident #90 did not have scissors in her room. This failure could place residents at risk of injury and contribute to avoidable accidents and a decline in health.The findings include:1.Record review of Resident #41's face sheet dated 12/03/2025 revealed a [AGE] year-old male originally admitted to the facility on [DATE], with a current admission date of 06/09/2025. Record review of Resident #41's admission Record, dated 12/03/2025, reflected a primary admission diagnosis of encephalopathy, unspecified (a group of conditions that cause brain dysfunction) with other diagnoses that included depression, Parkinson's disease without dyskinesia (movement disorder of the nervous system), muscle weakness, unsteadiness of feet, other abnormalities of gait and mobility (manner of walking), other lack of coordination, cognitive communication deficit (difficulties in communication affecting how individuals think, process information and express themselves) and other diagnoses. Record review of Resident #41's MDS dated [DATE] revealed a BIMS of 13 out of 15 indicating independent decision making and recorded the needed use of supervision or touching assistance with personal hygiene. Record review of Resident #41's care plan provided on 12/03/2025 revealed a focus area for the following: . an ADL self-care performance deficit r/t weakness and debility, initiated on 04/18/2025, with interventions including PERSONAL HYGIENE: requires (X)1 staff participation with personal hygiene and oral care initiated on 04/18/2025. During an observation on 12/03/2025 at 9:20 a.m., revealed Resident #41 was in his wheelchair, halfway out of his doorway with a razor in hand as CNA E proceeded to walk out of Resident #41's room and down the hallway. During an interview on 12/03/2025 at 9:20 a.m., Resident #41 stated the nurse gave him the razor to shave. Resident #41 stated he normally got to keep his razor in his room so he could shave and when he needed to shave, he asked a CNA for help. During an interview on 12/04/2025 at 8:35 a.m., CNA E stated Resident #41 mostly did everything on his own with little assistance. CNA E stated Resident #41 needed assistance with toileting and shaving. When asked if Resident #41 could have a razor in their room CNA E stated residents were not allowed to keep razors in their room. When asked if Resident #41 could be left alone with a razor, CNA E stated the resident was not allowed to be alone with a razor. When asked if any training had been given regarding residents having razors in their room or being left alone with a razor CNA E stated they were not sure. When asked where razors came from, CNA E stated they get them from the closet. When asked what the danger would be for a resident to have a razor in their room or be left alone with a razor, CNA E stated the risk depends on the resident and their abilities, if the resident had Parkinsons disease (movement disorder of the nervous system) they could shake and that staff need to be with them. CNA E stated they could be a risk of harm. During an interview on 12/04/2025 at 3:11 p.m., LVN F stated they weren't sure the assistance required for Resident #41. When asked about the process for shaving Resident #41, LVN F stated the resident alerted staff when they would like to be shaved, and a CNA would get the razor from the closet and assist the resident. When asked if Resident #41 could have a razor in their room or be left alone with a razor LVN F stated they were not aware if residents could. When asked if Resident #90 could have scissors in their room, LVN F stated they were not aware of any residents that could have scissors in their room. When asked what the danger would be for a resident to have a razor in their room or be left alone with a razor, LVN F stated there could be a risk for potential harm to themselves or others. When asked what the danger would be for a resident to have scissors in their room, LVN F stated it would be the same as a razor which could be a risk for potential harm to themselves or others. During an interview on 12/04/2025 at 3:18p.m., the ADON A stated Resident #41 needed minimal to maximal assistance and sometimes supervision depending on the day he's having and task. ADON A stated Resident#41 would ask a CNA if he needed to shave and usually waited for someone to help. ADON A stated he knew Resident #41 had his own personal shavers that his partner brought. When asked where Resident #41 kept his personal shavers ADON A stated they may be in a cubby by the dresser or different places at different times. When asked if a resident could have a razor in their room should it be documented, ADON A stated he was not sure and the thing would be to look at if the resident was a threat to themselves or others but most likely the documentation would be in the care plan but was unsure if it needed to be documented at all. When asked how residents were assessed for possible threat to themselves or others ADON A stated they could use the PHQ 9 (patient health questionnaire), BIMS level, or if they were able to independently use a razor. When asked if the MDS notes that reflected Resident #41 may need assistance with shaving if Resident #41 should be left alone with a razor ADON A stated he was not sure. When asked if Resident #90 was allowed to have scissors in their room ADON A stated he was not sure if she was allowed to have scissors or items like that in their room. ADON A stated Resident #90 could have scissors if she could use them safely which could be determined by the PHQ 9 or BIMS level to gauge independence level and cognition. ADON A stated they were unsure if a resident could have scissors in their room if it needed to be documented. When asked what the danger would be for a resident to have a razor in their room or be left alone with a razor, ADON A stated they didn't believe there was any risk to Resident #41 or others. When asked what the danger would be for a resident to have scissors in their room, ADON A stated there could possibly be a risk but believed Resident #90 was capable of having them in her room. During an interview on 12/04/2025 at 3:44 p.m., the DON stated regarding residents who requested to shave a CNA gets a basin and a razor and then CNA shaves them. When asked where razors are kept, the DON stated they are kept in the clean utility room either in the hallways if it has a keypad or central supply which has a keypad as well. The DON stated some residents can shave independently and if they could it would probably be documented under the care plan under ADL self-performance, it would depend on the assistance required and the care plan would not be specific if a razor can be used independently or not. When asked about Resident #41's ADL assistance needed, the DON stated he liked to be independent, for the most part was a one person assist with most ADLs. When asked what assistance Resident #41 required the DON stated someone would have to help him. When asked if Resident #41 could be left alone with a razor the DON stated he was allowed to be and he was safe. The DON stated they were not sure if it would need to be documented if Resident #41 could be left alone with a razor and that Resident #41 usually kept his razor in his drawer. When asked if Resident #90 was allowed to have scissors in their room the DON stated they try to get them not to have that stuff and that they educate family, but that the residents kept items like scissors in their room. The DON stated they would make sure the residents don't have dementia, so they don't keep sharp items in their room. When asked if a resident could keep scissors in their room if it would need to be documented and the DON stated they weren't sure if it would need to be documented. When asked what the danger would be for a resident to have a razor in their room or be left alone with a razor, the DON stated if Resident #41 had depression or suicidal thoughts they would be concerned he could harm himself and that it could be a risk to other residents who go in and out of other residents rooms. When asked what the danger would be for a resident to have scissors in their room the DON stated the residents keep them in their personal drawers that are not locked and that they can't take their items out of their rooms. 2. Record review of Resident #90's face sheet dated 12/03/2025 revealed a [AGE] year-old female with and admission date of 04/06/2024. Record review of Resident #90's admission Record, dated 12/03/2025, reflected a primary admission diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (a stroke characterized by paralysis or weakness on one side of the body) with other diagnoses that included rheumatoid arthritis, unspecified (autoimmune disorder that primary affects the joints which can result in joint deformity over time) other abnormalities of gait and mobility (manner of walking), need for assistance with personal care, cognitive communication deficit (difficulties in communication affecting how individuals think, process information and express themselves) and other diagnoses. Record review of Resident #90's MDS dated [DATE] revealed a BIMS of 12 out of 15 indicating independent decision making and recorded the needed use of supervision or touching assistance with personal hygiene and supervision or touching assistance to partial/moderate assistance with dressing. Record review of Resident #90's care plan provided on 12/03/2025 revealed a focus area for the following: . an ADL self-care performance deficit r/t impaired balance, initiated on 07/09/2024, with interventions including PERSONAL HYGIENE: requires (X)1 staff participation with personal hygiene and oral care, DRESSING: requires (X)1 staff participation in dress initiated on 07/23/2024, and . is at risk for falls r/t deconditioning, gait/balance problems, unaware of safety needs, initiated on 04/08/2024, with interventions including be sure [Resident #90's] call light is within reach and encourage her to use it for assistance as needed, initiated on 04/08/2024. During an observation on 12/02/2025 at 10:54 a.m., revealed Resident #90 had scissors in her top bedside drawer. During an interview on 12/02/2025 at 1:14 p.m., Resident #90 stated the staff at the facility knew Resident #90 had scissors in their room and that no one had told her she couldn't have scissors. Resident #90 stated she kept the scissors at her bedside in case she needed to use them for anything such as opening soda cans or if she needed to cut something but often must ask for assistance because of her hands. During an observation on 12/03/2025 at 8:55 a.m., revealed Resident #90 had scissors in her top bedside drawer. During an interview on 12/04/2025 at 2:54 p.m., CNA D stated they assumed safety scissors were allowed for Resident #90 to keep in her room. CNA D stated they weren't sure if it was documented anywhere but that it was not something that they had been spoken to about. When asked what the danger would be for a resident to have scissors in their room, CNA D stated for Resident #90 there was no risk and if she left them lying around CNA D would just pick them up. During an interview on 12/04/2025 at 5:40 p.m., when asked if residents could have items such as razors or scissors in their rooms the Administrator stated residents have rights that the facility cannot take away. When asked what the danger would be for a resident to have a razor or scissors in their room the Administrator stated that it would be more about if a resident had been judged incompetent or not. Record review of the facility's policy titled Residents Rights, undated, revealed the following:Dignity and RespectYou have the right to: - Live in safe, decent, and clean conditions

Based on interview and record review, the facility failed to ensure a drug regimen of each resident was reviewed at least once a month by a licensed pharmacist for 1 of 3 residents (Resident #2) reviewed for (DRR) Drug Regimen Review.The facility failed to have a record of Resident #2's DDR for November 2025.This failure could place residents at risk of not having their medications reviewed by a pharmacy consultant for appropriate doses or pharmacy recommendations.The findings included:Record review of Resident #2's face sheet dated 12/5/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included senile degeneration of brain (age-related deterioration of the brain tissue), heart disease, encounter for palliative care (a specialized medical focus on improving quality of life for people with serious, chronic, or life-limiting illnesses), abnormal weight loss, reduced mobility, and dementia with anxiety (a progressive decline in cognitive function that affects memory, thinking, problem-solving, and daily functioning).Record review of Resident #2's most recent comprehensive MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills and was treated with an antipsychotic and antidepressant.Record review of Resident #2's Order Summary Report dated 12/5/25 revealed the following:- Lorazepam 0.5 mg tablet every 4 hours as needed for anxiety/agitation with order date 11/7/25 and no end date.- Seroquel 25 mg tablet one time a day for hallucinations; give with 50 mg tablet to equal 75 mg with order date 12/1/25 and no end date.- Trazadone 100 mg tablet one time a day for insomnia with order date 10/29/25 and no end date.Record review of Resident #2's comprehensive care plan with revision date 12/2/25 revealed a focus area related to the use of psychotropic medications related to anxiety, depression, and history of hallucinations with interventions that included medication management to provide psychiatric services, administer medications as ordered, and consult with pharmacy, and MD to consider dosage reduction when clinically appropriate.Record review of the DRR for the residents by the Pharmacy Consultant dated 11/28/25 did not include Resident #2.During an interview on 12/5/25 at 10:42 a.m., the DON stated she would have to refer to the Pharmacy Consultant to determine why Resident #2 did not get a DRR for November 2025.During a follow up interview on 12/5/25 at 10:55 a.m., the DON stated she spoke with the Pharmacist Consultant and stated Resident #2 was not a part of the DRR because the resident was receiving respite care.During a telephone interview on 12/5/25 at 11:33 a.m., the Pharmacist Consultant stated she had been misinformed during a meeting in which she assumed a resident who was receiving respite care did not require a DRR. The Pharmacist Consultant stated she referred to her supervisor and was told that every resident who resided in the facility, regardless of status, including respite residents, were supposed to be included in the DRR. The Pharmacist Consultant stated the DRR was important because it ensured they followed regulations, and to ensure the medication therapy was appropriate. Record review of the facility document titled, Medication Regimen Reviews dated 7/1/18 revealed in part, .The Consultant Pharmacist shall review the medication regimen of each resident at least monthly.The Consultant Pharmacist will perform a medication regimen review (MRR) for every resident in the facility.Routine reviews will be done monthly.

Based on interview and record review, the facility failed to complete a Significant Change MDS assessment with 14 days after the facility determined, or should have determined, there had been a significant change in a resident's physical or mental condition for 1 of 24 residents (Resident #45) reviewed for assessments. The facility failed to complete a Significant Change MDS for Resident #45 within 14 days of the resident's discharge from hospice services. This failure placed residents who had a significant change in condition requiring an MDS assessment at risk of not receiving needed services. The findings were: Record review of Resident #45's admission Record dated 12/04/25 revealed a [AGE] year old woman admitted to facility on 07/16/25 with diagnoses that included cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior cerebral arteries (a stroke caused by blocked blood flow in major arteries to the brain), vascular dementia (a decline in thinking skills due to reduced blood flow to the brain often caused by stroke), aphasia (a communication disorder caused by brain damage that impairs a person's ability to speak), dysphagia, oral phase (a swallowing disorder), and encounter for attention to gastrostomy (a medical visit for care of a feeding tube). A record review of Resident #45's medical record revealed the resident had been placed on hospice and a Significant Change Assessment had been completed on 11/08/25. Upon further review of Nursing Progress Notes dated 11/14/25 it was noted that the family had decided to take Resident #45 off of hospice services as of 11/14/25. There was no additional Significant Change MDS completed to reflect the resident was no longer on hospice. Interview on 12/04/25 at 2:30 pm, ADON B was asked for the hospice binder for Resident #45. ADON B stated that since the resident had been taken off of hospice, her chart had been given to Medical Records. ADON B was able to retrieve the binder about an hour later. The hospice binder was reviewed, and it contained both an election form dated 10/31/25 and a cancellation form dated 11/14/25. During an interview with the DON on 12/04/25 at 3:20 PM, the DON stated Resident #45 was taken off hospice on 11/14/25 since family could not agree about the need for hospice. No additional MDS had been done to reflect this change. The DON stated the MDS Coordinator was responsible for updating MDS Assessments. The DON also stated the nurse managers had clinical meetings every morning to discuss changes in residents' conditions. Record review of the Medical Record indicated that the ADON B had made a note in the Progress Notes on 11/14/25 that Resident #45 had been taken off of hospice services. During a phone interview on 12/05/25 at 11:39 AM with MDS Coordinator, she stated she had seen the orders to take the resident off of hospice but did not get the information in time to make the change before she had to leave town for a family emergency. The MDS Coordinator stated, We had orders and I had written it down to do a sig change to take her off hospice. The BOM didn't notify us that she came off. Hospice usually notifies the BOM and she notifies us. The MDS Coordinator stated she knew a significant change MDS should have been done within 14 days but she failed to complete one on time. Review of the policy for Change in a Resident's Condition or Status revised 6/10/2025 stated:Change in the resident status or condition can be addressed by any staff member. The staff member noticing a change in the resident condition shall report to the Nursing supervisor/charge Nurse and at that point the assessment process will begin. The Nurse Supervisor/Charge Nurse is responsible for enacting the following protocol.2. A significant change of condition is a decline or improvement in the resident's status that:c. Requires interdisciplinary review and/or revision to the care plan8. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outline in the MDS RAI Instruction Manual.

Based on interview and record review the facility failed to ensure the comprehensive care plan and quarterly review assessments were reviewed and revised by an interdisciplinary team that included, but was not limited to the attending physician, a registered nurse, a nurse aide, and a member of food and nutrition services staff responsible for the resident for 2 of 8 residents (Resident #68, and #10) reviewed for care plan timing and revision. 1. The facility failed to have a complete interdisciplinary team attend Resident #68's care plan meeting to include the attending physician, a registered nurse, a nurse aide, and a member of food and nutrition services staff. 2. The facility failed to have a complete interdisciplinary team (to include the attending physician, a registered nurse, a nurse aide, and a member of food and nutrition services staff) attend Resident #10's care plan meeting. These deficient practices could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: 1. Record review of Resident #68's face sheet dated 12/3/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included heart disease, multiple sclerosis (chronic autoimmune disease in which the immune system attacks myelin, the protective covering around nerves in the brain, spinal cord, and optic nerves), diabetes (chronic medical condition in which the body either does not produce enough insulin or cannot use insulin effectively), hyperlipidemia (abnormally high levels of fats in the flood, high cholesterol), and hypotension (low blood pressure). Record review of Resident #68's quarterly MDS assessment dated [DATE] reflected the resident was cognitively intact for daily decision-making skills, was diagnosed with diabetes, and received insulin injections. Record review of Resident #68's most recent quarterly MDS assessment dated [DATE] reflected the resident was cognitively intact for daily decision-making skills, was diagnosed with diabetes, and received insulin injections. Record review of Resident #68's document titled Multidisciplinary Care Conference, unsigned and dated 7/17/25 under the Activities Summary section for Evaluation/Goals reflected, engage resident in daily activity of choice as tolerated. The Multidisciplinary Care Conference document reflected the following sections titled Attendance at Meeting, Nursing Summary, Name of Contributing Charge Nurse, Name of Contributing CNA, Other contributing nursing staff, Dietary Summary, Social Work Summary, Pharmacy Summary, Restorative Care/PT/OT Summary, Physician Summary, and Resident/Family sections were blank. Record review of Resident #68's Order Summary Report for December 2025 revealed the resident received Metformin 500 mg tablets two times a day for diabetes with start date 9/25/25 and no end date. Record review of Resident #68's comprehensive care plan with revision date 6/14/23 reflected that the resident had diabetes and interventions included to provide diabetes medication as ordered by the doctor. 2. Record review of Resident #10's face sheet, dated 12/02/2025, reflected a [AGE] year-old male with an initial admission date of 02/03/2025 and re-admission date of 03/21/2025. It reflected Resident #10 had diagnoses that included major depressive disorder, schizophrenia (serious mental health condition that affects how people think, feel, and behave), type 2 diabetes, hypothyroidism (thyroid gland does not make enough thyroid hormone), hyperlipidemia. Record review of Resident #10's quarterly MDS Assessment, dated 11/20/2025, reflected Resident #10 had a BIMS score of 9 out of 15, indicating the resident was moderately cognitively impaired. Record review of Resident #10's Multidisciplinary Care Conference, dated 10/23/25, reflected the staff who were present at the 10/23/25 care plan meeting was the SW, AD, and 2 LVNs (full names unknown). During an interview on 12/4/25 at 3:19 p.m., the DON stated it was the MDS Coordinator, the SW, and the Activities Director who attended the care plan meetings. The DON stated, other disciplines were invited to care plan meetings at the request of the Resident or the RP, such as nursing, dietary, housekeeping, etc. The DON stated the SW coordinated the care plan meetings. The DON stated, I can't tell you, can't remember the last time she was at a care plan meeting. The DON stated it was usually one of the two LVN ADONs who attended care plan meetings, but normally I don't attend a care plan meeting. During a follow up interview on 12/4/25 at 4:37 p.m. the DON stated, care plan meetings were attended by the SW, the MDS Coordinator, the Activities Director, and the resident and/or RP. The DON stated, no RN goes to those meetings. The DON stated that the MDS Coordinator was an LVN. During an interview on 12/4/25 at 5:00 p.m. ADON LVN M stated she could not recall the last time she was invited to a care plan meeting. ADON LVN M stated the MDS Coordinator was always present at the care plan meetings and usually the Activities Director, SW, and the Director of Rehab participated in care plan meetings. ADON LVN M stated, I have not seen a doctor at a care plan meeting, but one time when a family member requested it. ADON LVN M stated the SW schedules the care plan meetings and he runs them. During an interview on 12/4/25 at 5:10 p.m., ADON LVN N stated it had been a while since he had participated in a care plan meeting. ADON LVN N stated the MDS Coordinator, the SW, and the Activities Director participated in care plan meetings. ADON LVN N stated the MDS Coordinator and the SW run the meeting. ADON LVN N stated the MDS Coordinator represented the nursing department, but when he was invited, he would usually review medications. ADON LVN N stated the SW will give us a piece of paper regarding an invite to a care plan meeting. ADON LVN N stated if requested, it's rare, but unless invited, a doctor won't show up. ADON LVN N stated, disciplines were invited based on a specific problem, such as if there was a dietary issue, then dietary would be invited. During an interview on 12/5/25 at 8:16 a.m., CNA L stated she had been employed by the facility for almost 6 years and had never been invited or had attended a care plan meeting. CNA L stated she had not heard of other CNA staff being invited to a care plan meeting. CNA L stated the care plan meeting was when the team talked to the family regarding the resident's care. CNA L stated, I know that the SW, the MDS Nurse, Activities Director, Dietary Manager and the Therapy usually go. I have not heard of CNA's going to a care plan meeting. During an interview on 12/5/25 at 8:27 a.m., Resident #68 stated she could not recall participating in a care plan meeting or sitting down with a team of facility staff to discuss her medical needs. Resident #68 stated she believed a care plan meeting was for her benefit but could not elaborate. During an interview on 12/05/2025 at 8:33 a.m. the Director of Rehab stated she participated in care plan meetings for residents who were included in her case load. The Director of Rehab stated, care plan meetings were held on Thursdays usually, and run by the SW. She stated the SW, MDS Coordinator, herself, the Dietary Manager, and the Activities Director participated in those meetings. The Director of Rehab stated she had never seen the doctor at the meetings but sometimes they participated by phone. The Director of Rehab stated she had never signed anything indicating she had participated in a care plan meeting. During an interview on 12/5/25 at 11:42 a.m., the MDS nurse revealed it was important to have a multidisciplinary team to attend residents' care plan meetings to receive proper feedback to provide appropriate care for the residents. She further revealed the attendants for residents' care plan meetings would be noted in the resident's Multidisciplinary Care Conference assessments and to refer to this assessment to see who was in attendance. (The MDS nurse could not review any specific resident's assessments as she was out of town and did not have access to resident records.) During a telephone interview on 12/5/25 at 11:53 a.m., the MDS Coordinator stated she was pretty much the only person compiling the MDS assessments. The MDS Coordinator stated she relied on information provided by the medication administration record and the physician's orders when completing an MDS assessment. The MDS Coordinator stated she could not explain why Resident #68's most recent quarterly MDS assessment reflected the resident received insulin injections and could not refer to the resident's record because she was out of town. During an interview on 12/5/25 at 4:11 p.m., the SW stated, care plan meetings were coordinated by him and were scheduled every Thursday. The SW stated, he, the Activities Director, and the Rehab therapist participated in the care plan meetings. The SW stated that the MDS Coordinator also attended the care plan meetings, and she represented nursing, unless a charge nurse was invited. The SW stated he followed guidelines and basically it was the SW, the Activities Director, the MDS Coordinator, and maybe possibly a charge nurse or manager for the unit participated in care plan meetings. The SW stated, as far as he knew, there was no requirement for a doctor to be involved in the care plan meeting, and since I've been here, I have never had the doctor invited. The SW stated he did not keep a record or any paperwork related to who attended or participated in a care plan meeting. The SW stated the care plan meetings were important because it helped to update a resident's plan of care and used as a standard of practice for where we are with the resident and their feedback on how we are doing with their care. During an interview on 12/5/25 at 4:43 p.m., the Administrator stated he had been invited to care plan meetings and had even randomly shown up to ensure the meetings were occurring. The Administrator stated it was the SW who communicated when a care plan meeting would occur and was aware it required involvement by the IDT which included dietary, activities, nursing, therapy, SW, and housekeeping/laundry. The Administrator stated the doctor sometimes would participate in person or by phone, and because the care plan meetings were a requirement, the meetings were still held even if the doctor did not participate. Record review of the facility policy titled Care Plans – Comprehensive with revision date 3/1/22 revealed in part, .An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for reach resident.Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Record review of the facility policy titled Care Plans – Interdisciplinary Team revision date 3/1/22 revealed in part, .2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: a. The resident's Attending Physician; b. The Registered Nurse who has responsibility for the resident; c. The Dietary Manager/Dietician; d. The Social Services Worker responsible for the resident; e. The Activity Director/Coordinator.i. The Charge Nurse responsible for resident care; j. Nursing Assistants responsible for the resident's care.

Based on record reviews and interviews, the facility failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman, send the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged , and record the reason for the transfer or discharge in the resident's medical record in for 1 (Resident #99) of 2 residents reviewed for safe transfer or discharge.1.The facility failed to record the reasons for the transfer in Resident #99's medical record.2. The facility failed to send notice of transfers or discharges to the ombudsman.3. The facility failed to provide Resident #99 and/or the resident's representative with a thirty-day written notice of an impending transfer or discharge.This failure could result in residents experiencing psychosocial harm (feelings of anger and sadness) due to inappropriate discharges and placed residents at risk of being discharged without alternate placement and not having access to available advocacy services, discharge/transfer options, and denying them their rights in the appeal process.The findings include:Record review of Resident #99's admission Record, dated 12/05/2025, reflected a [AGE] year-old male with an admission date of 04/06/2025 and a discharge date of 09/23/2025. It reflected Resident #99 had diagnoses that included dependence on wheelchair, mild protein-calorie malnutrition (lack of proper nutrition), cognitive communication deficit, need for assistance with personal care, and major depressive disorder.Record review of Resident #99's Quarterly MDS Assessment, dated 09/01/2025, reflected Resident #99 had a BIMS score of 5 out of 15, indicating the resident was severely cognitively impaired. Record review of Resident #99's care plan, undated, reflected, [Resident #99] discharge planning will honor his personal wishes. The expectation, based on care plan meetings and talking with the patient, is to stay in facility for LTC., initiated 04/26/2025 and revised on 10/09/2025.Record review of Resident #99's progress note, dated 09/23/25 at 01:47PM, authored by LVN M, reflected [Resident #99] being discharged to [facility name], being picked up at this time via stretcher. discharged med list and medications sent with [Resident #99]. Transportation unable to take residents belongings. Notified RP [name]. No concerns expressed at this time. Attempted to call report to [facility name] x 3 attempts, unable to get ahold of a nurse at this time. No distress noted upon departure.Interview on 12/05/25 at 02:08PM, the SW revealed nurses oversaw discharge documentation in the residents' electronic medical record.Interview on 12/05/25 at 02:57PM, LVN M revealed he could be more specific in documentation for residents for transfers and discharges. He revealed he sometimes forgot to fill out the Final Discharge Summary assessment, which typically needed to be done, but he did put required information in his progress note. He revealed it was important for adequate documentation.Email communication on 12/05/25 at 03:25 PM, the ombudsman revealed she never received notice of Resident #99's discharge.Email communication on 12/05/25 at 03:39 PM, the ombudsman revealed the facility was not sending her their monthly discharge summary.Email communication on 12/05/25 at 04:29 PM, the ombudsman revealed the ADM or SW typically sent her the facility's discharge summary, but each facility was different.Interview on 12/05/25 at 04:43PM, the ADM revealed he was not aware that they had to notify the ombudsman of discharges or transfers. He revealed it was the SW that contacted the ombudsman for the monthly discharges.Interview on 12/05/25 at 05:34 PM, the DON revealed the basis for a transfer was not documented in the resident's medical record if it did not have to do with nursing. Interview on 12/05/25 at 05:40PM, the BOM revealed Resident #99 was discharged because of payment. She revealed she worked with his family to get him transferred somewhere else so they did not have to give him a 30-day discharge notice so Resident #99 could come back to this facility if they chose to.Record review of facility's policy Documentation of Transfers/Discharges, revised 09/13/17, reflected Our facility shall provide a resident and/or the resident's representative (sponsor) and a representative of the Office of the State Long-Term Care Ombudsman, with a thirty (30)-day written notice of an impending transfer or discharge.1. All documentation concerning the transfer or discharge of a resident must be recorded in the resident's medical record. The documentation must include: a. The basis for the transfer.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access for 3 of 5 Residents (Resident #1, #2, and #3) reviewed for medication storage:1. The facility failed to ensure Resident #1 did not have medication cups with cough syrup at the bedside.2. The facility failed to ensure Resident #2 did not have a jar of medicated mentholated ointment (a combination product that is used to relieve itching, minor muscle, or joint pain. This product may also be used as a chest rub to soothe symptoms associated with the common cold) at the bedside.3. The facility failed to ensure Resident #3 did not have a jar of medicated mentholated ointment (a combination product that is used to relieve itching, minor muscle, or joint pain. This product may also be used as a chest rub to soothe symptoms associated with the common cold) at the bedside.These deficient practices could affect residents who received medications in the facility and place them at risk for not receiving the correct medications, medication misuse or drug diversion.The findings included:1. Record review of Resident #1's face sheet dated 11/19/25 revealed a [AGE] year old female admitted to the facility on [DATE], and re-admitted on [DATE], and 8/23/25 with diagnoses that included heart disease, acute respiratory failure with hypoxia (a medical condition in which the lungs suddenly cannot provide enough oxygen to the blood), and seasonal allergic rhinitis (an allergic reaction that occurs during certain times of the year causing inflammation of the lining of the nose caused by an immune reaction).Record review of Resident #1's most recent quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills.Record review of Resident #1's Order Summary Report dated 11/19/25 revealed the following:- Guaifenesin Liquid 100 MG/5ML, give 10 ml by mouth every 4 hours as needed for cough, with order date 8/29/25 and no end dateDuring an observation and interview on 11/19/25 at 2:14 p.m., Resident #1 was seen sitting up in bed and the bedside table to the right of the resident was observed with 2 medication cups that had red liquid in them. Resident #1 stated the 2 medication cups had cough syrup and were prescribed for allergies. Resident #1 stated she did not like the taste of the cough syrup and those (the medication cups) have been there for 3 days.2. Record review of Resident #2's face sheet dated 11/20/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included rheumatoid arthritis (a chronic disease in which the immune system attacks the lining of the joints causing inflammation, pain and swelling), reduced mobility, cough, asthma (a chronic lung disease in which the airways become inflamed, narrowed, and over-responsive making it difficult to breath), and fibromyalgia (a chronic disorder characterized by widespread muscle pain, tenderness, and fatigue).Record review of Resident #2's most current quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills.During an observation and interview on 11/20/25 at 8:49 a.m., Resident #2 stated she received medications daily from the nursing staff and was not allowed to self-administer medications or keep medications in her room because staff were afraid other residents could have access to her medications. Resident #2 was observed with a jar of medicated mentholated ointment on her bedside table and stated she used the ointment on her feet. Resident #2 stated she last used the medicated mentholated ointment the night before.3. Record review of Resident #3's face sheet dated 11/20/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] and 11/4/25 with diagnoses that included chronic obstructive pulmonary disease (a long term lung disease in which airflow is partially blocked and breathing becomes difficult), respiratory failure, rheumatoid arthritis (a chronic disease in which the immune system attacks the lining of the joints causing inflammation, pain and swelling), muscle weakness, and asthma (a chronic lung disease in which the airways become inflamed, narrowed, and over-responsive making it difficult to breath). Record review of Resident #3's most recent quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills.During an observation and interview on 11/20/25 at 9:04 a.m., Resident #3 was observed with a jar of medicated mentholated ointment at the bedside. Resident #3 stated she used the ointment for her feet. Resident #3 would not indicate when she last used the ointment. During an interview on 11/20/25 at 10:12 a.m., MA C stated medications were not allowed at the resident's bedside because other residents could take it, or the resident could hide it and give it to somebody else. MA C stated there were no residents in the facility who were allowed to self-administer medications.During an interview on 11/20/25 at 10:37 a.m., LVN D stated it was unacceptable to leave medications at a resident's bedside because somebody else could have access to them, and they can pocket the medication. LVN D stated when medications were administered to a resident, the nurse was supposed to watch the patient take what was prescribed. LVN D stated there were no residents in the facility who were allowed to self-administer medications. During an interview on 11/20/25 at 11:19 a.m., LVN E stated it was not acceptable to leave medications at a resident's bedside because somebody can take them when it was not intended for them, or the patient could hoard the medication and could possibly overdose. During an interview on 11/20/25 at 2:09 p.m., the DON stated medications were not supposed to be left at the bedside because then it could not be determined if the resident took the medications. The DON stated, medications left at the bedside could result in the resident possibly hoarding the medication and could have adverse effects from not taking a scheduled medication such as blood pressure medication. The DON stated, the same could apply to over-the-counter medications. The DON stated there were no residents in the facility who were allowed to self-administer medications. Record review of the facility document titled Storage of Medications with revision date April 2007 revealed in part, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.The nursing staff shall be responsible for maintaining medication store.Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems.Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys.

Based on observations, interviews and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure [NAME] A wore a beard net on 11/12/25. This failure could place residents at risk of contaminated food and illness.Findings include:During an observation of the kitchen on 11/12/25 at 12:20 p.m., [NAME] A had facial hair and was not wearing a beard net and was checking food temperatures before lunch meal service. During an interview on 11/12/25 at 12:24 p.m., [NAME] A stated he was most recently reeducated on the beard net policy one year ago by the former DM. He stated all kitchen staff were responsible for following the facility's beard net policy. He stated he put on a beard net before checking food temperatures and preparing and serving meals. He also said, It was OSHA compliant to not wear a beard net if a beard was no more than 2 inches long. He stated he was still required to wear a beard net regardless of the facial hair length. He stated the DM oversaw and ensured kitchen staff wore beard nets. He stated he did not wear a beard net before checking food temperatures in the kitchen and said, Because I had really bad allergies this week and did not want to scratch and contaminate the food. He stated he notified the DM of his allergies before starting his shift on 11/12/25. He stated it was important to follow the beard net policy and said, To keep residents from getting sick. Residents could get sick. During an interview on 11/12/25 at 12:28 p.m., DA B stated she was most recently reeducated on the beard net policy approximately one or two months ago by the current DM. She stated all kitchen staff were responsible for following the facility's beard net policy. She stated the cooks were required to wear beard nets when handling food. She stated the DM oversaw and ensured kitchen staff wore beard nets. She stated it was important to follow the beard net policy and said, So no hair touches residents' food. Residents could become upset, and not following the beard net policy would affect their health.During an interview on 11/12/25 at 12:43 p.m., DA C stated she was most recently reeducated on the beard net policy two years ago by the former DM. She stated all kitchen staff were responsible for following the facility's beard net policy before entering the kitchen. She stated the cooks were required to wear beard nets when handling food. She stated the cooks and DM oversaw and ensured kitchen staff wore beard nets. She stated it was important to follow the beard net policy and said, To protect the food and make sure hair does not fall on residents' meals and trays. Residents could be at risk of getting sick. During an interview on 11/12/25 at 12:52 p.m., the DM stated he was educated on the beard net policy. He stated he most recently reeducated the kitchen staff on the beard net policy in the summer of 2025. He stated all kitchen staff and anyone who stepped into the kitchen were required to wear a beard net or facial hair must be clean shaven when handling food. He stated he oversaw and ensured kitchen staff wore beard nets by conducting rounds several times per shift. He stated he observed [NAME] A not wearing a beard net when [NAME] A was checking the food temperatures in the kitchen before lunch meal service, did not do anything, and did not know why he did not do anything. He stated it was important to follow the beard net policy and said, You don't want to contaminate the food with hair and other contaminants. Residents could be at risk of foodborne illness and other diseases. Review of the facility's Staff Attire policy, revised 01/2025, reflected, Procedures: 1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained.

Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 6 residents reviewed for infection control. The facility failed to ensure staff wore PPE when entering Resident #1's room on 11/12/25 at 8:00 a.m. This failure could place residents at risk of cross-contamination and infection. Findings include: Review of Resident #1's admission Record, dated 11/14/25, reflected she was an [AGE] year old female who was admitted to the facility on [DATE]. She had medical diagnoses including dementia (a set of symptoms that cause a significant decline in cognitive abilities like memory, thinking, and reasoning, to the point that it impairs daily life), weakness and COVID-19. Review of Resident #1's Quarterly MDS Assessment, dated 11/03/25, reflected she had a BIMS score of 2, which indicated she had severe cognitive impairment. Resident #1's COVID-19 vaccine was also not up to date.Review of Resident #1's Care Plan, revised 09/06/25, reflected she had diagnosis of COVID-19 and was at risk for developing respiratory complication including but not limited to impaired oxygen exchange and dehydration and decrease in mobility. One of the interventions included, isolation with droplet precautions in place, ensure proper signage is on doors and proper donning and doffing (putting on and taking off) is occurring when entering and exiting room or unit. Review of Resident #1's Electronic Monitoring Footage, dated 11/12/25 at 8:00 a.m., reflected Resident #1 was lying in bed in her room. A female staff member entered Resident #1's room with no PPE, placed a meal tray on Resident #1's bed side table next to Resident #1, woke Resident #1 and said, Buenos Dias (Good Morning), explained to Resident #1 that the meal tray was on the bed side table next to her, and exited her room. Review of the facility's Infection Report for November 2025 reflected Resident #1 had COVID-19 and was placed on droplet precautions on 11/05/25. Resident #1's infection resolved on 11/15/25. During an observation and interview on 11/12/25 at 10:31 a.m., Resident #1's room door was closed. There was a posting on her door that indicated she was on droplet precautions and staff were required to don and doff PPE before entering and exiting her room. There was a supply bin filled with PPE next to her room. Resident #1 was lying in an upright position in bed. Resident #1 stated she observed staff wear PPE before entering her room. During an interview on 11/12/25 at 1:25 p.m., Resident #1's RP stated she observed in-person and most of the time on camera the facility staff wearing PPE before entering and exiting Resident #1's room. During an interview on 11/13/25 at 3:11 p.m., LPN D stated she was most recently reeducated on infection control by the weekend supervisor in the Summer of 2025. She stated nurses were required to don PPE before entering and exiting residents' droplet precaution room. She stated that the Wound Care Nurse was the Infection Preventionist. She stated the Wound Care Nurse oversaw and ensured staff followed infection control protocols. She stated it was important to don PPE before entering and exiting residents' droplet precaution room and said, So we don't spread infection. Residents could be at risk of worsening sickness.During an interview on 11/14/25 at 10:29 a.m., the Wound Care Nurse stated she was the Infection Preventionist. She stated staff were reeducated on infection control quarterly by her and the ADONs. She stated she was unsure when she most recently reeducated staff on infection control. She stated staff were provided with the don and doff PPE posting or were required to notify the nursing staff if they did not know how to don and doff PPE. She stated she expected staff to don PPE, enter the room, provide care or service, doff PPE, perform personal hand hygiene and exit the room whenever residents were on droplet precautions. She stated that her, the DON, and ADONs oversaw and ensured staff followed infection control policy by conducting rounds every hour. She stated she knew it was important to don PPE before entering and exiting residents' droplet precaution room and said, To protect yourself and the resident. Residents could be at risk of developing infection if staff were not donning and doffing. During an interview on 11/14/25 at 10:49 a.m., ADON E stated the Wound Care Nurse was the Infection Preventionist. He stated he or the Wound Care Nurse reeducated staff on infection control monthly. He stated he expected staff to wear full PPE, which included gown, gloves, mask and face shield. He stated everyone at the facility was responsible for following the donning and doffing PPE policy. He stated it was important to don PPE before entering and exiting residents' droplet precaution room and staid, Primarily for infection control, and to prevent spread of infection, such as COVID-19. Residents could be at risk of possible infection. During an interview on 11/14/25 at 11:35 a.m., ADON F stated the Wound Care Nurse was the Infection Preventionist. She stated she was unsure when staff were most recently reeducated on infection control. She stated all staff who enter droplet precaution rooms must adhere to the donning and doffing PPE policy. She explained that staff were required to wear gown, gloves, face mask and face shield. She stated that the Wound Care Nurse, and the DON oversaw and ensured infection control policy was followed by conducting quarterly competencies on staff. She stated it was important to don PPE before entering and exiting residents' droplet precaution room and said, To prevent spread of infection. Residents could be at risk of infection spread. During an interview on 11/14/25 at 12:15 p.m., the NP stated Resident #1 recently had COVID-19. She stated Resident #1 was on droplet precautions. She stated she expected anyone who entered droplet precaution room to don and doff PPE before entering and exiting. She stated it was important to don PPE before entering and exiting residents' droplet precaution room and said, In order to keep COVID-19 from spreading and to protect everyone. Residents could be at risk for COVID-19 spread and epidemic. During an interview on 11/14/25 at 12:41 p.m., the DON stated the Wound Care Nurse was the Infection Preventionist. She stated she could not recall when she most recently in-serviced staff on infection control. She stated staff were responsible for donning and doffing PPE. She stated she expected staff to don and doff PPE before entering and exiting a droplet precaution room. She stated she, the Wound Care Nurse, and the ADONs oversaw and ensured infection control policy was followed by conducting quarterly competencies on staff. She stated it was important to don PPE before entering and exiting residents' droplet precaution room and said, To prevent infection spread. Residents could be infected. The surveyor requested the facility's infection control policy. During an interview on 11/14/25 at 1:28 p.m., the ADM stated the Wound Care Nurse was the Infection Preventionist. He stated he was unsure when staff were most recently in-serviced on infection control. He stated he was unsure if any reeducations were given related to infection control. He stated all direct care staff were responsible for following the infection control donning and doffing policy. He stated the DON, him, and ADONs oversee and ensure infection control was followed by conducting morning rounds and taking reports from staff. He stated it was important to don PPE before entering and exiting residents' droplet precaution room and said, To minimize the spread of infection and ensure resident safety from cross contamination. The surveyor requested the facility's infection control policy. The surveyor was not provided with the facility's infection control policy before exit on 11/14/25.

Based on observation, interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation for 1 of 11 residents (Resident #1) reviewed for resident abuse. The facility failed to ensure Resident #1 was free from physical abuse as evidence by on 08/05/2025, in the resident's room CNA A pushed Resident #1 onto the bed forcefully and held Resident #1 by pressing on the resident's chest when Resident #1 tried to get up. The noncompliance was identified as a PNC. The IJ began on 08/05/2025 and ended on 08/08/2025. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of serious injury, physical harm, serious impairment or death.The findings included: Record review of Resident #1's face sheet, dated 09/11/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included hepatic encephalopathy (the loss of brain function when a damaged liver does not remove toxins from the blood), dementia (loss of memory and thinking ability), anxiety disorder (a mental health disorder characterized by feelings of worry), and delusional disorder (A delusion is an unshakable belief in something that's untrue. The belief isn't a part of the person's culture or subculture, and almost everyone else knows this belief to be false). Resident #1 was discharged to another nursing home on [DATE] because of the resident's wandering behaviors. Record review of Resident #1's admission MDS assessment, dated 07/05/2025, revealed the resident's BIMS was 8 out of 15, which indicated the resident had moderate cognitive impairment, had verbal behavioral symptoms directed toward others, such as threatening others, screaming at others, and/or cursing at others, and required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to sit to stand, chair to bed, and toilet transfer. Record review of Resident #1's comprehensive care plan, dated 07/19/2025, revealed [Resident #1] resistive to care related to refuses medication, refuses care, refuses showers, becomes easily agitated and refused to be redirected. For intervention - 1:1 supervision, educate resident/family/caregivers of the possible outcomes of not complying with treatment or care, encourages as much participation/interaction by the resident as possible during are activities, give clear explanation of all care activities prior to an as they occur during each contact, and if resident resists with activities of daily livings, re-assure resident, leave and return 5 to 10 minutes later and try again. Record review of the facility's Provider Investigation Report, dated 08/08/2025, revealed On 08/05/2025, [Resident #1] was being transferred to bed by [CNA-A] used abrupt force to place resident in bed. Further record review of the Provider Investigation Report revealed the facility suspended CNA-A immediately, and the facility nurse assessed Resident #1 on 08/05/2025 at 6:15 p.m., and no injury was noted, and the facility immediately reported to Texas Health and Human Services the incident, contacted the local police and received a case number, physician and family were notified, staff educated on reporting abuse and neglect and resident rights and providing compassionate care to residents. Staff members and residents were interviewed. Record review of Resident #1's nurses notes, dated 08/05/2025, revealed At approximately 3:25 p.m., resident was observed by nurse ambulating in the hallway without wearing pants, and their brief was nearly falling down. Resident then entered another resident's room and stated, 'I want to use the bathroom.' Resident was redirected appropriately. Staff attempted to explain and encourage the resident to return to their own room. During redirection, resident displayed aggressive behavior and attempted to physically strike the CNAs. Resident was safely guided back to their room by staff. Nurse attempted to administer Ativan as needed order for agitation; however, resident refused multiple times. CNAs assisted resident with hygiene, changing clothing, and ensuring resident's dignity and comfort were maintained. Will continue to monitor behavior closely and ensure safety of resident and others. Resident's family member was aware. Further record review of the resident's nurse note dated 08/05/2025 at 6:30 p.m. revealed The administrator along with the nurse manager notified this resident's family reported resident was being mishandled by a CNA. This nurse completed head to toe assessment. This nurse assessed pain level and asking the resident 'Do you have any pain?' Resident denies any pain. Nurse observed that resident has no verbal/nonverbal indicated of pain. Resident family stay at the bed side while the nurse did head to toe assessment for resident. [CNA-A] removed from patient care. Medical doctor was notified. The resident denies pain at times and continues one on one due to wandering. Record review of Resident #1's incident report, dated 08/05/2025, revealed on 08/05/2025, [Resident #1] was being transferred to bed by [CNA-A] used abrupt force to place resident in bed, and [Resident #1]'s skin was dry and intact. No bruising was noted. Resident family was present when nurse do skin assessment for resident. [Resident #1] denies any pain or discomfort at this time. Observation on 09/11/2025 at 1:18 p.m. of the video footage dated 08/05/2025 inside Resident #1's room revealed CNA-A held both of Resident #1's arms behind him and approached Resident #1's bed. CNA A pushed Resident #1 onto the bed forcefully and held Resident #1 by pressing on the resident's chest when Resident #1 tried to get up. During an interview on 09/11/2025 at 1:20 p.m. with Resident #1's family member revealed he saw the video footage on 08/05/2025 and he thought CNA-A pushed Resident #1 onto the bed, so he notified the administrator immediately. Further interview with Resident #1's family member revealed Resident #1 did not have any abuse or neglect before this incident and after this incident. This was only incident related to abuse. Resident #1's family member said he thought Resident #1 was a little bit scared of the staff after this incident because the resident refused more cares, and Resident #1 was unable to interview because he was confused. During an interview on 09/10/2025 at 12:25 p.m., CNA-A stated Resident #1 was very aggressive and tried to enter a female resident's room on 08/05/2025, so CNA-A re-directed and guided Resident #1 to the resident's room. CNA-A said when he guided Resident #1, he was behind the resident and approached the bed, the resident tripped, lost his balance, and was about to fall. To prevent the actual fall, CNA-A pushed Resident #1 a little bit onto the bed. That was it, but later the facility told CNA-A to go to home, and the facility finally terminated CNA-A. During an interview on 09/10/2025 at 11:14 a.m., Sitter-B stated she was doing one to one supervision inside Resident #1's room on 08/05/2025, and Sitter-B saw Resident #1 was very aggressive to staff by throwing the television remote control and tried to hit staff, so CNA-A tried to re-direct and guide Resident #1 to the bed. Sitter-B said she did not see CNA-A push Resident #1 onto the bed, and she did not see any abuse to the resident. During an interview on 09/10/2025 at 10:09 a.m., the DON stated she saw the video footage on 08/05/2025 because Resident #1's family member showed it, and per the video footage, CNA-A hugged Resident #1 from behind the resident and guided the resident to the bed, then forcefully pushed the resident onto the bed because the resident was trapped and about to fall, so CNA-A tried to prevent the fall, but the facility immediately suspended CNA-A and finally terminated the CNA because he hugged the resident and did not request help from other staff. The DON said the facility assessed Resident #1 and found no injury was noted, reported it to the family and doctor, and provided in-services to all staff regarding Rights, Compassionate Care, Abuse and Neglect, and how to take care of residents with aggressive behaviors. During an interview on 09/10/2025 at 10:44 a.m., the facility Administrator stated Resident #1's family member called and showed the video footage to the Administrator on 08/05/2025, and according to the scene on the video footage, CNA-A tried to guide Resident #1 to the bed and pushed the resident forcefully onto the bed to prevent a fall, but CNA-A did not request any help from other co-workers. That was why the administrator suspended CNA-A immediately and terminated the CNA on 08/08/2025. The Administrator said the facility assessed Resident #1 and found no injury was noted, reported it to the family and doctor, and provided in-services to all staff regarding Rights, Compassionate Care, Abuse and Neglect, and how to take care of residents with aggressive behaviors, and the Administrator said the facility did not have residents with wandering and aggressive behaviors. During interviews on 09/11/2025 from 2:00 p.m. to 2:43 p.m. with Residents #2, #3, #4, #5, #6, #7, #8, #9 and #10 revealed they felt very safe and did not have or see any abuse or neglect in the facility. During an interview on 09/12/2025 at 9:30 a.m., LVN-C stated LVN-C worked the evening shift (from 2 p.m. to 10 p.m.) and assessed Resident #1 on 08/05/2025 and noted the resident did not have any injury and denied any pain. Resident #1's behaviors after the incident occurred were not changed, and the resident never was scared of staff but still was aggressive sometimes. LVN-C said the facility staff received in-service trainings regarding Resident Rights, Compassionate Care, Abuse and Neglect, and how to take care of residents with aggressive behaviors, and the nurse said she learned that the resident had right for free from abuse, the definition of abuse, staff must report any abuse immediately to the abuse coordinator (The Administrator), and using therapeutic communication skills when taking care of resident with aggressive behaviors. During interview on 09/11/2025 from 1:24 p.m. to 1:59 p.m. with CNA-D, CNA-E, CMA-F, Housekeeper-G, CNA-H, LVN-I, CNA-J and LVN-K revealed they worked at morning shift (6 am to 2 pm) and sometimes evening shift (2 p.m. to 10 p.m.) at the facility and Resident #1's behaviors after this incident occurred were not changed, and the resident was never scared of staff and was still aggressive sometimes, and they received in-service trainings regarding Resident Rights, Compassionate Care, Abuse and Neglect, and how to take care of residents with aggressive behaviors, and they answered they learned that the resident had right for free from abuse, the definition of abuse, staff must report any abuse immediately to the abuse coordinator (The Administrator), and using therapeutic communication skills when taking care of resident with aggressive behaviors, such as keep voice at a conversation level, maintain eye contact, ask a few questions, and maintain a safe distance from the resident. During interview on 09/12/2025 from 10:00 a.m. to 11:15 a.m. with CNA-L, CNA-M, and CNA-N stated they worked the night shift (10 pm to 6 am) at the facility and Resident #1's behaviors after this incident occurred were not changed, and the resident was never scared of staff and was still aggressive sometimes, and they received in-service trainings regarding Resident Rights, Compassionate Care, Abuse and Neglect, and how to take care of residents with aggressive behaviors, and they answered they learned that the resident had right for free from abuse, the definition of abuse, staff must report any abuse immediately to the abuse coordinator (The Administrator), and using therapeutic communication skills when taking care of resident with aggressive behaviors, such as keep voice at a conversation level, maintain eye contact, ask a few questions, and maintain a safe distance from the resident. Record review of CNA-A's employee profile revealed CNA-A was hired on 11/18/2024 and terminated on 08/08/2025 because of the incident of 08/05/2025. CNA-A's employee profiles revealed the facility conducted checking criminal background on 11/17/2024, and CNA-A completed in-services training regarding abuse and neglect on 11/25/2024 before he started working the floor. Record review of the facility's in-service training regarding Resident Rights related to residents to have right to live in safe condition, be free from abuse, and be free from any physical restraint, Compassionate Care related to take care care of not only physical well-being but also the emotional, social, and spiritual well-being, Abuse and Neglect related to types of abuse, how to prevent and screening procedures, and how to identify abuse, signs of abuse, and how to report abuse, and how to take care of residents with aggressive behaviors, such as keep voice at a conversation level, maintain eye contact, ask a few questions, and maintain a safe distance from the resident. revealed 98 Staff out of total 103 staff completed receiving these in-service trainings on 08/05/2025. Record review of the facility's policy, titled Abuse & Neglect Policy and Procedure, revised 08/10/2022, revealed The facility is charged with the safeguard of each resident and will follow a consecutive plan in the pursuit of maintaining a safe environment. Suspected actions or allegations of abuse including physical, mental, verbal, sexual, involuntary seclusion, neglect or misappropriation of property by any individual including resident to resident altercations with injury will be reported to local authorities, state, and federal agencies and other appropriate agencies as required by law. The noncompliance was identified as PNC. The IJ began on 08/05/2025 and ended on 08/08/2025. The facility had corrected the noncompliance before the investigation began.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that 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 5 (Resident #2) reviewed for care plans.CNA L and CNA X failed to follow the care plan for Resident #2 and transferred Resident #2 without a mechanical lift on 08/16/2025. This deficient practice could place residents who are transferred at risk for injury.The findings included:Record review of an undated face sheet revealed Resident #2 was an [AGE] year-old female who admitted to the facility for hospice respite on 08/13/2025 with diagnoses that included Alzheimer's Disease (a progress disease that affects memory and other important mental functions) and Hypertension (high blood pressure). Record review of a facility form titled, Facility Order Form, dated 08/13/2025 revealed Resident #2's name and an order, Utilize [mechanical lift] to tx into high back wc. Record review of Resident #2's August 2025 physician order summary revealed an order, Utilize [mechanical lift] to transfer into high back wheelchair, dated 08/13/2025. Record review of Resident #2's care plan for ADL self-care performance revealed an intervention, TRANSFER: requires (x)2 staff participation with [mechanical] lift for transfers. Record review of Resident #2 Kardex provided by the MDS Nurse revealed, TRANSFER: requires (x) 2 staff participation with [mechanical] lift for transfers. Record review of a facility document titled, Provider Investigation Report, dated 08/21/2025 revealed on 08/21/2025 at 4:00 p.m. Resident #2 was transferred by 2 CNAs without the use of a [mechanical] lift. The document revealed the physician, and responsible party was notified, and staff was educated on reporting abuse and neglect, resident rights and transferring residents. During an interview with Resident #2's family member, 08/29/2025 at 9:06 a.m., the family stated Resident #2 was a mechanical lift transfer at home and Resident #2 was admitted to the facility on [DATE] for a 5 day respite stay and returned home on [DATE]. Resident #2's family member stated they were at the facility on 08/16/2025 and asked 2 CNAs to get Resident #2 out of bed so the family member could take Resident #2 to the dining room for dinner. The family member stated 2 CNAs entered the room and the family member stepped outside of the room while the resident was transferred from the bed to her wheelchair. The family member stated a mechanical lift was not in the room or and was not brought into the room for Resident #2's transfer. The family member stated she did not tell or remind the 2 CNAs that Resident #2 was a mechanical lift transfer. The family member stated she left the facility after feeding Resident #2 and was not present when Resident #2 was transferred back to bed. During an interview with CNA L, 08/29/2025 at 3:24 p.m., CNA L stated she would determine a resident's transfer status by reviewing the resident's Kardex that reflected how a resident was to be transferred from one surface to another. CNA L stated, if the resident Kardex did not reveal a transfer status, CNA L would have asked the Charge Nurse prior to transferring a resident. CNA L stated she had received training on reviewing a resident's transfer status on the Kardex prior to performing a transfer. CNA L stated Resident #2's family member requested CNA L and CNA X to get Resident #2 out of bed and into her wheelchair on 08/16/2025 before dinner. CNA L stated she did not review Resident #2's Kardex or ask the charge nurse about Resident #2's transfer status prior to performing the transfer with CNA X without the mechanical lift. CNA L stated she placed Resident #2's hands on CNA L's shoulders and CNA L wrapped her arms around Resident #2's waist and picked her up off of the bed like a bear hug and sat her down in Resident #2's wheelchair. CNA L stated CNA X was adjusting Resident #2's high back wheelchair during the transfer. CNA L stated she could not remember if she assisted Resident #2 back to bed that evening and stated she did not transfer Resident #2 out of bed on 08/17/2025. During an interview with the DON, 08/29/2025 at 6:45 p.m., the DON stated Resident #2 admitted to the facility on [DATE] and was a mechanical lift transfer. The DON stated CNA staff was made aware of a resident's transfer status by reviewing the Kardex and nurses would review a residents physician order and care plan. The DON stated the transfer status information in the Kardex was originated from the resident's care plan. The DON stated staff had been trained and educated on using the Kardex to identify transfer status during orientation upon hire and on quarterly competencies. The DON stated it was important for staff to use to correct transfer techniques and procedures to prevent injury or harm to residents and stated CNA L and CNA X received written counseling and was reeducated on using the Kardex to determine a resident's transfer status prior to transferring a resident. During an interview with CNA X, 08/30/2025 at 12:11 p.m. CNA X stated she had received training on resident transfers when CNA X began working at the facility in February 2025 and stated she was trained to look at a resident's Kardex to determine a resident's transfer status. CNA X stated she would ask the charge nurse about a resident's transfer status if CNA X did not see transfer status information in a resident's Kardex. CNA X stated she assisted CNA L with transferring Resident #2 from the bed to the wheelchair before dinner on 08/16/2025 and CNA X stated she did not check Resident #2's Kardex to determine Resident #2's transfer status prior to the transfer. CNA X stated Resident #2 was transferred with 2 people without using the mechanical lift. During an interview with CNA X, 08/30/2025 at 1:25 p.m., CNA X stated she assisted Resident #2 back to bed after dinner on the evening of 08/16/2025 with the assistance of another CNA and Resident #2 was transferred without the mechanical lift. During an interview with the MDS Nurse, 08/30/2025 at 3:40 p.m., the MDS Nurse stated she was responsible for adding individualized care plans to a resident's comprehensive plan of care and the MDS Nurse would add the care plan to each resident's Kardex. The MDS Nurse stated she added Resident #2's transfer status information into the Kardex the day after admission, that morning. The MDS Nurse stated a resident could sustain a skin impairment, fracture, or fall if the information on the transfer status for a resident on the Kardex was not followed when a staff member was providing care.During an interview with the Administrator, 09/03/2025 at 1:01 p.m., the Administrator stated he was notified by Resident #2's family member on 08/20/2025 that the family member observed 2 staff members transfer Resident #2 without the mechanical lift. The Administrator stated he reported the incident to HHSC because the facility staff failed to transfer Resident #2 correctly and it could have posed a risk to Resident #2. The Administrator stated CNAs should review a resident's Kardex prior to providing care and prior to transferring a resident and stated failure to follow the Kardex could result in physical harm or cause physiological complications. Record review of a facility policy titled, Care Plan (Copyright 2001 [company name] Revised August 2007), revealed a policy statement, our facility develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. The Policy and Interpretation and Implementation revealed, 2. The comprehensive care plan has been designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Reflect treatment goals and objectives in measurable outcomes; e. Identify the professional services that are responsible for each element of care; f. Prevent declines in the resident's functional status and/or functional levels.

Based on observations, interviews and record reviews the facility failed to each resident received assistance devices to prevent accidents for 2 of 2 Residents (Resident #2 and Resident #3) who were observed during mechanical lift transfers. 1. CNA F failed to lock the mechanical lift while raising and lowering Resident #2 during a transfer. He failed to widened the base of the mechanical lift which resulted in the wheelchair getting stuck between the legs while lifting Resident #2. CNA F failed to widened the base when transferring Resident #2 from the wheelchair to the bed while suspended in the air and when lowering Resident #2 onto the bed. 2. CNA I failed to lock the base of the mechanical lift while raising and lowering Resident #3 during a transfer. CNA H reached behind CNA I and locked the base of the mechanical lift with her left foot while CNA I was lowering Resident #3 into the bed. These deficient practices could affect any resident who was transferred via mechanical lift and could result in avoidable accidents and possible injuries. The findings were: 1. Review of Resident #2's face sheet, dated 1/12/25, revealed she was admitted to the facility on [DATE] with a diagnosis of unspecified Dementia (according to Mayo Clinic Dementia is a term used to describe a group of symptoms affecting memory, thinking and social abilities.), difficulty walking and muscle weakness. Review of Resident #2's MDS assessment, dated 10/28/24, revealed her BIMS score was 13 indicative of mild cognitive impairment and she required substantial/maximal assistance for transfers. Review of Resident #2's Care Plan, revised 2/15/24, revealed Resident #2 has an ADL Self Care Performance Deficit r/t dementia, weakness and debility. The intervention for transfers read: TRANSFER: requires (X)2 staff participation with hoyer lift for transfers. Observation on 1/8/25 at 3:45 PM revealed CNA F and CNA G transferring Resident #2 from the wheelchair to the bed using a mechanical lift. CNA F did not lock the mechanical lift or widen the base when raising Resident #2 up from the wheelchair. The wheelchair was stuck in the base. Resident #2 and the wheelchair started to go up in the air together until CNA G pushed down on the wheelchair preventing the wheelchair to be lifted off the floor. CNA F transferred Resident #2 over to the bed and then lowered her into the bed. CNA F never locked the base or widened the base of the mechanical lift during the transfer. Interview on 1/8/25 at 4 PM with CNA F and CNA G revealed CNA F stated he thought he widened the base on the mechanical lift but did not remember locking the lift. CNA F stated the wheelchair got stuck on the base of the mechanical lift and then commented, I guess I didn't widen the base. CNA G stated she did not see CNA F lock or widen the base on the mechanical lift; however, stated she was not looking. CNA F and CNA G stated they should always lock and widen the base of the mechanical lift so that it did not tilt over and so the resident did not fall during the transfer. CNA F and CNA G both stated Resident #2 could get injured had she fallen. 2. Review of Resident #3's face sheet, dated 1/12/25, revealed she was admitted to the facility on [DATE] with a diagnosis of difficulty walking, need for assistance with personal care and muscle weakness. Review of Resident #3's MDS assessment, dated 12/21/24, revealed her BIMS score was 0 indicative of severe cognitive impairment and she required partial to moderate assistance for transfers. Review of Resident #3's Care Plan, revised 2/5/24, revealed Resident #2 has an ADL Self Care Performance deficit r/t weakness and debility. An intervention for transfers read: TRANSFER: requires (X)1 staff participation with transfers. Observation and interview on 1/10/25 at 1:45 PM revealed CNA H, CNA I and CNA J transferring Resident #3 from the wheelchair to the bed using a mechanical lift. CNA J applied the brakes on the wheelchair. CNA H guided Resident #3 while on the sling and suspended in the air. CNA I operated the mechanical lift. She did not apply the brakes on the mechanical lift while lifting or lowering Resident #3 during the transfer. While CNA I was lowering Resident #3 onto the bed CNA H noted the brakes on the lift had not been applied. CNA H reached around CNA I with her foot and applied the right brake. Interview with CNA I revealed she did not apply the brakes on the mechanical lift while transferring Resident #3. She stated she should always apply the brakes before raising the Resident into the air and lowering the Resident onto the bed. She stated this would ensure stability preventing the mechanical lift from moving during the transfer and to prevent the Resident from falling. CNA H, CNA I and CNA J all stated Resident #3 could have been injured if she fell . Interview on 1/12/25 at 1:06 PM with the DON revealed nursing staff should lock the base of the mechanical lift before lifting, lowering a resident and while transferring a resident to prevent the mechanical lift from moving. Furthermore, nursing staff should widen the base during the transfer for stability so the mechanical lift did not tilt and the resident did not fall. The DON stated it was important to use the safety technique to prevent falls and possible injuries. The DON stated that Resident #2 and Resident #3 were both transferred by two staff using a mechanical lift. She also stated staff should never lock the base of the mechanical lift while in use by another staff because it could cause it to tilt; it could result in a fall and the resident could get injured. Review of a the manufacturer operating instructions provided by the DON on 1/12/25 read in relevant part Lift Preparation and Procedure: Warning: During lifting and lowering, whenever possible, always keep the base legs of the lift in the widest position. Warning: Before transfer, ensure wheelchair wheel locks are in locked position. Warning: Do not lock or block the patient lift casters when lifting. The casters must be free to roll so that the patient lift can stabilize as the patient is lifted or lowered.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition for 1 of 5 Residents (Resident #1) who needed assistance with meals. Nursing staff failed to set up Resident #1's meal tray to include raising the head of the bed, opening up condiments, ensuring the meat was cut when served and ensuring the bedside table was close to Resident #1 and in a position where she could reach the food on the meal tray. This deficient practice could affect any Resident who required set-up assistance during meals and could result in the resident having difficulties reaching the food and it could discourage the resident to eat their meal. The findings were: Review of Resident #1's face sheet, dated 1/12/25, revealed she was admitted to the facility on [DATE] with diagnosis of unspecified Dementia (according to Mayo Clinic Dementia is a term used to describe a group of symptoms affecting memory, thinking and social abilities.), Dysphagia (according to Mayo Clinic: Dysphagia is a medical term for difficulty swallowing.), unsteadiness on feet, Generalized Anxiety Disorder, Muscle Weakness, unspecified protein-calorie malnutrition and history of falling. Review of Resident #1's quarterly MDS assessment, dated 12/24/24, revealed Resident #1 revealed her BIMS score was 7 of 15 reflective of severe cognitive impairment and was independent when eating her meals. Review of Resident #1's Care Plan revised on 3/22/22 read: Resident #1 [Resident name] has an ADL Self Care Performance Deficit r/t cognition impairment, weakness & debility. Intervention included requires staff assist X1 to eat per family request. Observation on 1/10/25 at 12 PM revealed Resident #1 was lying in bed with the head of bed up at about 30 degrees. There was a call light wrapped around the left 1/4 siderail. There were two siderails up on each side of Resident #1's bed. Resident #1 did not wake to her name. Further observation revealed a bedside table positioned at an angle by the bed and in front of the nightstand on the right side while looking at Resident #1. The bedside table was at about the level of Resident 1's knees. Interview on 1/10/25 at 5:16 PM with Resident #1's family member D revealed she had videos that showed staff walking into Resident #1's room delivering meal trays but not helping Resident #1 with her meals. Family member D stated Resident #1 was able to feed herself but she needed staff to cut her meat. She also mentioned staff would leave the trays on the bedside table away from Resident #1. Resident #1 was not able to easily reach the food making it awkward when she ate. In addition, staff did not raise the head of the bed which resulted in Resident #1 sitting up in bed suspended without back support, reaching across the bed to her left side to reach the food on the meal tray. Family member D stated that sometimes Resident #1 would put the plate of food on her laps and often times she would get food on the front of her shirt. Staff would not change her shirt. Family member D stated she did not expect staff to provide Resident #1 with one to one supervision. However, she expected staff to raise the head of the bed, to sit Resident #1 up in bed, and place the bedside table close to her where she could reach the food easily so she would be comfortable during meals. Review of video #1 dated 12/9/24 (no time) revealed CNA C entering Resident #1's room with a meal tray. She placed it on the bedside table in front of the nightstand and at an angle on the edge of the right side of the bed when looking at Resident #1. CNA C did not remove the cover of the plate, did not ask Resident #1 if she needed help opening condiments, or set up the utensils. Further observation revealed CNA C did not ask Resident #1 if everything was ok or if she needed help with anything. Resident #1 was talking to CNA C in Spanish and CNA C shrugged her shoulders while walking to the other side of the room behind the privacy curtain. CNA C commented I need to learn Spanish, I don't know Spanish from the other side of the privacy curtain and then she re-appeared on Resident #1's side of the room. Resident #1 commented, no. CNA C shook her head and walked out of the room. Review of video #2 dated 12/13/24 (no time) revealed CNA C coming into Resident #1's room with a meal tray on top of a bedside table. She did not greet Resident #1; did not introduce herself or explain the purpose of her visit. CNA C placed the bedside table with the meal tray in front of the nightstand, at an angle on the edge of the right side of the bed when looking at Resident #1. CNA C did not remove the cover of the plate, did not ask Resident #1 if she needed help opening condiments, or set up the utensils. Further observation revealed CNA C did not ask Resident #1 if everything was ok or if she needed help with anything. Resident #1 was talking to CNA C in Spanish (most of the conversation could not be made out). Resident #1 stated during her conversation, this was the food that was brought to me earlier. I can't eat this; the following comments were not understandable. At the end of the conversation Resident #1 asked CNA C if CNA C could bring her something else as CNA C was walking away. CNA C did not re-appear in front of the camera and was heard talking in the background and the door closing. Her comments were not understandable. Review of video #5 dated 12/20/24 (no time) revealed the AD was in Resident #1's room by the bedside table. There was a meal tray on top of the bedside table which was located in front of the nightstand at the edge of the side of the rights side of the bed when looking at Resident #1. The AD had poured sugar into Resident #1's coffee. She was speaking with Resident #1 in Spanish, was very respectful during the conversation. However, she did not lift the head of the bed. Resident #1 was observed propping herself up on her left arm as she stirred the cup of coffee. Further observation revealed the plate of food was still covered and the orange juice was covered with a plastic lid. There was also a unopened carton but could not make out the content. Observation and interview on 1/11/25 at 4:15 PM with Resident #1 and family member E revealed family member E and Resident #1 engaged in conversation in Spanish. Resident #1 presented as being anxious and confused. Family member E reiterated concerns that family member D expressed on 1/10/25. She stated some staff did not speak Spanish and not able to understand Resident #1. Staff would not get another staff to help with translation and would ignore Resident #1. Observation and interview on 1/11/25 at 5:05 PM with Resident #1 revealed she was sitting in the common area with CNA A. She engaged in conversation, spoke plainly and in Spanish and stated she was good, making the best of living in this place with no concerns reported. Surveyor was Spanish speaking and able to converse with Resident #1. Surveyor asked how staff communicated with her. She stated not all staff spoke Spanish and she could not talk to them. Surveyor asked other questions about her care and Resident #1 did not respond. She presented as alert with confusion. Interview on 1/11/25 at 5:10 PM with CNA A revealed he spoke some Spanish and did the best he could to communicate with Resident #1. He stated he had a good rapport with Resident #1 and took the time to listen and understand what she was telling him. CNA A stated Resident #1 usually ate her meals in her room. He stated she could feed herself but needed help with cutting the meat, opening up milk cartons, opening up condiments, setting up her tray. Interview on 1/11/25 at 5:30 PM with the ADM and the DON revealed, upon reviewing videos #1 #2 and video #5, the DON identified CNA C and the AD in the videos. The DON and ADM stated Resident #1's family members had not expressed any recent concerns. They stated in the past they had expressed concerns about there not always being Spanish speaking staff and that it was difficult for Resident #1 to communicate with staff. The DON and ADM stated if there was not a Spanish speaking staff assigned to Resident #1's hall there was always someone in the facility who was Spanish speaking who could help with translation. The DON stated that Resident #1 was able to eat on her own. However, staff should be setting up her tray which included removing the lid from the plate, opening condiments as needed, setting up utensils, removing lids from the drinks and opening up other food items provided in a carton. The DON stated staff should raise the head of the bed and position the bedside table over the bed and close to Resident #1 where she could access the food easily. The DON stated CNA C and the AD did not follow protocol which resulted in Resident #1 propping herself up in bed and not having easy access to the meal tray and food. The ADM stated he agreed with the DON. Review of a facility policy, Assistance with Meals, revised on 3/27/2013, read in relevant part Residents shall receive assistance with meals in a manner that meets the individuals needs of each resident.

Based on observation, interview and record review 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 for 1 of 5 Residents (Resident #1) reviewed for dignity. Nursing staff failed to greet Resident #1 upon entering her room; failed to engage with Resident #1 while she was attempting to talk with them in Spanish and failed to request the assistance from other staff who could understand Resident #1 so they could determine if she needed assistance. Resident #1 was Spanish speaking only. This deficient practice could affect any Resident who did not speak English and could result in the Residents needs not being met and contribute to feelings of unworthiness. The findings were: Review of Resident #1's face sheet, dated 1/12/25, revealed she was admitted to the facility on [DATE] with diagnosis of unspecified Dementia (according to Mayo Clinic Dementia is a term used to describe a group of symptoms affecting memory, thinking and social abilities.), Dysphagia (according to Mayo Clinic: Dysphagia is a medical term for difficulty swallowing.), unsteadiness on feet, Generalized Anxiety Disorder, Muscle Weakness, unspecified protein-calorie malnutrition and history of falling. Review of Resident #1's quarterly MDS assessment, dated 12/24/24, revealed Resident #1's BIMS score was 7 of 15 reflective of severe cognitive impairment; her preferred language of English/Spanish; she had impairment of one side (lower extremity) and she used a manual wheelchair. Review of Resident #1's Care Plan revised on 8/8/23 read: Resident #1 [Resident name] has a communication problem r/t: Language barrier. Resident #1 [Resident name] is primarily Spanish speaking and family requests to have a Spanish speaking CNA each shift every day. DON informed family that Spanish speaking staff is available if not in respective hall that other staff is available in facility to assist with translating. Some interventions included: Anticipate and meet needs. Discuss with resident/family concerns or feelings regarding communication difficulty. Monitor/document/report to MD PRN changes in: Ability to communicate, Potential contributing factors for communication problems, Potential for improvement. Interview on 1/10/25 at 5:16 PM with Resident #1's family member D revealed she had videos that showed staff walking into Resident #1's room, unable to communicate with Resident #1 due to the language barrier and some staff ignoring Resident #1 while she was trying to talk with them. She stated this was very upsetting because the ADM and DON assured her that if a Spanish speaking staff was not assigned to the hall then there would be another staff who spoke Spanish to assist with translation. Family member D stated that according to the videos some of the staff did not engage a Spanish speaking staff to assist. Family member D stated it was also upsetting that staff ignored Resident #1 like she was not even a person without trying to determine if she needed help. Review of video #1 dated 12/9/24 (no time) revealed CNA C entering Resident #1's room with a meal tray and she placed it on the bedside table. She did not introduce herself or explain the purpose of her visit. Resident #1 was talking to CNA C in Spanish and CNA C shrugged her shoulders while walking to the other side of the room behind the privacy curtain. CNA C commented I need to learn Spanish, I don't know Spanish from the other side of the privacy curtain and then she re-appeared on Resident #1's side of the room. Resident #1 commented, no. CNA C shook her head and walked out of the room. CNA C did not state she was going to get another staff member to help with translation. Review of video #2 dated 12/13/24 (no time) revealed CNA C coming into Resident #1's room with a meal tray on top of a bedside table. She did not greet Resident #1; did not introduce herself or explain the purpose of her visit. Resident #1 was talking to CNA C in Spanish (most of the conversation could not be made out). Resident #1 stated in Spanish this was the food that was brought to me earlier. I can't eat this; the rest of it was not understandable. At the end of the conversation Resident #1 asked CNA C in Spanish if CNA C could bring her something else. CNA C did not re-appear in front of the camera and was heard talking in the background but could not understand what she said. Further review revealed CNA A did not tell Resident #1 that she would get another staff to help translate while she was in Resident #1's vicinity. Review of video #3 dated 12/13/24 (no time) revealed CNA B entering Resident #1's room. She did not introduce herself or explain the purpose of her visit. Resident #1 was talking to CNA B in Spanish and asked about her cell phone. CNA B commented, huh, no hablo [NAME], (I don't speak Spanish) twice. Resident #1 asked CNA B in Spanish to send someone who spoke Spanish and commented, I want them to understand me. CNA B said something like (maybe I'll try to see if I can get [name of another staff] while looking and walking to the other side of the room behind the privacy curtain. CNA B did not direct her attention at Resident #1 and Resident #1 asked her twice, what, what. CNA B came around the privacy curtain and then Resident #1 asked CNA B in Spanish to send the lady or girl who spoke Spanish. Review of video dated #4, dated 12/25/24, no time, revealed CNA B standing at the foot of the bed while Resident #1 was talking to her in Spanish. CNA B did not responding or engage with Resident #1. Another staff member approached the doorway and CNA B met the other staff at the doorway and then exited the room all the while Resident #1 was trying to talk in Spanish with CNA B. Observation and interview on 1/11/25 at 4:15 PM with Resident #1 and family member E revealed family member E and Resident #1 engaged in conversation in Spanish. Resident #1 presented as being anxious and confused. Family member E reiterated concerns that family member D expressed on 1/10/25. She stated some staff did not speak Spanish and not able to understand Resident #1. Staff would not get another staff to help with translation and would ignore Resident #1. Observation and interview on 1/11/25 at 5:05 PM with Resident #1 revealed she was sitting in the common area with CNA A. She engaged in conversation, spoke plainly and in Spanish and stated she was good, making the best of living in this place with no concerns reported. Surveyor was Spanish speaking and able to converse with Resident #1. Surveyor asked how staff communicated with her. She stated not all staff spoke Spanish and she could not talk to them. Surveyor asked other questions about her care and Resident #1 did not respond. She presented as alert with confusion. Interview on 1/11/25 at 5:10 PM with CNA A revealed he spoke some Spanish and did the best he could to communicate with Resident #1. He stated he had a good rapport with Resident #1 and took the time to listen and understand what she was telling him. Interview on 11/11/25 at 5:20 PM with Family Member D revealed she provided verbal permission to share Videos with the ADM and the DON and not any other staff. Interview on 1/11/25 at 5:30 PM with the ADM and the DON revealed upon reviewing Videos #1 through #4, the DON identified CNA B and CNA C in the videos. The DON stated that protocol required any staff who walked into Resident #1's room to greet Resident #1, while introducing themselves and explaining the purpose of their visit even if they did not speak Spanish. The DON stated staff should acknowledge any resident while the resident was talking to them which was common courtesy. She stated the non-Spanish speaking staff should find another Spanish speaking staff to help with translation. Although, she stated there was not always Spanish speaking staff on the night shift. The DON stated that CNA B and CNA C did not follow protocol when entering Resident #1's room and did not engage with her failing to treat Resident #1 with dignity. The ADM agreed with the DON and stated it looked like staff needed sensitivity training. Review of facility policy, Residents' Rights Nursing Facilities, undated, read in relevant part You have the right to be treated with dignity, courtesy, consideration and respect.

Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 2 residents (R#6 and R#5) reviewed for abuse. The facility did not properly monitor or put in place preventative measures for R #1 to prevent an act of sexual abuse on 09/27/23, when R#1 was found without a brief laying in the bed of R#6 without the consent of R#6. The facility did not properly monitor or put in place preventative measures for R #1 to prevent further acts of sexual abuse on 10/14/23, when R#1 was found on top of R#5, in her bed, without the consent of R#5. An IJ was identified on 10/26/23. The IJ template was provided to the facility on [DATE] at 3:50 PM. While the IJ was removed on 10/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy because of facility's need to monitor the implementation and effectiveness of its corrective systems. Failure to put in place supervision measures and training on abuse measures could result in residents denied the right to be free from sexual abuse. Findings included: Record review of facility's Abuse and Neglect Policy dated 8/10/22 read: The facility is charged with the safeguard of each resident and will follow a consecutive plan in the pursuit of maintaining a safe environment. Suspected actions or allegations of abuse including physical, mental, verbal, sexual, [involuntary] seclusion, neglect or misappropriation of property by any individual including resident to resident altercations with injury will be reported to local authorities, state and federal agencies, and other appropriate agencies as required by law . Sexual abuse-is defined as non-consensual contact of any type with a resident . Record review of Resident#1's face sheet, dated 10/17/23, and EMR revealed, the resident was admitted on [DATE] and discharged [DATE] (inappropriate behaviors with another resident) with diagnoses that included: Parkinson's disease ( a form of dementia), mood disorder, and anxiety disorder. Resident was a male; age 69. RP (responsible party) was listed as: the resident. Record review of Resident#1's MDS assessment, dated 8/24/23, revealed: o BIMS Score was 12 (moderate impairment) o ADLs : Transfer was listed as partial assistance. Bed Mobility was listed partial assistance. R#1's ROM was listed as no impairment. [R#1 assistive device was a wheelchair. The resident could maneuver the wheelchair, and lift himself out of the wheelchair and engaged in limited locomotion and difficult walking distance without assistance. The Resident had a diagnosis of Parkinson's Disease] Record review of R#1's CP revealed: goal of behavioral management and interventions included: 9/27/23 incident: move to another room, monitoring, and administer medications.[interventions did not include contacting law enforcement] Record review of R#6's face sheet, dated 10/17/23, and EMR revealed, the resident was admitted on [DATE] with diagnoses that included: hemiplegia and hemiparesis ( paralysis of one side of the body) , dementia, and cerebral infarction (stroke). Resident was a male; age 67. RP was listed as: family member. BIMS score was a zero (severely impaired). The resident was total care for ADLs. Record review of R#6's CP revealed: total care for ADLs and required assistance with his paralysis. Record review of R#5's face sheet, dated 10/17/23, and EMR revealed, the resident was admitted on [DATE] with diagnoses that included: dementia, Parkinson's Disease, and poor vision. Resident was a female; age 67. RP was listed as: family member. Record review of R#5's Quarterly MDS dated 2023 revealed, the resident had a BIMS score was a 10 (moderate impairment). The resident required moderate supervision and assistance for her ADLs. Record review of R#5's CP dated 10/14/23 revealed she was at risk for psychosocial harms due to R#1 entering her room and found on top of her. Record review of R#1's Behavioral note dated 09/27/23 at 11:55 PM, authored by LVN A, read: .This Nurse was making rounds on patients when this patient was noted to be lying in his roommates bed with no brief on. Resident [R#1] was lying face down with one leg on top of his roommates [R#6] leg. This Nurse immediately called for staff assistance. CNA [name not documented] arrived in the room and this Nurse and CNA immediately placed this patient [R#1] in his wheelchair and removed him from the room. Resident was taken off unit and moved to unit on the other side of the building in room . in a room by himself. Nurse and CNA's on that unit given report on patients behavior. DON immediately called, and Administrator made aware. Record review of R#1's Nurse Note dated 10/14/23 at 3:51 PM, authored by LVN B, read: .Upon answering call light ., this nurse witnessed this patient [R#1] on top of patient [R#5] in [who ]was lying supine (lying with face upward) in her bed with eyes closed. Upon entering room this nurse immediately question this PT [R#1]why he on top of patient in room ., this Pt states, ' were just talking' Both PT were fully dressed and Pt [R#5] in room . had her blanket on. This nurse immediately removed this PT [R#1] and call Administrator and R(N) Supervisor. This Pt was transferred out of room .and currently on 1:1 care (physically monitor by a staff member) with Male CNA [name not documented]. [family member] was called and this PT is to be discharged home . During an interview on 10/17/23 at 4:40 PM, LVN A stated: on 9/27/23, R#1 was found with no brief on in the bed of R#6 without the consent of R# 6. LVN A stated, R#1 was moved to another hall and room; and 15 minutes checks for 72 hours were started. LVN A stated, both families (R#1 and R#6) and MD were notified. In-service on abuse/neglect was initiated by the facility. LVN A stated, there was no psychosocial harm to R#6. Another intervention included Psych services (referral to a mental health clinic) for both residents. LVN A stated, on 10/14/23, R#1 was found fully clothed on top of R#5 who was in bed covered in a blanket. LVN A stated Interventions included: notified families and MD, in-service on abuse/neglect; exploring immediate discharge. R#1 was sent to ER for a psychological evaluation; and 1:1 monitoring was initiated. LVN A stated, R#1 was discharged [DATE] to a personal care home under hospice care. No psychosocial harm occurred to R#5. LVN A stated she received in-service on abuse/neglect after the incident. During a interview on 10/17/23 at 5:08 PM, the Administrator confirmed that R#6 did not consent to R#1 being in his bed; nor did R#5. During an observation and interview on 10/18/23 at 9:19 AM, R#6 was in a tilted wheelchair, alert and not oriented. Resident was cleaned and groomed; skin tears to the head. Contracture to the right hand. No signs of anxiety, fear, or sadness. The resident could not answer any direct questions. [RP was not interviewed because of the sensitive nature of the investigation.] During an interview on 10/18/23 at 9:22 AM, LVN D stated: R#6 tended to scratch himself in the head because of agitation. The resident could be anxious because of his co-morbidity (multiple diagnoses). The resident had not revealed signs of being afraid or not feeling safe. The resident received medication for the anxiety. LVN D stated she was trained and abuse and neglect after the 10/14/23. LVN D stated that the abuse coordinator was the administrator and suspicion of abuse needed to be reported immediately. LVN D stated that sexual contact between residents required consent and the assessment of the residents. During an observation and interview on 10/18/23 at 9:29 AM, R#5 was in bed watching TV; alert and oriented to person and place. The resident was cleaned and groomed; no signs of bruises, wounds, or skin tears. The resident was anxious. The resident stated: this is a nursing home .a man came into my room and tried to rape me .he got on my bed .he tried to touch me .I told him to stop .he told me ugly words in Spanish I do not know how long he was in my room .thank God staff came in .he would have hurt me .the nurse pulled him off me I feel safe today .no other man has come into my room .the door is opened .the nurse checks .the call light works .[resident scratched her nose and it started bleeding; some old scratches were present on top of the forehead from her history of anxiety. Surveyor ended the interview because of the resident's anxiety]. During a telephone interview on 10/18/23 at 10:03 AM, LVN B stated: I found (10/14/23 around 3-4 PM) [R#1] on top of [R#5] and both residents were clothed; and [R #5] had a blanket covering her. [R #5] had triggered the call light. LVN B stated, R #5 was saying help. LVN B got R#1 off R#5 and called for help. R #1 was placed in his wheelchair and moved out of the room, Skin assessments on both residents were negative. LVN B called the family members. LVN B stated, R#1 was put on one of one monitoring; R#5 was not anxious and felt safe. LVN B stated he was trained on abuse/neglect after the incident on 10/14/23. Part of the training involved reporting immediately to nursing management and/or administrator any incident or suspicion of sexual abuse. During a telephone interview on 10/18/23 at 10:14 AM, LVN E stated: on 9/27/23 at night she found R#1 in R#6's bed without a brief on and R#6 had his brief on. LVN E stated, R #1 was naked from the torso down. R#1 had his leg over on R#6. I requested assistance and we separated the residents .he was placed in another room vitals and skin assessments were done and negative for [R#6] .other safety measures included 15 minute checks and door opened .[R#1] was put on 15 minute checks .the MD was notified and the administrator notified the family because of the delicate situation . LVN E stated she was trained on abuse and neglect after the incident on 09/27/23. Part of her training involved notifying the administrator or nurse management when abuse was suspected; to include sexual abuse. During an interview on 10/18/23 at 10:25 AM, RN C stated: on 10/14/23 the charge nurse (LVN B) requested assistance involving R#1 and R#5. RN C went with LVN F to the room and R#1 was sitting on the floor mat, and R#1 was transferred to his wheelchair and moved him to another room. RN C stated, R#5 said she was okay. R#1 was put on 1:1. Both families were contacted. I contacted (R#1's) family and requested whether they could take the resident home because of inappropriate behaviors .the family refused because they did not have the resources .I informed the Administrator of the situation .I have been trained on abuse and neglect .not sure whether the MD was notified .this was an emergency discharge .there was a previous incident with him (R#1) [09/27/23] . RN C stated she was trained on abuse and neglect after the incident on 10/14/23. During a telephone interview on 10/18/23 at 10:55 AM, R#1 stated: I am safe in my new home .I agreed to the placement .I am under hospice care I agreed with the placement because this is a good place I did not like the nursing home .I went to the hospital but did not want to stay .I do not remember whether I got [psych services] at the nursing home .I do not remember lying in other residents' beds .[either in September or October 2023]. During a telephone interview on 10/16/23 at 9:30 AM, the NP said she was made aware by the facility that R#1 was found in the bed of his roommate R#6. The NP stated: the facility addressed R#1's behavior by moving him to another room. R#1 was also referred to psychological services for behavior management. The NP stated no medication adjustment was made to R#1's physician's orders. The NP stated she arrived at the facility and assessed R#6 and there were no residual effects from the incident. The NP did not answer the question as to whether R#1's behavior of being found in his roommates bed with brief removed constituted sexual abuse. During a telephone interview on 10/18/23 at 9:45 AM, The MD stated: R#1 engaged in erratic behavior and possible criminal behavior and he, as the physician, was notified by the facility of the incidents on 09/27/23 and 10/14/23. The MD stated: his main recommendation after the 09/27/27 incident was to transfer the resident (R#1) to a locked secured unit and to closely monitor pending a discharge. According to the MD the facility was unsuccessful in finding a nursing facility that would accept the resident (R#1). The MD did not consider a psychotropic medication adjustment because it could be used as a chemical restraint. On the question of whether R #1's behavior constituted sexual abuse; the MD stated: the facts are in front of you . During an interview on 10/26/23 at 10:00 AM, LVN F stated: regarding the 09/27/23 she was informed by LVN E that R#1 was found in R#6's bed with no brief on. R#1 was moved from hall 100 to hall 400 to a private room. LVN F stated that she kept a close eye on him and my staff was made aware to track his movements . LVN F stated, the inappropriate behavior by R#1 did not repeat itself until 10/14/23. I was upset to hear about the incident on 10/14/23 since we closely monitored him . LVN F stated, R#1 was found in R#5's bed; and it was a potential sexual assault. LVN F stated she was trained on abuse and neglect. During an interview on 10/26/23 at 10:22 AM, LVN D stated: she had no direct knowledge of the 09/27/23 incident involving R#1 and R#6. LVN D, stated: R#1 was moved to another hall (400). LVN D stated: sexual abuse could constitute a sexual behavior between residents without consent. During an interview on 10/26/23 at 10:37 AM, LVN A stated: the interventions put in place to address R#1's behaviors after the 09/27/23 incident included: R#1 was moved to another hall and put on a Q15 for 72 hour regimen (15 minutes every hour, 30 minutes every hour, and then hourly up to 72 hours). LVN A stated, by nursing practice every two hours check were made on residents to include R#1. LVN A stated: R#1 did not show any inappropriate behaviors after 09/27/23; but had another episode of inappropriate sexual behavior on 10/14/23. LVN A stated: she was not sure how the resident got into R#5's room on the day of the incident on 10/14/23. LVN A stated: sexual abuse was inappropriate behavior without consent. During an interview on 10/26/23 at 10:56 PM, the DON stated: the interventions put in place after the 09/27/23 incident included: R#1 was moved to a private room; Q15 for 72 hours[record review of CP dated 09/28/23 contained the intervention to check on resident q shift for wellness]then routine monitoring for 72 hours. The DON stated: between the period of 09/27/23 to 10/14/23 there were no other inappropriate incidents involving R#1 with other residents. The DON stated: R#1 could self-propel his wheelchair; not observed by staff when he entered R#5's room on 10/14/23 between 3:00-4:00 PM. The DON stated: the facility tried to discharge R#1 but no other nursing home wanted the resident. The DON stated she was trained on abuse and neglect; sexual abuse was when the parties did not give consent. The DON stated: all the residents had dementia and the residents could not consent to inappropriate behaviors .therefore it did not meet the definition of sexual abuse The DON stated that there were no adverse effects to the residents. During an interview on 10/26/23 at 11:15 AM, the Administrator stated: the actions put in place involving the 09/27/23 incident included: R#1 was moved to another hall; Q15 checks for 72 hours; and nursing practice to monitor every 2 hours after the 72 hours ended. The administrator stated: the facility pursued a discharge plan and involved the family and the ombudsman; but no other facility wanted the resident. R#1 was referred to psych services and was being monitored by the MD, NP and mental health facility. The administrator stated: abuse/neglect training was given to staff from 09/27/23 to 10/18/23. The administrator stated: R#1 got into R#5's room during the time he was not monitored; the resident was not on 1:1 after the 72-hour monitoring had ended. The administrator stated, sexual abuse by policy is nonconsensual sexual contact .by policy the incidents involving the residents (09/27/23) and 10/14/23 did not constitute sexual abuse .all the residents had dementia. Record review of facility's sign-in sheets from 09/27/23 to 10/17/23 (surveyor entrance) revealed : on 09/28/23 the facility conducted abuse/neglect training for 31 staff members ( 60% of 52 paid staff). On 10/16/23 the facility conducted abuse/ neglect training for 43 staff members (83% of 52 paid staff members). The Administrator was given the IJ template and was notified of the Immediate Jeopardy {IJ} on 10/26/23 at 3:50 PM; and a plan of removal was requested. On 10/27/23 at 11:00 AM, the facility provided a plan of removal and it was accepted on 10/27/23 At 2:00 PM. It was documented as follows: Date: 10-27-2023 Subject: Plan of Removal PLAN OF REMOVAL Preparation and/or execution of his plan of removal does not constitute admission or agreement by the provider of the truth of the facts alleged, or conclusions set forth on the template that was provided by state surveyor. This plan of removal is prepared and/or executed solely because it is required by the provisions of Federal and State law. The following immediate actions were implemented as follows: c On 10-14-23, resident #1 was sent out for a psych eval and returned to facility the same day. Resident was placed on 1:1 until alternate placement could be established. Resident was discharged on [DATE]. c Resident #6 has a dx of dementia and does not communicate. Resident was assessed for signs and symptoms of distress after the initial incident occurred on 9-27-23 and again on 9-28-2023 with no signs present. Resident will be re-evaluated again on 10-27-2023, by [local mental health facility]. Additionally, this resident was evaluated on 9-28-23 and 10-6-23 by [local mental health facility]. Family visited resident on 9-28-2023 and was happy with the care being provided and did not notice any behavioral concerns. c Resident #5 has a dx of dementia and verbally communicates. Resident was assessed on 10-14-2023 for signs and symptoms of distress from alleged incident and no signs present. Resident family made aware of the incident and were comfortable with the actions taken. Resident was also evaluated by [local mental health facility] 10-16-2023 and routinely thereafter. c Social Services and designee will be conducting interviews with all residents to determine if they feel safe from abuse at this facility. These interviews will be completed on 10-27-2023 and any negative findings will be addressed immediately. c The facility completed a 100% audit of all staff and residents against the Sexual Abuse Registry for the state of Texas, without any findings on 10/27/2023. c The administrator and DON were in-serviced on abuse and neglect on 10-16-2023 and again on 10-26-2023. These in-services were conducted by Corporate Nurse Consultant and COO, LNFA. c The facility started in-servicing on abuse and neglect, to include reporting requirements, for all full-time staff on 10-16-2023 until completion was accomplished on 10-18-2023. The facility initiated the following training on 10-26-2023: o Full-Time Staff All staff received training on 10-26-2023. o PRN Staff Training has been completed on all staff but 1. This staff member has been removed from the schedule until training has been completed. o New Employees Each new employee will be trained in abuse and neglect during orientation. c The facility will conduct a QAPI meeting on 10-27-2023 to discuss the findings noted on the IJ Template. This will include a review of our current abuse and neglect policy. c The Medical Director was notified of the immediate jeopardy on 10-27-2023. Please let me know if more additional information is needed. Thank you for considering this Plan of Removal. [ LNFA] On 10/27/23, the surveyor confirmed the facility implemented their Plan of Removal sufficiently to remove the IJ by: Interviews: During a telephone interview on 10/27/23 at 2: 05 PM, the COO, LNFA stated: the DON and Administrator were in-serviced on abuse and neglect. The highlight of the training was to report to HHS and law enforcement incidents of suspected sexual abuse. During a joint interview on 10/27/23 at 2:10 PM, the Administrator and DON stated they received the abuse/neglect training and the highlights were: report to HHS and law enforcement if sexual abuse was suspected. Also, they received information on the definition of sexual abuse from the facility's policy of abuse/neglect. 1. During an interview on 10/27/23 at 2:26 PM, CNA G (6A-2P) stated: you need to report to the nurse suspicion of abuse and sexual abuse. The abuse coordinator was the administrator. 2. During an interview on 10/27/23 at 2:30 PM, CNA H (6A-2P) stated: if something happens to report to the administrator and after that the DON .because someone needs to do something . 3. During an interview on 10/27/23 at 2:34 PM, CNA I(6A-2P): there were several types of abuse and neglect. If abuse was suspected to inform the DON and Administrator; and in emergency call 911 for sexual assault. 4. During an interview on 10/27/23 at 2:38 PM, CNA J(6A-2P) a staff needed to be observant and report any suspicion of abuse. The abuse coordinator was the administrator. 5. During an interview on 10/27/23 at 2:41 PM, LVN D stated: incidents needed to be immediately to the administrator. Consent needed to be given for any sexual contact between residents; even consent was present to report and allow the administrator. 6. During an interview on 10/27/23 at 2:51 PM, LVN K (2P-10P) stated: to report abuse and neglect to the administrator immediately. Sexual abuse needed to be reported immediately. Check behaviors or change of condition when there was a suspicion of sexual abuse. 7. During an interview on 10/27/23 at 2:55 PM, LVN L(2P-10P) stated: to be aware of the most vulnerable victim and to report any suspicion of abuse or neglect to the administrator. 8. During an interview on 10/27/23 at 3:09 PM, CNA M (2P-10P) stated: to report immediately to the DON, administrator; and in an emergency the Police. Signs and symptoms of sexual abuse are many; for instance inappropriate touching of a resident or a resident having sexual contact with another resident without consent . Believe any outcry of sexual abuse. 9. During an interview on 10/27/23 at 3:10 PM, CNA N (2P-10P) stated: anyone can be an abuser; report all suspicions to the administrator. Be aware of the vulnerable residents who are bedbound and cannot speak. if you see something, say it to the administrator. 10. During an interview on 10/27/23 at 3:30 PM, CNA O (2P-10P) stated: she attended training and the highlight was to report to the administrator. Also, she learned about some of the signs and symptoms of sexual abuse; for example, resident to resident sexual contact without consent. 11. During an interview on 10/27/23 at 3:35 PM, (10P-6A), CNA P stated: if you see it .or hear it .report to the administrator and an emergency call 911. Signs of sexual abuse include resident behaviors and skin changed and injuries, and bruises and skin tears. 12. During interview on 10/27/23 at 3:35 PM, CNA Q(10P-6A), stated: check the resident's behaviors. Check on signs and symptoms of sexual abuse and report immediately to the nurse or the administrator the abuse coordinator. 13. During telephone interview on 10/27/23 at 3:42 PM, (10P-6A), LVN R stated: report to the administrator. Signs and symptoms of sexual abuse appear in skin assessments and interactions with the resident. Prevention by monitoring. Report any suspicion. 14. telephone interview on 10/27/23 at 3:46 PM, CNA S(10P-6A), stated: report it; call the administrator anytime; let the charge know. Signs and symptoms of sexual abuse could include injuries, bruises and skin tears. 15. During telephone interview on 10/27/23 at 3:54 PM, CNA T(10P-6A), stated: report any abuse to the administrator immediately. Signs and symptoms of sexual abuse could involve non-consensual; injuries and bruises can be discovered during peri-care and bathing. During an interview on 10/27/23 at 3:04 PM, the HR Manager stated she conducted a 100% audit of all staff and residents against the Sexual Abuse Registry for the state of Texas, without any findings on 10/27/2023. During an interview on 10/27/23 at 3:25 PM, SW stated: he conducted interviews with all residents to determine if they felt safe from abuse at the facility; and there were no negative findings. During a joint interview on 10/27/23 at 4:50 PM, the DON and Administrator stated a local mental health provider assessed R#6 who had a BIMS of zero and there were no concerns. Record Reviews: Record review of R#1's Nurse Note dated: 10/14/23 authored by LVN B: revealed: On 10-14-23, resident #1 was sent out for a psych eval and returned to facility the same day. Resident was placed on 1:1 until alternate placement could be established. Resident was discharged on [DATE]. Record review of facility's discharge list for November 2023 revealed: R#1 was discharged on [DATE] at 5:15 PM to .to home or self-care. Record review of R#6 skin assessment dated [DATE] revealed no new injuries, bruises or skin tears. Record review of R#6's mental health documents dated 09/28/23 and 10/06/23 revealed resident was assessed with no adverse effects. Record review of R#6's general notes dated 10/14/23 revealed: administrator spoke to the family; and the family had no concerns. Resident was not in distress. Record review of R#5's skin assessment on 10/14/23 revealed: no new skin issues after the incident on 10/14/23. Record review of R#5's mental health assessment by local mental health provider on 10/16/23 revealed: chronic history of anxiety. No anxiety due to sexual encounter on 10/14/23. Record review of facility Social Work binder dated 10/27/23 revealed: 72 contact sheets with entries made that the resident felt safe and free from abuse and neglect. Of the 72 residents, all were contacted or the RP except for one resident with a request for a return call. Record review of corporate sign in sheet dated 10/18/23 revealed the DON and Administrator received training on abuse and neglect. Record review of facility's sign-in sheets on abuse and neglect training from 10/18/23 to 10/26/23 revealed the signatures for 52 staff (100% completion rate). Record review of facility's QAPI meeting on 10-27-2023 revealed the required attendees were: administrator, DON, and Medical Director. Six other staff members attended the meeting. Topic of abuse/neglect was part of the agenda. Record review of facility's text message to Medical Director on 10/27/23 at 4:17 PM revealed, he was contacted on the IJ. On 10/27/23 at 5:00 PM , the administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its corrective systems.