Every finding on record at Kingsville Nursing and Rehabilitation Center

Based observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 dining rooms reviewed for infection control practices.The facility failed to ensure the CNA-A knew the correct way to perform proper hand hygiene.The facility failed to ensure CNA-A knew the correct way to handle residents' dining utensils.The facility failed to ensure CNA-A knew the correct way to wear a surgical mask to prevent the spread of infection.These failures and deficient practices could place residents at risk for cross-contamination and the spread of infection.The findings included:In an observation on 04/29/2026 between 12:10 PM and 12:50 PM, CNA-A was observed to be wearing a surgical mask below the level of her nose while handling residents' food and leaning over residents. She was observed to perform hand hygiene twice during this time in which she put alcohol-based hand sanitizer in the palm of her hand, and rubbed her hands 3-4 seconds each time, then she held her hands in the air prior to grabbing residents' trays and food. CNA-A was also observed to be handling resident cups containing water and tea by grabbing cups around the tops (where the residents would have placed their mouths to drink from the cups). In an interview on 04/29/2026 at 12:55 PM, the ADON stated wearing a mask beneath the nose was ineffective and would not protect the person wearing it or the person they were caring for. The ADON also stated alcohol-based hand sanitizers should be used like soap in which all areas of the hands are rubbed together until they are completely dry, or approximately 20 seconds. She stated if it was not being done this way, then it was probably ineffective. The ADON stated cups should not be grabbed or passed from the rim because it could have caused cross-contamination and a risk for infection.In an interview on 04/29/2026 at 1:07 PM, CNA-A stated she was wearing a mask because her family member had been sick, and she did not want to pass it to the residents. She stated she was aware that wearing it below her nose was ineffective, but it frequently fell down on her face. CNA-A stated to use alcohol-based hand sanitizer, put the sanitizer in the palm of the hand and rub for approximately 20 seconds or at least until they were dry. She stated it was not effective if they did not rub their hands until they were dry, and she realized she had not done it the right way. CNA-A also stated cups should not be grabbed around the rim because it was where the residents placed their mouths, and it could have caused cross contamination. Record review of the facility's Hand Hygiene Policy, implemented 10/24/2022, revealed Policy Explanation and Compliance Guidelines: 2. Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. 3. B. Rub hands together, covering all surfaces of hands and fingers until hands feel dry. C. This should take about 20 seconds.Record review of the facility's Infection Prevention and Control Program, implemented 05/13/2023, revealed Policy: This facility has established and maintains 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 as per accepted national standards and guidelines. 15. B. Based on specific circumstances, employees with a communicable disease or infected skin lesion will be prohibited from direct contact with residents or their food .Record review of CDC Respiratory Illnesses, Masks and Respiratory Viruses Prevention, dated 08/18/2025, revealed Wearing a mask can help lower the risk of respiratory virus transmission. When worn by a person with an infection, masks reduce the spread of the virus to others. Masks can also protect wearers from breathing in infectious particles from people around them. When choosing to wear a mask, choose the most protective type. https://www.cdc.gov/respiratory-viruses/prevention/masks.htmlRecord review of CDC Personal Protective Equipment, Community Respirators and Masks, dated 03/25/2025, revealed Masks are designed to cover your nose and mouth. Using masks that are tighter to your face forces particle through the filter material. https://www.cdc.gov/niosh/ppe/php/community-respirators-masks/index.html

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #1, #2, and #3) of 5 residents reviewed for infection control practices.The facility failed to ensure CNAs were aware of the correct technique and infection control practices when providing incontinent care to Resident #1.The facility failed to ensure Residents #2 and #3 had the appropriate PPE outside the residents' rooms. These failures could place residents at risk for cross-contamination and infection.The findings included:1. Record review of Resident #1's face sheet, dated 03/24/2026, revealed a [AGE] year-old female with an original admission date of 12/27/2018, and a current admission date of 05/19/2023. Pertinent diagnoses include Cerebral Infarction (a type of stroke which occurs when a blood clot blocks a brain artery, leading to a loss of blood flow to a specific area of the brain) and Type 2 Diabetes with Hyperglycemia (a chronic disorder characterized by high blood sugar levels due to insufficient insulin [a crucial hormone which regulates blood sugar levels and plays a vital role in energy metabolism] production or ineffective use of insulin by the body).Record review of Resident #1's Quarterly MDS assessment, dated 02/23/2026, revealed a BIMS score of 99 due to Resident #1 was unable to complete the assessment. MDS also indicated Resident #1 was dependent in toileting hygiene. Record review of Resident #1's care plan initiated 10/06/2022 revealed Resident #1 was at risk for skin breakdown as evidenced by bladder incontinence. Interventions included check every 2 hours and as needed for incontinence, and clean peri-area with each incontinence episode. Resident #1 also had a care plan for ADL self-care deficit, initiated 10/06/2022, with an intervention which included resident required total assistance by staff for toileting.In an observation on 03/24/2026 at 1:45 PM CNA-A and CNA-B were observed gathering clean supplies and placed supplies into a clean bag, which was utilized as their clean barrier. Another trash bag was set open on Resident #1's bed to discard their dirty and soiled supplies into. Both CNA's performed hand hygiene, then donned clean gloves. They assisted Resident #1 with getting her clothing off and removing the top portion of the brief by pushing it between Resident #1's legs, which smeared feces down Resident #1's leg. CNA-A proceeded to remove clean wipes from clean bag to wipe and clean the front of Resident #1. Without performing hand hygiene, CNA-A rolled resident toward her, she then proceeded to pull clean supplies from the clean bag to hand to CNA-B who removed the brief and continued to clean feces from the backside of resident and between resident's legs. CNA-B was noted to manipulate the trash bag on Resident #1's bed after dirty gloves fell out of bag onto the resident's bed. CNA-B put the dirty, soiled gloves back into the trash bag and pulled the sides of the trash bag up higher to keep soiled, dirty items from falling out. CNA-B then returned to performing incontinent care. After incontinent care, CNA-B went into the bathroom to perform hand hygiene while CNA-A continued to fasten clean brief and pull resident's clothing up without performing hand hygiene. After CNA-A performed hand hygiene, she grabbed trash bag containing dirty, soiled trash with both clean hands, tied it into a knot, and carried it out of the room. In an interview on 03/24/2026 at 2:09 PM, CNA-A stated she was asked to assist with incontinent care for Resident #1, but she did not typically provide care for this resident. CNA-A stated she should have performed hand hygiene and applied new gloves after pulling down Resident #1's brief and cleaning her front, and prior to opening the bag with the clean supplies and grabbing clean supplies to pass to CNA-B. She also stated CNA-B should not grab clean wipes from CNA-A's clean hands/gloves after wiping feces off of the resident. CNA-A also stated she should have performed hand hygiene and applied new/clean gloves anytime she went from a dirty area to a clean area on the resident, to include grabbing clean supplies, applying and fastening a clean brief, and putting resident's clean clothes back on. CNA-A stated they should not have grabbed the dirty trash bag, which had been touched and manipulated with dirty gloves during incontinent care, with bare, clean hands, but they should have utilized one gloved hand to carry out the trash while using the clean, ungloved hand to touch clean surfaces.In an interview on 03/24/226 at 2:24 PM CNA-B stated anytime she went from a dirty area to a clean area she should have performed hand, and if she was the person cleaning the bowel movement, she should not have grabbed clean supplies with her soiled gloves from the other CNA with clean gloves and hands. CNA-B also stated she should not have manipulated the outside of the trash bag with her dirty gloves, but she had to readjust it because soiled gloves had fallen out of it onto the resident's bed. She also stated she should not have grabbed the trash bag with all the soiled and dirty items in it with both clean hands and no gloves on, but she should have utilized a gloved hand to carry out the trash while using the other clean hand to touch clean surfaces. Record review of the facility's Hand Hygiene policy, dated 10/24/2022, revealed Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 5. Additional considerations: a. The use of gloves does not replace hand hygiene.Record review of the facility's Perineal Care policy, dated 10/24/2022, revealed 2. Gather supplies needed. 7. Set up supplies. 9. If perineum is grossly soiled, turn resident on side, remove any fecal material. then discard. A. cleanse vagina to anus in females. 10. Re-position resident in supine position. Change gloves if soiled and continue with perineal care.2. Record review of Resident #2's face sheet, dated 03/25/2026, revealed a [AGE] year-old male with a current admission date of 03/21/2026. Pertinent diagnoses include Osteomyelitis (a serious bone infection), Local Infection of the Skin and Subcutaneous (the layer beneath the skin) Tissue, and Type 2 Diabetes (a chronic disorder characterized by high blood sugar levels due to insufficient insulin [a crucial hormone which regulates blood sugar levels and plays a vital role in energy metabolism] production or ineffective use of insulin by the body).Record review of Resident #2's active physician orders, started 03/23/2026, revealed an order for Enhanced Barrier Precautions: use gown and gloves for high contact resident care activities for those known to be colonized or infected with a CDC targeted MDRO, as well as those with increased risk (residents with wounds or indwelling medical devices) every shift. Record review of Resident #2's Quarterly MDS assessment, dated 03/25/2026, revealed a BIMS score of 15, intact cognition. MDS also indicated Resident #2 had an active diagnosis of a wound infection.Record review of Resident #2's care plan initiated 03/23/2026 revealed the need for EBP due to diabetic ulcers. Interventions included provide resident and family members with education on and the reason for EBP. 3. Record review of Resident #3's face sheet, dated 03/25/2026, revealed a [AGE] year-old female with an original admission date of 07/15/2021 and a current admission date of 03/23/2026. Pertinent diagnoses included Displaced Trimalleolar Fracture of Right Lower Leg with Subsequent Encounter for Closed Fracture with Routine Healing (involved breaking three bony sections of the ankle, typically requiring surgery and extensive rehabilitation for recovery).Record review of Resident #3's active physician orders, started 03/24/2026, revealed an order for Enhanced Barrier Precautions: use gown and gloves for high contact resident care activities for those known to be colonized or infected with a CDC targeted MDRO, as well as those with increased risk (residents with wounds or indwelling medical devices) every shift. Record review of Resident #3's Annual MDS assessment, dated 01/22/2026, revealed a BIMS score of 99 due to Resident #1 was unable to complete the assessment. MDS also indicated Resident #1 was dependent in toileting hygiene.Record review of Resident #3's care plan initiated 03/24/2026 revealed the need for EBP due to surgical incision. Interventions included place EBP sign on the door to notify staff and visitors of the precautionary measures: gown and gloves only for high-contact activities (dressing, bathing/showering, personal hygiene, changing linens, assisting with toileting, perineal or incontinent care, medical device care, wound care). Use a mask or eye shield as indicated. In an observation on 03/24/2026 at 9:21 AM, Resident #2 and Resident #3's rooms did not have PPE immediately outside or near the residents' rooms. One PPE cart was noted to be toward the ends of each hall. In an interview on 03/25/2026 at 10:05 AM, CNA-C stated EBP signs were used to let the staff know when a resident was on precautions and PPE should be worn with certain activities such as showering, bathing, or changing a resident. She stated the PPE was usually located in a bin outside of the residents' rooms so it could be put on prior to going in to perform a high contact activity. She stated she was not sure where the PPE for Resident #3 was located, but it should have been there. She stated there was PPE located in the shower room in the residents' hall if she needed it for Resident #3.In an interview on 03/25/2025 at 10:15 AM, the DON stated she was also the infection control nurse for the facility, and hand hygiene should be performed when going from any dirty area to any clean area, but CNAs were able to grab the outside of the trash bag with their clean, ungloved hands because the outside of the bag was considered clean. She stated EBP was for residents with things like wounds, feeding tubes, and Foley catheters, and EBP rooms did not need PPE outside of the residents' rooms as long as it was available on the hall or close by. The DON stated this was also what the CDC and all her training recommended She stated the PPE required for EBP was only a gown and gloves for high contact activities. She stated face shields and goggles were not utilized for EBP, even for splash back, because if goggles or face shields were needed, she would have placed the resident on droplet precautions. She also stated if a resident had a known or colonized (when a germ or microbe was found on or in the body but did not cause symptoms or disease) MDRO which was targeted by the CDC, they would be placed on contact precautions, not EBP. Record review of the CMS Memorandum: Enhanced Barrier Precautions in Nursing Homes, dated 03/20/2024, revealed Facilities should ensure PPE and alcohol-based hand rub are readily accessible to staff. Discretion may be used in the placement of supplies which may include placement near or outside the resident's room. Information regarding CDC-targeted MDROs and current recommendations on EBP are available on the CDC's webpage, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), at https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html.Record review of the CDC: Long-term Care Facilities, dated 04/02/2024, revealed Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs): When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this:*Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves)*Make PPE, including gowns and gloves, available immediately outside of the resident roomRecord review of the facility's Enhanced Barrier Precautions policy, dated 11/24/2025, revealed Policy Statement: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Policy Explanation and Compliance Guidelines: 2. Initiation of Enhanced Barrier Precautions: b. i. An order for enhanced barrier precautions will be obtained for residents with any of the following: wounds (chronic such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, central lines, midline catheters) even if the resident is not known to be infected or colonized with an MDRO. ii. Infection or colonization with a CDC targeted MDRO when contact precautions do not otherwise apply. 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available near or outside of the resident's room.

Based on interview and record review the facility failed to ensure the comprehensive care plan was developed and implemented for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans.The facility failed to develop the diabetic comprehensive care plan for Resident #1. The facility failed to implement fall mats listed in Resident #1's care plan. These failures could place residents at risk of receiving improper or inadequate care and services.The findings included:Record review of Resident #1's face sheet, dated 03/24/2026, revealed a [AGE] year-old female with an original admission date of 12/27/2018, and a current admission date of 05/19/2023. Pertinent diagnoses include Cerebral Infarction (a type of stroke which occurs when a blood clot blocks a brain artery, leading to a loss of blood flow to a specific area of the brain) and Type 2 Diabetes with Hyperglycemia (a chronic disorder characterized by high blood sugar levels due to insufficient insulin [a crucial hormone which regulates blood sugar levels and plays a vital role in energy metabolism] production or ineffective use of insulin by the body).Record review of Resident #1's Quarterly MDS assessment, dated 02/23/2026, revealed a BIMS score of 99 due to Resident #1 was unable to complete the assessment. MDS also indicated Resident #1 had an active diagnosis of Diabetes Mellitus. Record review of Resident #1's care plan revealed there were no care plans which addressed her diagnosis of Diabetes, to include addressing her glucose levels, diet, routine diabetic labs and diagnostic tests. Resident #1 had a care plan for ADL self-care performance deficit initiated 10/06/2022. Interventions included floor mats. MDS did not indicate falls. In an observation on 03/24/2026 at 1:45 PM it was observed there were no floor mats in Resident #1's room while she was in bed.In an interview on 03/24/2025 at 2:50 PM, the MDS nurse stated the fall mats on Resident #1's care plan were supposed to have been removed because she knew they were not being utilized in Resident #1's room. She also stated Resident #1's Diabetes should have been care planned, to include diet, labs and anything else which would apply to the diagnosis. She stated if the care plan was not completed appropriately, residents may not receive appropriate or consistent care. In an interview on 03/25/2026 at 2:40 PM, the ADON stated the MDS nurse typically updated the clinical aspects of the care plan. She stated Resident #1's Diabetes should have been care planned so the resident received the appropriate care. Record review of the facility's Comprehensive Care Plans policy, revised 10/24/2022, revealed Policy Explanation and Compliance Guidelines: 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on interviews and record reviews, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for 1 of 5 residents (Resident #1) reviewed for developing and implementing abuse and neglect policies and procedures.1.The facility failed to follow their policy to report to HHSC within two hours when Resident #1 alleged Resident #2 sexually assaulted him on 02/07/26.2. The facility failed to follow their policy to investigate an allegation of sexual abuse made by resident #1 on 02/07/26.This failure could place residents at risk for abuse/continued abuse and could lead to a diminished quality of life and psychosocial harm.Record review of Resident #1's admission record reflected an [AGE] year-old male admitted to the facility on [DATE] with hospice (end of life care). His diagnoses included chronic obstructive pulmonary disease (a progressive, incurable lung disease that causes inflammation and difficulty breathing), type 2 diabetes (chronic condition that happens when blood sugar levels are persistently high which can lead to heart disease, kidney disease, and stroke), unspecified dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental disorder characterized by excessive and persistent worry, fear, or anxiousness which significantly interferes with daily life), and cerebral infarction (stroke). Record review of Resident #1's admission MDS dated [DATE] reflected a BIMS score of 3 which indicated he had severe cognitive impairment. Record review of Resident #1's progress notes reflected the following entries:Nursing note created by LVN D on 02/07/26 at 9:48pm, effective on 02/07/26 at 8:00pm which stated, Resident was moved from [hall number] to [room number] with all meds and belongings.Nursing note created by LVN D on 02/07/26 at 10:14pm, effective 02/07/26 at 10:13pm, and struck out on 02/08/26 at 6:17am, which stated, [Hospice company] nurse just left facility. I was in room with her as she assessed resident due to report that was made today.Social service note created by the ADM on 02/09/26 at 9:18am, effective 02/08/26 at 9:16am, which was a follow up to the nursing note by LVN D effective 02/07/26 at 8:00pm, which stated, Administrator informed that room move was requested due to the hall being too loud. Also request made to have resident in a room closer to the nurse's station.Record review of HRN F's visit note report dated 02/07/26 at 9:44pm reflected the following:Reason for PRN visit: Sexual assault reportedCare coordination:Indicate details/comments: Assault was reported to family member by patient, who then reported the said incident to facility and hospice.Collaboration with facility staff: YesStaff name and title: will follow up with [ADM name] DONIdentified changes and/or issues: YesSpecify changes/ issues: An outcry was made by patient to his family.Is care team coordination needed: YesSelect coordination team: Medical director, social worker, chaplain, otherSpecify other: Admin directorIndicate what was discussed with care coordination team: Conducting an investigation regarding a sexual assault and notifying appropriate agencies.Narrative: PRN visit: Rec'd notice from admin director of a reported sexual assault by the patient to his RP, who then reported the alleged incident to the facility and hospice nurse. Follow up visit made by on call hospice nurse. Upon arrival, I was briefed by [LVN D] who accompanied me to patient room. Pt denied any pain. Patient did not repeat the details he reported to his family. His speech consists of some unintelligible words. Few words could be understood clearly. Pt was positioned in a side-lying position, contracted into a fetal position. Gloved and witnessed by [LVN D], brief was unsnapped. Pt had to be positioned more to his left side with a greater effort to assess the anus for any trauma, tears, laceration. Other than a bit of BM, anus was intact. No appearance of visible trauma. Patient's brief was secured back in place. Pt was covered and left to rest for the evening. Hospice & facility Admin will follow-up per protocol. [sic] Record review of Resident #2's admission record reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included moderate intellectual disabilities (developmental delays resulting in an average mental age of 6 to 9 years old), generalized anxiety disorder (mental disorder characterized by excessive and persistent worry, fear, or anxiousness which significantly interferes with daily life), recurrent major depressive disorder (persistent feeling of sadness and loss of interest that occurs in episodes lasting weeks to months), dementia (memory and cognitive decline) in other diseases with mood disturbance, cognitive communication deficit (difficulty with communication), and mixed receptive-expressive language disorder (difficulty understanding spoken language and expressing thoughts through speech).Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 15 which indicated Resident #2 was cognitively intact. Record review of Resident #2's progress notes reflected the following entries:Nursing note created by the DON, effective on 02/09/26 at 1:30pm, which stated, Resident was placed on a 1:1 monitoring for any inappropriate behavior post allegation. Guardian [name] was made aware of resident being placed on 1:1 while facility conducts investigation. [Doctor name] was made aware.Social service note created by the SW, effective 02/10/26 at 11:14am, which stated, MSW checked on resident who is being monitored 1:1. Resident was sleeping in his bed with no television or radio on. Will follow up.In a telephone interview on 02/09/26 at 1:14pm, the RP stated on 02/07/26 she was feeding Resident #1 dinner. Resident #2 was walking into his own room and Resident #1 started getting a little fearful/ anxious. The RP stated Resident #1 held her hand and said he had to tell her something. The RP stated Resident #1 got a little antsy and told her, that man who was standing at the door (Resident #2) went into his room and put his finger in his rectum. Resident #1 did not tell the RP when this incident allegedly happened. The RP stated Resident #1 had dementia and a little bit of confusion sometimes, but he also had some very clear days. The RP stated Resident #1 had never made this kind of allegation before. The RP stated she told the nurse who told the ADM, and they told hospice. The RP stated they (the HRN) assessed Resident #1 and did not find anything, so she did not know if Resident #1 got confused with a male nurse or what, so she got a camera for his room. The RP stated the facility did not deny anything or hide anything and they were very cooperative. The RP stated they moved Resident #1 to another hall and close to the nurse's station right away. On 02/09/26 at 1:33pm, the ADM went to the surveyors in the facility and stated she had just gotten a phone call from the hospice company in reference to an abuse allegation involving Resident #1. The ADM stated she had talked to the RP on 02/07/26 and the RP stated she and Resident #1 wanted a room change. The ADM stated the RP told her that the resident that walked up and down the hallway (Resident #2) made Resident #1 and the RP nervous and Resident #2 was too loud and that was why she requested the room change. The ADM stated she did not know about the allegation of sexual abuse before she received the phone call from the hospice company on 02/09/26, and that she made a self-report at that time. In an interview on 02/09/26 at 2:18pm, Resident #1 denied any abuse, sexual or otherwise. Resident #1 stated, yes when asked if staff was good to him. Resident #1 stated, no when asked if staff hurt him when providing care. Resident #1 was asked in both English and Spanish about the allegation that someone put a finger in his anus and denied it. Resident #1 stated no one has ever hurt him and he was not afraid of anyone or of reporting anything.In an interview on 02/09/26 at 3:56pm, CNA A stated Resident #1 was on the [hall number] and then got moved to the [hall number] on 02/07/26 around 6:30pm. CNA A stated that LVN C, the charge nurse, told her they moved Resident #1 because he said that Resident #2 touched him.In an interview on 02/09/26 at 4:33pm, CNA B stated she had only worked with Resident #1 on 02/07/26 when he moved to her hall. CNA B stated she was told by LVN C that Resident #1 was moved to her hall because Resident #2 touched him.In a telephone interview on 02/09/26 at 4:39pm, the HSW stated a family member told HRN E that Resident #1 said that Resident #2 had put his finger in his anus. HRN E contacted the HD who contacted HRN F, the on call hospice nurse, to go to the facility to assess Resident #1. The HSW stated she contacted APS and made a complaint on 02/07/26 at approximately 9:00pm.In a telephone interview on 02/09/26 at 4:50pm, the HD stated she was informed on 02/07/26 by HRN E that a family member called her and said that Resident #1 said that someone touched his butt and the RP was asking for someone to go assess him. The HD stated called her RN on call (HRN F) to go to the facility and do an assessment. The HD stated when HRN F was in route to the facility, she talked to the RP who said that she was visiting Resident #1, and he told her (the RP) that someone touched his butt which evolved into someone put their finger in his rectum. The RP told the HD that Resident #1 could not verbalize who did it but when Resident #2 yelled out, Resident #1 squeezed her hand and the RP theorized that it was him (Resident #2) that did it. The RP told the HD she talked to the ADM and told her about it, and they agreed to move him to another hall. The RP also stated the family had permission from the ADM to put a camera in Resident #1's room. The HD called the ADM of the facility at [ADM's personal phone number] on 02/07/26 at 7:42pm to let her know HRN F was headed to the facility to assess Resident #1 due to his allegation, and they spoke for approximately 9 minutes. The HD stated the ADM told her she was already aware of the allegation because she had talked to the RP and that she (the ADM) was going to do an investigation. The HD stated HRN F went with LVN D and examined Resident #1. The HD stated HRN F did not find any signs of trauma and Resident #1 could not verbalize what happened. In an interview on 02/10/26 at 9:48am, CNA G stated she asked why Resident #1 got moved to another hall and she was told by LVN D they moved him due to allegations.In an interview on 02/10/26 at 11:30am, the SW stated she found out in the morning meeting on 02/09/26 that Resident #1 had been moved because the family complained that Resident #2 had been loud. She stated she asked Resident #1 on 02/09/26 at approximately 5:00pm if any other residents had been in his room and he said no. The SW stated she asked Resident #1 if anyone had touched him, he said no, and if he was in pain and he said no. The SW stated she did not know the allegations about Resident #2, only that he was loud, and the family complained. She stated she noticed that Resident #2 was on 1:1, but she did not know why and had not asked anyone why.In a telephone interview on 02/10/26 at 2:05pm, LVN C stated she worked from 6:00pm to 10:00pm on 02/07/26 and did not know why Resident #1 was moved to another hall around 6:30pm to 7:00pm that evening. LVN C stated no one talked to her about why Resident #1 was moved. LVN C stated it was not until 02/08/26 that she heard something had happened between Resident #1 and Resident #2. Initially LVN C stated she did not know why Resident #1 was moved and did not find out until 02/08/26, however when asked if she told the CNAs on 02/07/26 why Resident #1 was moved she stated she told them that something happened between Resident #1 and Resident #2, but she did not know what. She stated she saw the ADM walking toward the front door and the DON in her office when she clocked in at 6:00pm on 02/07/26 then she went to the floor and did not see them after that. In an interview on 02/10/26 at 2:30pm, ADON H stated she had heard that Resident #2 was on a 1:1 until the investigation was complete because he was accused of something, but she did not want to say what she heard because she did not know what was real or the truth.In an interview on 02/10/26 at 2:42pm, ADON I stated she was the ADON on call on 02/07/26 and was not aware of the situation between Resident #1 and Resident #2. ADON I stated she found out that Resident #1 had been moved during the morning meeting on 02/09/26 and was told it was because the family was concerned that it was loud in the hallway, he was at the end of the hall, and they wanted him closer to the nurse's station. ADON I stated she found out the rest of the situation when she followed up with the HD before lunch on 02/09/26. ADON I stated she spoke to the HD directly and was told that HRN F went to the facility on [DATE] assessed Resident #1 due to an allegation that was made of possible sexual abuse. ADON I stated she then immediately told the ADM and the DON about the allegation. ADON I stated to her knowledge the ADM and the DON did not know about the allegation before she told them on 02/09/26, sometime before lunch. ADON I stated any allegations of abuse were to be reported right away to the ADM. ADON I stated when residents were moved, staff had to contact the ADM to get approval and no one else could make that decision. ADON I stated she did not know why staff did not call her on 02/07/26 when Resident #1 made an allegation and was moved. ADON I stated it was the charge nurse's responsibility to call her and LVN J was the charge nurse on 02/07/26 from 6:00am to 6:00pm. ADON I stated staff usually called her for every little thing but did not call her about this. ADON I stated she assumed staff called the ADM since Resident #1 got a room change. ADON I stated the reason a hospice nurse went to the facility to assess Resident #1 on 02/07/26 should have been documented. ADON I stated she was not aware of the allegation of sexual abuse, and she did not know why no one reported it to her on 02/07/26. She stated staff should have notified the ADM as well as the on call immediately and if abuse was not reported or investigated, it could cause the resident to experience emotional distress, ongoing abuse, and depression.In an interview on 02/10/26 at 3:22pm, the DON stated if the ADM was not there and an allegation of abuse was made; she would be responsible for the paperwork and the investigation. The DON stated the staff member who claimed, witnessed, or was told about any type of abuse was responsible for telling the ADM. The DON stated Resident #1's room change was on 02/07/26. The DON stated the ADM called her the evening of 02/07/26 and let her know that staff had called her about some concerns that the RP had. The ADM told the DON that the RP had some concerns about Resident #2 being loud and it made Resident #1 anxious, so the ADM offered the RP a room change. The DON stated she did not come into the facility that night and she was not sure if the ADM had come in. The DON stated she found out on 02/09/26 either right before or right after lunch when ADON I went to tell her and the ADM of the abuse allegation. The DON stated she talked to HRN E after ADON I told her about the allegation. The DON stated she saw the RP on Monday morning (02/09/26) and the RP did not tell her about the sexual abuse allegation. The DON stated in relation to the struck out note by LVN D on 02/07/26, maybe HRN F just came in to assess Resident #1. The DON stated they tried to teach the staff to document thoroughly, accurately, and timely. The DON stated she did not think LVN D knew why HRN F was at the facility to assess Resident #1. The DON stated the ADM was the person who talked to the RP on Saturday evening (02/07/26). The DON stated if she received a report of abuse from someone, she first went to the original person who made the allegation and ensured what was actually said. The DON stated if there was an abuse allegation made, even if she knew that it did not happen, it would have to be reported. The DON stated if she talked to the resident who made an allegation and they said they did not make the abuse allegation, then she would not report it. The DON stated she did not feel like Resident #1 would be a reliable source because he would only say a few words. The DON stated if the facility did not report or investigate an allegation of abuse, it could potentially harm a resident because it could cause psychosocial or physical harm. The DON stated If there was a significant event, it was to be reported to the provider and documented as soon as possible, but no later than the end of the shift. In an interview on 02/10/26 at 4:14pm, the ADM stated she got a call from LVN J on 02/07/26 who told her that Resident #1's RP told her that someone touched his butt. The ADM asked if the RP was making an allegation and LVN J said no, she did not think so because she (LVN J) asked Resident #1 about it and he said no so LVN J told the RP she would let the ADM know about it. The ADM asked LVN J if the RP gave her any other context or if Resident #1 was hurt and LVN J said no. The ADM told LVN J she would call back to the nurse's station and to have the RP come talk to her. The ADM stated when she called back and the RP got on the phone with her, the ADM asked the RP if she felt like someone hurt Resident #1 or touched him inappropriately and the RP said no. The ADM stated the RP told her Resident #1 told the RP that, someone touched his [spanish slang word for anus]. The RP asked Resident #1 who did it and he did not answer her, but a few minutes later when Resident #2 yelled, Resident #1 squeezed her hand, so she assumed it was Resident #2 that had put a finger in Resident #1's anus. The ADM stated she asked the RP again if she was making an allegation and the RP told her, well, Resident #1 was very prideful, and she wanted the staff to be very careful when moving or changing him. The ADM stated the RP told her that she did not like that hallway because Resident #2 was too loud or his tv was too loud and she felt like the loudness made Resident #1 more anxious. The ADM stated she offered the RP a room change and the RP asked for a room closer to the nurse's station in a different hall and that she wanted the room changed that night. The ADM stated the RP asked about putting a camera in Resident #1's room and the ADM told her that would not be a problem. The ADM stated she spoke to LVN J again and they discussed moving Resident #1. The ADM stated she got a phone call from HRN F with [name of hospice company] at 7:40pm on 02/07/26 who said that she had been trying to call but not getting an answer at the facility to let them know she was on her way. The ADM stated she called the facility to let them know that hospice was trying to call. The ADM stated, That was pretty much all for that night. The ADM stated on Sunday morning, the RP talked to the ADM and stated she wanted to thank her for moving Resident #1 and she was not going to stay at the facility for very long. The ADM stated she did not know what time it was but on 02/09/26, the RNC went to her and told her they had an allegation of abuse, so she notified the surveyors who were on site and made a self-report. The ADM stated she spoke to HRN F and not to the HD on 02/07/26 and that she was not told why HRN F went to the facility that evening. The ADM stated she found out about the allegation early afternoon on 02/09/26. The ADM stated she was told (unknown by who) that the RP's family member reached out to HRN E directly and told her about the allegation of abuse, so HRN E talked to a CNA (hospice) and then talked to the HD. The ADM stated if they got an allegation of abuse, it was reported immediately. The ADM stated if she got an allegation of abuse, then asked the resident (or RP) about it and they said it did not occur, she would still report it, but in this case, the RP did not make an actual allegation of abuse to her. The ADM stated the RP just stated that Resident #1 was very prideful and did not like anyone to touch his butt. The ADM stated if an allegation of abuse was made it was the ADM's responsibility to report it immediately to HHSC. The ADM stated If it was not reported, the resident could be left in jeopardy, and it could result in continued abuse or abuse to others. The ADM stated, in her opinion, this was not reportable initially from the information she was given. If an allegation had been made, it would have been reported to the provider, the RP, ombudsman, and her staff immediately. In an interview on 02/10/26 at 5:02pm, LVN D stated whatever happened with Resident #1 on 02/07/26 happened before she got there. LVN D stated HRN F went in to assess Resident #1 and asked LVN D to go in the room with her to do that assessment. LVN D stated she struck out her note from 02/07/26 because she did not feel comfortable using the word report because she did not what, if any, report had been made. LVN D stated HRN F stated she was there about the concern that had been made earlier. LVN D stated she did not talk to family, so she did not know what the concern was or what had been said and HRN F only said she was there to check Resident #1's bottom. LVN D stated HRN F checked Resident #1's bottom and his rectum and said it was because of whatever complaint or concern had been made that evening. LVN D stated HRN F was trying to talk to Resident #1, but he was hard to understand most of the time and HRN F could not understand him. LVN D stated HRN F just told him hi, and asked if she could check him, but he was not understandable. LVN D stated she did not remember HRN F asking any questions about why she was checking his bottom. LVN D stated LVN J told her Resident #1 had told his RP he was touched inappropriately but she did not get any details of what happened or what he said happened. LVN D stated allegations of abuse were to be reported to the administrator right away and if abuse was not reported, it could happen again or continue to happen and could lead to harm to the resident in more than one way.In a telephone interview on 02/11/26 at 8:51am, HRN F stated she was the on call nurse for the hospice company on 02/07/26. HRN F stated she got a call from the HD at 7:53pm on 02/07/26 to let her know that a complaint had come in from the RP.HRN F stated the HD told her she was going to reach out to the facility and the family but wanted her to head to the facility. HRN F stated the HD was detailed about the allegation the resident made. HRN F stated she met up with LVN D at the facility and told her exactly why she was there- which was because, Resident #1 stated another resident went into his room and put a finger in his butt. HRN F asked LVN D to accompany her into the room to assess Resident #1. HRN F stated she did not see any trauma and Resident #1 denied any accusations. HRN F stated some of Resident #1's words were clear, but some were very garbled. HRN F stated no family was at the facility when she assessed Resident #1. HRN F stated she typed up a progress note to go with the visit in her company's charting system. In an interview on 02/11/26 at 9:23am, the HD stated she spoke to the ADM on 02/07/26 and called her directly from her cell phone to the ADM's personal cell phone. The HD provided the cell phone number she called, and it was the ADM's personal cell phone number. The HD stated when she spoke to the ADM, the ADM already knew about the allegation and had already spoken to the RP, had talked to staff, and told the HD she was starting the investigation process. The HD stated to her knowledge, the RP called HRN E directly and told her what Resident #1 said and told HRN E she wanted a hospice nurse to go and assess so that it was not just a facility nurse that assessed him. The HD stated that she did not speak to the ADM again after that.In a telephone interview on 02/11/26 at 9:43am, HRN E stated a family member of Resident #1's messaged her on a social media application and asked her to call another of Resident #1's family members, ASAP. HRN E stated she called Resident #1's family member to find out what was going on HRN E stated the family member was distraught and told her it was about, Resident #1 and the facility and they needed to report the facility, and it was so awful and she couldn't speak of it. HRN E named several things that could have happened and when she said rape, the family member said, yes, that one. HRN E then told the family member she had to call her boss and report it. HRN E stated she called the HD, the HD called the RP, then HRN E was not involved with that situation anymore. HRN E stated Resident #1 always said, don't touch my [spanish slang word for anus], and when HRN E asked him what it was Resident #1 said, my ass. HRN E stated he would say it when she checked on his pressure wounds on his sacrum and gluteus and when the hospice CNA was giving him a bed bath with soap and water.Record review of the facility's Abuse, Neglect and Exploitation policy dated 08/15/22 reflected in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Sexual Abuse is non-consensual sexual contact of any type with a resident.Policy Explanation and Compliance Guidelines:1. The facility will develop and implement written policies and procedures that:b. Establish policies and procedures to investigate any such allegations;2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law.3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.The components of the facility abuse prohibition plan are discussed herein:II. Employee TrainingC. Training topics will include:2. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property;4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources;V. Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include:3. Investigating different types of alleged violations;5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and6. Providing complete and thorough documentation of the investigation.VII. Reporting/ResponseA. The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on interview and record review, the facility failed to ensure residents were free from any significant medication errors for one of five residents (Resident #1) reviewed for medication errors. The facility failed to hold Resident #1's carvedilol (blood pressure medication) when Resident #1's blood pressure was outside of physician's parameters on December 12th and 22nd of 2025. This failure could place residents at risk for complications such as increased blood pressure, exacerbation of symptoms, and potential hospitalization.The findings include:Record review of Resident #1's face sheet, dated 01/07/26, reflected a [AGE] year-old male with an original admission date of 10/29/25 and a current admission date of 01/04/26. Resident #1's pertinent diagnosis included essential hypertension (high blood pressure with no single identifiable cause, developing gradually from a mix of genetics, age, and lifestyle factors like poor diet, obesity, inactivity, and stress). Record review of Resident #1's Comprehensive MDS Assessment, dated 11/20/25, reflected a BIMS score of 8 which indicated moderate impairment. Record review of Resident #1's comprehensive care plan, dated 01/07/26, reflected the focus The resident has hypertension (HTN) [related to] lifestyle choices. initiated on 11/06/25 and revised on 11/24/25. An intervention listed for the focus included Give anti hypertensive medication. as ordered initiated on 11/06/25 and revised on 11/07/25. Record review of Resident #1's order summary reflected a discontinued order for Carvedilol Oral Tablet 6.25 MG. Give 1 tablet by mouth two times a day for HTN hold if BP is less than 120/60 and pulse less than 60 initiated on 12/09/25 and discontinued on 12/29/25. Record review of Resident #1's MAR for December 2025 reflected carvedilol was administered by LVN A on 12/12/25 and 12/22/25 with blood pressures 115/65 and 112/67 mm/hg respectively. In an interview with LVN A at 4:09 PM on 01/07/26, LVN A stated she signed the MAR on 12/12/25 and 12/22/25 indicating she administered carvedilol to Resident #1 on those days. LVN A stated she was not supposed to administer blood pressure medications outside of specified parameters unless given specific instructions by a physician or nurse practitioner. LVN A stated administering blood pressure medications outside of parameters could cause the resident fatigue, headache, or make them faint. In an interview with the DON at 4:21 PM on 01/07/25, the DON stated, based on the MAR, it appeared LVN A administered carvedilol to Resident #1 on 12/12/25 and 12/22/25 despite his blood pressure being outside of the stated parameters for the medication. The DON stated LVN A should not have administered carvedilol on those days. The DON stated administering blood pressure medications outside of parameters could cause low blood pressure leading to dizziness, fainting, confusion. Record review of the facility's policy Medication Administration, dated 10/24/22, reflected the following policies: .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals properly and in locked compartments on 1 of 5 carts reviewed for storage of drugs and 1 (med-room [ROOM NUMBER]) of 2 medication rooms reviewed for storage. 1. The facility failed to ensure the WCN cart located on the 200 hall was locked when not in use. 2. The facility failed to ensure Resident #54's expired medications were disposed of in a timely manner. 3. The facility failed to ensure Resident #81 and Resident #54's medications were stored in the appropriate boxes for the residents. These deficient practices could affect residents who have medications on the wound care cart and in the medication rooms and could result in lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications. Findings included: 1. During an observation and interview on 07/03/25 09:34 AM revealed the wound care cart was unlocked and unattended in the 200 hall. This surveyor opened the top drawer recognizing the wound care cart being unlocked and unattended while not in use. Multiple wound care medications in bulk bottles and wound care supplies were easily assessable for removal. The WCN was in a resident's room and identified herself as being responsible for the unlocked wound care cart. In an interview on 07/03/25 09:35 AM, the WCN stated she thought she locked the wound care cart with her hip after putting on her PPE and before entering the resident room. The WCN stated the wound cart should be locked when not in use to prevent residents or unauthorized staff from having access to medications and supplies within the wound care cart. The WCN could not recall the last in-service on locking wound/medication carts but stated they were done often. In an interview on 07/03/25 09:42 AM, the DON stated the wound care cart should have been locked when not in use. The DON stated all carts should be locked when not in use for the safety of residents and to prevent unauthorized staff and visitors access to the wound cart supplies and medication. The DON stated in-service on locking the wound and medication carts were done frequently. 2. Record review Resident #54's face sheet, dated 07/02/2025, revealed an [AGE] year-old female with an original admission date of 01/04/2022 and a current admission date of 05/16/2025. Diagnoses included Dementia. Record review of Resident #54's physician orders revealed Divalproex (Depakote) 250 MG started 06/03/2025 and was discontinued 06/10/2025. Record review of Resident #54's progress notes dated 06/10/2025 revealed a new order to discontinue Depakote 250mg and change Resident #54 to Depakote 125 MG for mood stabilization due to behaviors associated with Dementia. Record review of Resident #81's face sheet 07/03/2025 revealed a [AGE] year-old female with an admission date of 01/13/2025. Diagnoses included Anemia. Record review of Resident #81's physician orders revealed a current order for Folic Acid started 01/14/2025. In an observation on 07/01/2025 at 3:45 PM it was revealed med-room [ROOM NUMBER] contained the locked cabinet and box with the medications for destruction, as well as cubbies, or boxes, labeled with residents' names and room numbers to hold their overflow, or extra, medications for the med-carts. In an observation on 07/01/2025 at 3:47 PM it was revealed Resident #54's discontinued Divalproex (Depakote - a medication used to treat seizures, bipolar, and/or migraines) 250 MG tablets were sitting in a box labeled with another resident's name and room number. In an observation on 07/01/2025 at 3:47 PM it was revealed Resident #81's Folic Acid (Vitamin B9 used in the production of red blood cells) 1 MG tablets were sitting in a box labeled with another resident's name and room number. In an interview with the DON on 07/02/25 at 1:08 PM she stated the cubbies labeled with residents' names and room numbers were her idea, and a system to help keep up with the residents' extra or overflow medications. The DON stated Resident #54's medication should have been dropped in the locked cabinet used for med-destruction. After the DON looked back at the orders and progress notes, she stated the medication had been discontinued since 06/10/2025, and she was not sure who placed the medication into another residents' cubby instead of dropping it in the med-destruction cabinet/box. She also stated she wasn't sure why Resident #81's medication was sitting in a cubby labeled for another resident. She stated sometimes the residents' switched rooms, and the medications would end up in the wrong cubby. She stated that could be a hazard, especially if a nurse was not paying attention and grabbed the wrong resident's medication without reading or paying attention. She stated that could have caused a med-error, and a resident could have gotten the wrong medication administered. In an interview with the ADON on 07/02/25 at 3:14 PM she stated Resident #54's medication should have been dropped in the locked cabinet/box labeled for med-destruction since it had been discontinued for almost a month, and she was not sure who placed the medication into a cubby labeled with another resident's name and room number, or why it was placed there. She stated the med-destruction cabinet was right next to the cubbies, and it was just as easy to drop it in there as it was to just set it down in in an area it did not belong. She also stated she was not sure why Resident #81's medication was sitting in a cubby labeled for another resident. She stated sometimes the residents switched rooms and the medications would end up in the wrong cubby. She stated that could be a hazard, especially if a nurse was not paying attention and grabbed the wrong resident's medication without reading or paying attention. She stated this could have caused a med-error, and a resident could have gotten the wrong medication administered. Record review of the facility's Medication Administration policy dated 10/01/19 reflected:Med CARTs: 2. The medication cart is locked at all times when not in use. 3. Do not leave the medication cart unlocked or unattended in the resident care areas. Record review of the facility's Medication Policies: Medication Storage and Disposal: Discontinue Medications, dated 10/01/2019 and revised 03/22/2023, revealed 1. if a physician discontinues a medication, the medication container was placed in a location marked for discontinued medications as soon as possible. 2. Medications awaiting disposal or return were stored in a locked secure area designated for that purpose until disposed of. Record review of the facility's Medication Policies: General Guidelines: Medication Carts and Supplies for Administering Medications, dated 10/01/2019, revealed 7. Label drawer or divider clearly with the resident's name and/or room and bed number.

Based on record reviews and interviews the facility failed to ensure that residents were free from abuse for one of six (Resident #33) residents reviewed for abuse.The facility failed to ensure that the SW did not take Resident #33's DVD player away when he displayed unwanted behavior on 04/11/25.This deficient practice could put residents with unwanted behaviors at risk of not attaining or maintaining their highest practicable levels of mental and psychosocial wellbeing.Findings included:Record review of Resident #33's admission record reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included moderate intellectual disabilities (developmental delays resulting in an average mental age of 6 to 9 years old), generalized anxiety disorder (mental disorder characterized by excessive and persistent worry, fear, or anxiousness which significantly interferes with daily life), recurrent major depressive disorder (persistent feeling of sadness and loss of interest that occurs in episodes lasting weeks to months), dementia (memory and cognitive decline) in other diseases with mood disturbance, cognitive communication deficit (difficulty with communication), and mixed receptive-expressive language disorder (difficulty understanding spoken language and expressing thoughts through speech).Record review of Resident #33's quarterly MDS dated [DATE] reflected a BIMS score of 12 which indicated Resident #33 had moderate cognitive impairment. Record review of Resident #33's LIDDA Habilitative assessment dated [DATE] reflected in Section IV- Social Development and Relationships, Resident #33's favorite activity was shopping in the community, and he was usually accompanied by the AD. Section V- Independent Decisions and Judgements reflected Resident #33 exercised his right to personal possessions as he had his own TV and DVD player and exercised his right to spend his money on things he wanted. Section VI- Academic and Vocational Development reflected Resident #33 watched movies in his room and expressed that he would like to be able to watch movies all night, eat snacks, and nap all day. Section VII- Person's Preferences for Specialized Supports with Daily Living reflected Resident #33 was able to perform some ADLs independently with some supervision such as shopping, eating, and ambulating. The necessary supports needed to assist Resident #33 in maintaining possessions in his living environment included assistance with house (room) cleaning and laundry. Section VIII- Social Inclusion reflected Resident #33 did not like to be told he could not do something such as eat what he wanted. Section IX- Speech and Language reflected Resident #33's family member, who passed away in June 2024, was the person who understood him best who and was best able to interpret what Resident #33 was trying to communicate.Record review of Resident #33's LIDDA Individual Profile dated 02/20/25 reflected Resident #33 had a history of a brain injury at birth and had behavioral needs, medical needs, and needed assistance with toileting. Section 4- Profile Information reflected Resident #33 felt it was important that he was able to choose his daily routine. He enjoyed staying up late watching movies in his room and sleeping late the next day. Resident #33 did not like to be told what to do. This section also reflected Resident #33 had a history of behavior problems such as he spent an excessive amount of time in the restroom, smeared feces on the toilet, and threw excessive amounts of toilet paper (clean and dirty) on the floor and in the toilet. Resident #33 had a history of verbal aggression (yelling out/screaming) 1 to 3 times a week. This section also reflected Resident #33's care plan interventions and medications appeared to be helping although he was difficult to redirect at times and a behavior support plan was not needed at that time.Record review of Resident #33's care plan dated 03/14/20 reflected he had behavior problems such as spending excessive amount of time in the restroom, smearing feces on the toilet, and throwing excessive amounts of toilet paper on the floor and in the toilet as well as verbal aggression. Interventions for these included intervene as necessary to protect the rights and safety of others, approach/ speak in a calm manner, divert attention, praise any indication of progress/ improvement in behavior, analyze key times, places, triggers, and what de-escalates, and provide positive feedback for good behavior/ emphasize the positive aspects of compliance. Record review of Resident #33's progress notes reflected a progress note dated 04/11/25 by the SW that stated, resident continues to overflood toilet with paper. Guardian was notified and explained that residents DVD player would be taken up until Monday 4/14/25. Guardian agreed. If resident can keep room clean and not cause toilet to overflow DVD would be given back. Resident stated he understood and that he would keep room clean. [sic] There were no progress notes between 04/11/25 and 07/02/25 which indicated Resident #33's DVD player was returned to him.In an interview on 07/02/25 at 2:26 pm Resident #33 stated, They (the SW) took my DVD player away a couple of months ago because I kind of misbehaved. Resident #33 stated he had not gotten it back yet and it made him feel bad because he watched his movies a lot. When asked who bought the DVD player, he stated [name], MRC bought it for him at [store] out of his money that is kept up front for him. When asked if there were any other things that were taken away Resident #33 replied, My radio. When asked when it was taken away, Resident #33 stated, A little time after they took my player. Resident #33 stated the radio was taken because he had it kind of loud. When asked if he was told when he could have it back, Resident #33 replied, When I behave- and I did not have it that loud. Resident #33 stated it made him feel bad and upset that the facility took his radio away and he has not gotten it back yet. In an interview on 07/02/25 at 2:42 pm RN B stated abuse was anything unwanted or neglectful, that could harm any resident and included verbal, physical, and financial abuse. RN B stated harm could be emotional, medical, or physical. RN B stated taking someone's property because they were not behaving was abuse. In an interview on 07/02/25 at 3:14 pm, the ADON named the types of abuse and stated emotional abuse/mental abuse was when a resident felt sad because a staff member made them feel that way due to how they were treated. When asked if there was a resident who had something in their room they really liked and had purchased with their own money and a staff member took it out of their room and put it away somewhere and told the resident they could only have it back if they behaved, would that be abuse, she stated, Yes, that would be abuse- emotional or mental. It could cause psychosocial harm. The ADON stated she did not suspect abuse in the facility but if she suspected abuse, she would report it right away to the Adm. The ADON stated none of the residents complained about any of the staff. In an interview on 07/02/25 at 3:32 pm, the DON named the types of abuse and what to do if abuse was seen or heard. When asked if there was a resident who had something in their room they really liked and had purchased with their own money and a staff member took it out of their room and put it away somewhere and told the resident they could only have it back if they behaved, would that be abuse, the DON stated, I would not consider that abuse. It could cause them distress, but I am not saying that would be abuse. After reading the definition of abuse in the facility's abuse policy, the DON stated she did not feel like it was abuse. The DON stated she was not aware of anyone having something taken away because they misbehaved but if she knew about something like that she would, definitely have to look into it to see what the situation was. In an interview on 07/02/25 at 3:54 pm the SW named the types of abuse and the abuse coordinator. The SW stated abuse was bad because it removed the dignity of the resident and took away their rights which could cause emotional harm or distress to the resident and/or lead to some bad behaviors. The SW stated if abuse was seen or heard she would report it to the administrator, follow up, and refer the resident to psychiatric services. She stated it was abuse if someone took away something a resident liked and told them they could have it back if they behaved. The SW stated it removed the resident's dignity because they were being treated like a child. When asked if she was aware of any situation like that in the facility, the SW stated, There is one resident, but I know he is IDD and to have him keep his room clean and not spread feces around, the Guardian said to take away his sodas. The SW stated she believed he had a radio and a DVD player that were taken away from him, also but did not recall how long ago those were taken away. The SW stated the person appointed as his Guardian had been his Guardian since before 2023 and she gave the facility feedback on how to redirect and encourage Resident #33. When asked how long ago Resident #33's DVD player and radio were taken away, the SW stated, I wouldn't say it has been months that he had his DVD player and radio taken away. I think he has the radio back. The DVD player was taken by myself and the radio- I'm not sure about the radio. When asked why they were taken away, she stated it was to redirect him from walking into offices and stealing stuff or spreading feces in the bathroom. The SW stated it did not make him feel sad. She stated she felt like it had been effective to take away his things. The SW further stated, I have not asked him how it made him feel. The SW stated she would not feel it was appropriate to take Resident #33's things away if the Guardian had not told her to take them. She also stated it should have been care planned that the Guardian said to take his things. When asked where the DVD player and radio were at this time, the SW stated the DVD player was in her office, but she was not sure where the radio was. The SW stated she consulted with the Administrator before taking things away from Resident #33. When asked who purchased the DVD player and the radio, the SW stated, I believe that he paid for the DVD player, but I'm not sure about the radio. He gets his money from the business office and goes to Wal Mart with the AD and MRC (Medical Records Clerk) to buy things. The SW stated, After reading the policy and especially if it makes him sad, I do feel like it is abuse.In an interview on 07/02/25 at 4:26 pm the Adm stated it would be abuse and dignity if someone took something away from a resident due to behaviors because the residents were adults, not children. The Adm stated Resident #33's radio and DVD player were not taken away by staff members. The Adm stated Resident #33's DVD player was taken at the direction of his Guardian as more of an unofficial behavior contract. The Adm stated, We called her and asked her what we could do to help improve his behaviors. She called him and told him, today we are going to work on not flooding the bathroom. She told him if he did not flood the bathroom then they could go to the store and buy some DVDs, but if he kept flooding the bathroom and throwing things, they would have to take away his DVD player. The Adm stated Resident #33 told his Guardian he would not flood the bathroom. The Adm further stated, It was not something we would initiate, it was something [his Guardian] did. Because his behaviors were getting more violent, we were trying to deescalate those behaviors. It was more of not a deprivation, but it was so that he would understand that things can't be thrown. I remember he did have it back; they went on a shopping trip, and he bought a scary DVD. The Adm stated if someone took away Resident #33's things for behaviors it would not be right and when she looked at the SW's documentation of the incident, it looked like abuse. The Adm stated, Had I not been privy to the conversation, I would feel like it would be abuse. I do not feel like that conversation and the way it was done was abusive, but I do feel like the way it is written, it looks bad. The Adm stated she was pretty sure Resident #33 had his DVD player back and, if the SW has the DVD player, that is news to me. I would be interested to know why the SW still has it. The Adm stated the intent was not to deprive Resident #33 of something or to abuse him, but to get him to stop throwing things and his Guardian phrased it that it was a behavior contract. The Adm stated she did not know if the radio being taken was a present issue or a past issue because as far as she knew, he did not have a radio now; however, his family member, who used to be in the same room as him, would often yell at him, tell him his radio was too loud, and take it away from him. When told Resident #33 stated he was sad about not having his DVD player, the Adm stated, I feel horrible because I do not want anyone to feel that way. In a telephone interview on 07/02/25 at 4:56 pm, Resident #33's Guardian stated taking away the DVD player first came up when the Adm contacted her about Resident #33's issues with behaviors like throwing trash all over, spreading feces all over and not wanting to shower. She stated those behaviors got better and then worse after his family member passed away a year ago. The Guardian stated the ILS people were going to the facility to see him, but they stopped because his room was not sanitary. She stated Resident #33 had never been taught appropriate skills such as cleaning up after himself and not breaking things and the staff had been trying positive reinforcement to help him. The Guardian stated the Adm called her and asked, If we (the Adm and the Guardian) explained it to him, could we (the facility) try taking his DVD player away to work on those skills and to keep his room in at least decent condition? I checked and we can do this. The Guardian stated she was not really in favor of it, but she agreed because Resident #33 was involved in the call, and he was willing to work on it. The Guardian was not able to see Resident #33 in April and May 2025 (someone else from her office saw him those months) but when she went to see him in June 2025 and on 07/01/25, he did not have his DVD player. She stated she talked to him about it on 07/01/25 and went to talk to the Adm and SW to tell them that they needed to try something different, but they were not in the facility at that time. The Guardian stated the behaviors they were trying to remedy had continued to the point where the Adm told her she was looking at alternative placement for him. The Guardian stated she now felt it (taking away his DVD player) had become punitive and it was not having a behavioral modification effect. She stated when she went to the facility in June there was a tracking chart on the wall with the days of the week, and staff would mark down if his room and/ or bathroom were clean and she thought to herself, well, that's kind of good, but when she was there on 07/01/25, the chart was not there. The Guardian stated, We really do not like being punitive with our clients. When I went to his room in June, his room smelled really bad because of the feces in the bathroom so I talked with him about why it was important to keep our areas clean. She stated the goal initially was to get Resident #33 into a group home, but she did not think that would be possible because he needed more supervision and assistance than a group home could provide. The Guardian stated she told the facility they needed to consult with a psychiatric provider before trying to find alternate placement for him because they might need to make some medication changes and the facility was supposed to be sending her his psychiatric notes. The Guardian stated MHMR was having trouble with Resident #33 in the day program also, and he would usually only be at the adult day care facility for an hour or two due to his behaviors. She stated for positive reinforcement, they would let him get a fast food meal on the way back to the nursing facility and it seemed to be improving his behavior as he would shower, put on clean clothes, and straighten up his room before he went to the adult daycare location. The Guardian stated she felt like taking things away was not going to have the desired effect with Resident #33, as the behaviors he had were long standing behaviors he has had his whole life. On 07/02/25 at 5:40 pm while the surveyor was on the phone with Resident #33's Guardian, the Adm and DON stated Resident #33 now told them the DVD player got wet and he took it to the SW to get it fixed and they (staff) forgot about it. This was stated to the two other state surveyors who were in the hallway at that time.In a telephone interview on 07/03/25 at 8:10 am, Resident #33's Guardian stated the Adm called her the previous evening to talk about the abuse case and told her Resident #33 got his DVD player back on Monday (04/14/25), and that he had it the whole time since then. Resident #33's Guardian stated the Adm then told her that Resident #33 took the DVD player to the SW one day before he went to the adult day care, told her it was broken, and they (the facility) were going to get maintenance to fix it. The Adm also told Resident #33's Guardian she (the Adm) was not aware the SW had the DVD player back and the SW did not know how long she had the DVD player. Resident #33's Guardian stated the Adm told her she gave the DVD player back to Resident #33 the previous day (07/02/25) and it was working. In an interview on 07/03/25 at 9:26 am Resident #33 stated the SW gave his DVD player back and the MRC gave his radio back yesterday (07/02/25). When asked if the radio had been in his room or in a drawer, Resident #33 stated it had not. Resident #33 stated he felt happy that he got his DVD player back and had already watched some movies.Record review of the facility's Abuse, Neglect and Exploitation policy dated 08/15/22 reflected in part: Policy:It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.Definitions: Abuse means the willful inflictions of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.Policy Explanation and Compliance Guidelines:3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.The components of the facility abuse prohibition are discussed herein:III. Prevention of Abuse, Neglect and ExploitationThe facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves:D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for one (Resident #61) of 4 residents reviewed for infection control practices, in that: The facility failed to ensure the WCN wore proper PPE during wound care for Resident #239 who required enhanced barrier precautions. The facility failed to ensure Resident #239's surgical incision did not come in contact with a potentially contaminated surface during wound care. These failures could place residents that require wound care at risk for healthcare associated cross-contamination and infections. The findings included:Record review of Resident #239's face sheet dated 07/02/25 reflected a [AGE] year-old-female with an original admission date of 06/20/25. Diagnoses included spinal stenosis, lumbar region (narrowing of the spinal canal in the lower back), atherosclerotic heart disease (hardening and narrowing of the arteries caused by cholesterol plaques lining the artery over time), and high blood pressure. During an observation of wound care on 07/02/25 at 09:31 AM, the WCN was observed wearing gloves, but no gown as indicated to do so in the facility's EBP policy for residents with unhealed surgical wounds. The WCN was observed removing Resident #239's previous dry dressing to begin wound care. After the dry dressing was removed, the WCN proceeded to grab supplies to cleanse the surgical incision, allowing Resident #239's pant to come in contact with the wound. Once cleansed, the WCN stopped to grab gauze to pat dry the area, allowing Resident #239's pant to come in contact with the surgical incision again. The WCN then pat dried the area, then stopped to grab the dry dressing, allowing Resident #239's pants to come in contact with the surgical incision again. Record review of Resident 239's orders dated 06/22/25 reflected: Cleanse surgical incision to the back with normal saline, pat dry and apply dry dressing. Monitor for signs and symptoms of infection every day until resolved. In an interview on 07/02/25 at 09:47 AM the WCN stated she was very nervous as she had not been the WCN for very long. The WCN stated Resident #239 was not on enhanced barrier precautions because the wound was considered closed and did not think Resident #239 had to be on EBP. The WCN stated Resident #239's wound should not have come in contact with her pant, a potentially contaminated surface, to prevent the spread of infection. The WCN stated she had just gotten checked off on her wound care skills but could not remember when. In an interview on 07/02/25 at 01:16 PM the DON stated EBP is ordered for residents who meet the criteria such as residents with G-Tubes, open wounds, wounds that are draining, central lines, a tracheostomy, foley catheters, or central lines. The DON stated Resident #239's surgical incision was considered closed and not draining. The DON stated Resident # 239's surgical incision in her opinion, was closed with stitches, was not open or draining and therefore did not require EBP. The DON stated Resident #239's surgical incision should not have come in contact with her pants. The DON stated Resident #239's surgical incision could have been at risk for contamination and infection if a contaminated surface came in contact with the surgical incision. The DON stated the WCN had a skills check off on 07/01/25 and was fairly new to the wound care nurse position. In an interview on 07/02/25 at 03:04 PM the ADON stated residents are placed on EBP depending on the situation of the resident. The ADON stated the Resident #239's surgical incision did have stitches, but the wound was not open and not draining. The ADON stated based off the facility's EBP policy, unhealed surgical wounds should have required EBP to prevent infection. Record review of the facility's Enhanced Barrier Precautions policy dated 04/05/24 reflected: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms/ 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devises (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation, and sanitation. The facility failed to ensure the juice gun nozzle was clean. The facility failed to ensure the juice gun nozzles were stored properly. The facility failed to ensure food was stored properly in refrigerator number 2. These failures could place residents who received meals and/or snacks from the kitchen risk for food contamination and food borne illness. Initial tour and observation of the kitchen on 07/01/25 at 8:20 am revealed the following:*The left juice gun nozzle had a thick brownish yellow substance stuck inside and all over the outside of the nozzle as well as a thick white substance in spots on the outside of the nozzle.*Both juice gun nozzles were left hanging down off the shelf and dangling approximately 12 inches above the floor.*A thick red and a thick brown substance streaked and puddled on the front right table leg of the table the juice machine was on.*A one-gallon size zipper bag which contained a sliced meat product in a cloudy, light pinkish liquid with white particles floating in it was dated 6-23-25, partially unsealed and sitting on a wire shelf above a tray that contained 30 uncovered 8-ounce cups of a dark colored liquid substance in reach-in refrigerator number 2. In an interview on 07/01/25 at 9:18am the DM stated the juice nozzle was not acceptable and the white substance stuck to the outside of the juice nozzle might have been paper. He stated the juice nozzles were cleaned by night shift every evening, but it did not get cleaned the night before because it was a new month and he had not put out the cleaning schedule yet. In an interview with the RD, DM, and DA on 07/03/25 at 1:28 pm the DA stated the night shift DA was supposed to clean the juice nozzles and the day shift DA was supposed to check it to make sure it was cleaned before it was used because it could grow bacteria and cause the residents to get sick. The DA stated the juice nozzles were not supposed to be left hanging down because they could become contaminated and cause residents to get sick. The DA stated the food items in the refrigerators were to be labeled, dated, and covered by the DAs every day, every shift to avoid spoiling and contamination and the DM would check daily to ensure it was done. The DA stated left over food was good for one day and if it was left too long it could go bad and cause stomach problems for the residents. The DM stated he checked the refrigerators and freezers daily to ensure that food items were stored, labeled, and dated correctly. The DM also stated the meat in refrigerator number 2 was pre-cooked lunchmeat (ham) that was placed in a zipper bag because it originally came in a large box of lunchmeat that was kept frozen, and he only took out a portion at a time to thaw and use so that it would not go bad. The DM stated pre-cooked lunch meat not stored in the original package was good for 7 days as long as it was kept sealed and refrigerated. Record review of the facility's Coffee Machine and Juice Machine Policy Number 04/010 dated 10/01/18 and revised 06/01/19 reflected in part: Policy: The facility will maintain coffee machines and juice machines in a clean and sanitized condition to minimize the risk of food hazards. Coffee and juice machines will be cleaned once daily.2. Juice machines should be cleaned following the manufacturer's instructions. The nozzle will be cleaned daily. Record review of the facility's Food Storage Policy Number 03.003 dated 10/01/18 and revised 06/01/19 reflected in part: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal, and US Food Codes and HACCP guidelines.

Based on observations, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one of eight residents (Resident #2) reviewed for accidents and hazards. The facility failed to ensure a floor mat was in place beside Resident #2's bed as indicated on her current comprehensive care plan and current physician's orders. This failure could place residents at risk for an injury. The findings include: Record review of Resident #2's face sheet, dated 06/17/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included unspecified dementia(A group of thinking and social symptoms which interferes with daily functioning), unspecified osteoarthritis (Type of arthritis that occurs when flexible tissue at the ends of bones wears down), age related osteoarthritis(A degenerative joint desease where cartilage, the cushioning tissue in the joints breaks down over time, leading to pain and stiffness), and mild cognitive impairment. Record review of Resident #2's MDS dated [DATE] indicated she had a BIMS (Brief Interview for Mental Status) score of 3 which indicated, severe cognitive impairment. The ma also indicated she was dependent on staff for ADL's (Activities of Daily Living.) Record review of Resident #2's care plan dated 11/26/24 indicated: 08/23/23 unwitnessed fall- no injury 4/3/2024 an unwitnessed fall with no injury 05/20/24 Witness fall without injury 07/31/24 Fall w/o injury Add floor mats X2 for safety precautions 01/04/25 Witness fall with injury laceration to left forehead hematoma to left side of forehead. 01/30/2025 Fall without injury Record review of Resident #2's July 2024 physician orders reflected there was an order for floor mats X2 usage as precaution. Record Review of Resident #2's Fall Risk Assessment/ Morse Fall Scale reflected 30 -a moderate risk or falling. Observation on 06/18/25 at 11:15 AM, revealed Resident #2 was lying in bed with eyes closed. Resident #2 had a floor mat on the floor on the left side of her bed but not on her right side. In an interview on 06/18/25 at 12:03 PM, CNA B and CNA C said all staff was responsible to check to see if mats was in place. They said the CNA's are the front-line staff and should notice if the floor mat is not in right place or missing. Both staff said if mats were missing the resident could sustain an injury which can lead to a major injury or possibly death. Both staff said last fall prevention in-service was just a week ago. In an interview on 06/18/24 at 12:11 PM LVN A said she was responsible for making sure the fall mats were in place. The resident only had one mat and is to have two mats per care plan. Resident is at risk for injury for not having both mats alongside each side of her bed. The supply clerk is responsible for suppling mats and did not know the reason why she did not have other mat on right side of bed. In joint an interview 06/18/2025 at12:15 PM with the Administrator and DON, the Administrator stated the resident was to have two fall mats in place as indicated in her care plan and physician's orders. The Admin and the DON stated not having the fall mats could place the resident at risk for a major injury or death. Both the Admin and DON stated it was all staff's responsibility to ensure the mats are in place for the safety of the resident, but the main responsibility fell on the nurse caring for the resident at the time. Record review of the facility's Fall Prevention Program Policy dated 8/15/22 reflected Each resident will be assessed for fall risk and will receive care and services in accordance with their Individualized level of risk to minimize the likelihood of falls. When a resident who does not have a history of falling experiences a fall, the facility will update the care plan and interventions.

Based on interview and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 5 residents (Resident #1) reviewed for pharmacy services. 1. The facility failed to clarify the blood pressure parameters for Resident #1's Hydrochlorothiazide (a diuretic that helps treat high blood pressure and fluid retention) orders for April and May of 2025. 2. The facility failed to administer Resident #1's Hydrochlorothiazide per the recommended and prescribed blood pressure parameters in April and May of 2025. These failures could place resident at risk for complications, as well as jeopardize their health and safety. Findings included: Record review of Resident #1's face sheet, dated 06/17/25, revealed a [AGE] year-old male with an original admission date of 10/17/2023, and a current admission date of 05/22/25. Resident #1's diagnoses included Wernicke's Encephalopathy (an acute neurological condition caused by vitamin B1 deficiency), Dementia with Mood Disorder (decline in cognitive function severe enough to interfere with daily life), and Essential Hypertension (high blood pressure). Record review of Resident #1's Quarterly MDS assessment, dated 05/25/25, revealed Resident #1 rarely or never makes self understood. The Brief Interview for Mental Status was skipped and not conducted. Record review of Resident #1's care plan revealed risk for decreased cardiac tissue perfusion initiated 10/16/23 and revised on 02/16/24. Goals included: the resident would remain free from signs and symptoms of hypertension, and the resident would remain free of complications related to hypertension. Interventions included: administer Hydrochlorothiazide routinely as ordered. Monitor for side effects such as orthostatic hypotension, increased heart rate, and effectiveness. Record review of Resident #1's physician orders, revealed Hydrochlorothiazide 12.5 MG give 1 tablet by mouth one time a day for Hypertension started 10/20/23 and ended 05/12/25 (check blood pressure, may hold if less than 100/60), started 05/23/25 and ended 05/23/25, started 05/24/25 and ended 05/27/25, started 05/28/25 and ended 06/10/25 (check blood pressure, hold if less than 100/60). Record review of Resident #1's April 2025 MAR revealed Resident #1's blood pressure on 04/29/25 was 124/54. Hydrochlorothiazide was still administered. Record review of Resident #1's May 2025 MAR revealed Resident #1's blood pressure on 05/01/25 was 98/62. Hydrochlorothiazide was still administered. No blood pressures were documented for this medication on 05/23/25, 05/24/25, 05/25/25, 05/26/25, and 05/27/25. Record review of Resident #1's progress notes (orders administration notes) dated 06/05/25 and 06/09/25, revealed a medication note for Hydrochlorothiazide 12.5 MG, give 1 tablet by mouth one time a day for Hypertension; Check blood pressure and hold if less than 100/60. In an interview with the DON on 6/17/25 at 2:50 PM she stated Hydrochlorothiazide was a diuretic not a blood pressure medication, but it could affect the blood pressure. She also stated she knew who the initials belonged to, but she was not sure why the nurses gave the medication outside of the recommended parameters. The DON stated the check mark above the nurse's initials on the MAR meant the medication was administered. She was unsure why some of the Hydrochlorothiazide orders had blood pressure parameters, but some did not, and stated this should have been clarified with the provider, and she was going to get with the provider to clarify if he wanted to have parameters on this order or not when the resident returned back to the facility since he was currently away at a psychiatric hospital. The DON stated if Resident #1's blood pressure dropped too low he may have experienced possible dizziness, weakness, and organ failure. In an interview with the ADON on 06/17/25 at 3:00 PM, she stated she did not remember giving the medication outside of parameters and was unsure why she had not looked at or paid attention to the blood pressure parameters. She stated she typically looked at blood pressure parameters prior to administering Hydrochlorothiazide and held it if the blood pressure was too low. She also stated if this medication was given while his blood pressure was already low, his blood pressure could have continued to drop, and he could get dizzy and faint, and there could even be a risk of death. She did not recall receiving any in-services in the past regarding blood pressure medications or blood pressure parameters, but she stated they went over blood pressure medications and parameters on their annual skills checkoff. She stated she did not remember when their most recent annual skills checkoff was, but she thought it was sometime this year. In an interview with LVN-A on 6/17/25 at 3:09 PM, she stated it was just an error, and she should not have administered Resident #1's medication with his blood pressure below the recommended parameters. She also stated she typically looked at the medication and parameters before administering, but she did not remember why she had not look at the parameters that day other than she was probably busy and overlooked it. LVN-A stated if the blood pressure dropped too low Resident #1 could have had dizziness, passed out, or even possibly death. She stated she thought they had been in-serviced recently regarding blood pressures and medications but she could not remember for sure, but she did state they went over it in their annual skills checkoffs that were sometime this year. In a record review of the Medication Administration Policy, implemented 10/24/22, 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 14. Administer medications as ordered in accordance with manufacturer specification. 17. For those medications requiring vital signs, record the vital signs onto the MAR. 20. Correct any discrepancies and report to nurse manager.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The Dietary Manager was observed in the kitchen not wearing a beard hair restraint. 2. There were two 6.5 lb bags of sliced strawberries in the freezer that were not dated. 3. There was a bag of tostada chips in the kitchen store- room that was not labeled or dated. 4. There was an electrical outlet in the kitchen that did not have an attached cover on the outlet. 5. There was a ceiling vent in the dish-room that had rust on the sprinkler head and dirt on the ceiling around the vent. 6. There was a ceiling vent in the dish-room that had dirt particles and grease on the vent slats. These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness from improper infection control, from a lack of food label date monitoring, from a lack of equipment maintenance, and improper sanitation in the kitchen area. The findings included: Observation on 05/21/24 from 9:05 a.m. to 9:50 a.m. during the kitchen tour with the Dietary Manager revealed the following: a. The Dietary Manager was observed in the kitchen not wearing a beard hair restraint. b. There were two 6.5 bags of sliced strawberries in the freezer that were not dated. c. There was a bag of tostada chips in the kitchen store- room that was not labeled or dated. d. There was an electrical outlet in the kitchen that did not have an attached cover on the outlet. e. There was a ceiling vent in the dish-room which measured approximately one foot in diameter that had rust on the attached sprinkler head. There was also dirt on the ceiling surface around the parameter of the ceiling vent. f. There was a ceiling vent in the dish machine room which measured approximately 1x1.5 foot that had dirt particles and grease on the vent slats. During an interview with the Dietary Manager on 05/21/24 at 9:55 a.m., the Dietary Manager stated wearing a hair and beard restraint was important to keep hair from falling onto the floor or food. The Dietary Manager stated it was important for food to be labeled and dated to know when it was out of date. He stated having an attached electrical outlet cover was important for employee safety. The Dietary Manager stated having clean ceiling vents in the dish-room was important to maintain kitchen sanitation. During an interview with the Maintenance Director on 05/21/24 at 1:50 p.m., he stated having the outlet cover on the electrical outlet would be important for employee safety. The Maintenance Director stated having the ceiling vents cleaned in the kitchen was important to maintain kitchen sanitation. During an interview with the Administrator on 05/22/24 at 4:40pm she stated kitchen employees wearing hair restraints would help keep hair from falling onto the floor or into the food. The Administrator stated dating food items in the kitchen helped to establish when the food item should be discarded. The Administrator stated keeping the ceiling vents clean from dirt would have promoted kitchen sanitation. Record review of facility's policy on Employee Sanitation, Policy Number 04.001 dated 2018 stated that hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food contact surfaces. Record review of the facility's policy on Food Storage, Policy Number 03.003, dated 2018 stated that food items in dry storage rooms and refrigerators should be dated and labeled. Record review of the facility's policy on Fire Containment, Policy Number 05.008 dated 2018 stated electrical outlets were to be checked to make sure they were intact. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Non-food-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. The facility failed to employ a certified dietary manager as required. This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition. The findings were: Record Review of the Employee Service List, undated, revealed the Dietary Manager with a hire date of 11/20/2015 and a re-hire date of 12/2/2016 During an interview on 05/23/24 at 1:20 p.m., with the Dietary Director he revealed he had not completed the certified Dietary Manager course which was started in 11/23 but he hoped to have it completed in the next three months. The Dietary Director stated he had been working in the facility's kitchen as a cook prior to becoming the Dietary Manager in 09/23. The Dietary Manager stated he felt completion of the dietary manager course would help him to better manage the kitchen, work with Resident menus, and better understand the recommended resident diets. During an interview on 05/23/24 from 1:45p.m., to 2:00p.m., with the Human Resource Director and the Administrator, the Administrator stated she felt having the Dietary Director enrolled in the certified dietary manager course had met the facility's requirement. The Administrator stated she felt the Dietary Director finishing the certified manager's course would help him to better manage the kitchen. The Human Resource Director stated the facility did not have a policy on employees maintaining their licenses or certifications. The Human Resource Director stated the Dietary Director's completion of the certified manager's course would help him to teach the kitchen manager role to others if there was a need. Record review of the Dietary Food Service Supervisor Job Description dated 8/1/23 revealed the Food Service Supervisor was responsible for the daily operations of the dietary department, according to facility policy and procedures and federal/state regulations. The Job Description revealed an additional discussion section dated 9/1/24 which authorized the payment for the Certified Dietary Manager Course.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 5 residents (Resident #51) reviewed for infection control, in that: 1. CNA A and B failed to wash or sanitize their hands or change their gloves after touching items in close proximity of Resident #51 before starting incontinent care. 2. CNA B did not clean between her fingers with hand sanitizer while providing incontinent care. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #51's face sheet, dated 05/23/2024, revealed an admitted [DATE], with diagnoses which included: Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Dementia(decline in cognitive abilities), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Parkinsonism (Group of neurological conditions that cause difficulty with movement), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Anxiety disorder (A group of mental illnesses that cause constant fear and worry), Delusional disorder (A person has one or more fixed and persistent beliefs that are not based on reality). Record review of Resident #51's quarterly MDS assessment, dated 04/15/2024, revealed Resident #18 had memory problem, and was severely cognitively impaired. Resident #51 required total care and, was frequently incontinent of bowel and bladder. Record review of Resident #51's care plan, dated 09/19/2029, revealed a problem of is at risk for skin breakdown as evidence by bladder incontinence, with a goal of The resident will remain free from skin breakdown due to incontinence and brief use through the review date. 1. Observation on 05/23/24 at 11:30 a.m. revealed while providing incontinent care for Resident #51, CNA A after putting gloves on, touched the bed remote and the call light that were on Resident #51's bed and then without changing her gloves or sanitizing her hands touched the wet wipes that were going to be use on the resident to provide care. CNA A touched the bed remote again to lower the head of the bed. Both CNA A and CNA B touched the pillow under Resident #51's feet to remove it from under his feet. Both CNAs started the incontinent care for the resident without changing their gloves or sanitizing their hands. During an interview on 05/23/2024 at 12:00 p.m. with CNA A and CNA B confirmed the environment around the resident was considered dirty and they should have changed their gloves and sanitized their hands prior to providing care. They confirmed they received infection control training within the year. During an interview with the DON on 05/23/2024 at 3:50 p.m., she confirmed the environment around the resident was considered dirty and the staff should change their gloves and wash. Staff should sanitize their hands after touching anything in the environment, before touching the resident and at the start of care. She confirmed the staff were in-serviced in infection control and incontinent care and skills were checked annually and as needed if there were concerns with infection control. The DON revealed herself and the ADON were in charge of the training and checking of the staff's kills. Record review of the annual skills check for CNA A revealed CNA A passed competency for infection control on 02/16/2024. Record review of the annual skills check for CNA B revealed CNA B passed competency for infection control on 01/29/2024. Record review of the facility policy, titled Infection prevention and control program , dated 05/13/2023, revealed All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. 2. Observation on 05/23/24 at 11:30 a.m. revealed while providing incontinent care for Resident #51, CNA B used hand sanitizer 3 times between change of gloves. For 2 of the 3 times, CNA B did not rub the sanitizer between her fingers. During an interview on 05/23/2024 at 12:00 p.m. with CNA B confirmed she should have rubbed between her fingers every time she used the hand sanitizer. She confirmed she received training in hand washing within the year. During an interview with the DON on 05/23/2024 at 3:50 p.m., she confirmed the CNA should have rubbed the sanitizer between her fingers to completely sanitize her hands and that it could be a cause for infection to the resident. She confirmed the staff were in-serviced in infection control and hand washing and skills were checked annually and as needed if there were concerns with infection control. The DON revealed herself and the ADON were in charge of the training and checking of the staff's kills. Record review of the annual skills check for CNA B revealed CNA B passed competency hand washing on 01/29/2024. Record review of the facility policy, titled hand Hygiene , dated 10/24/2022, revealed Hand hygiene technique when using an alcohol based hand rub [ .] rub hand together, covering all surfaces of hands and fingers until hands feel dry

Based on interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 1 (Resident #42) of 24 residents reviewed for MDS accuracy and completion, in that: Resident #42's Discharge MDS Assessment was not exported within 14 days of completion. This deficient practice could result in MDS inaccuracies. The findings were: Record review of Resident #42's closed record revealed a Discharge MDS Assessment was completed on 12/29/2023 and had not been exported as of 05/23/2024. During an interview with MDS C on 05/23/2024 at 3:07 p.m., MDS C confirmed that Resident #42's Discharge MDS Assessment was completed on 12/29/2023 and had not been exported. MDS C stated the MDS should have been exported, confirmed she was responsible to do so, and stated the failure was an oversight. During an interview with the Administrator on 05/24/2024 at 1:15 p.m., the Administrator stated the facility had no policy regarding the timeliness of MDS transmission.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 5 resident (Resident #1) reviewed for infection control, in that: The facility failed to ensure the PTD was wearing the appropriate PPE while in Resident #1's room, who was in isolation. This deficient practice could place residents at risk of infection for transmission of communicable diseases and a decline in health. The findings were: Record review of Resident #1's face sheet dated 02/02/2024 revealed an admitted [DATE] and diagnoses which included: Clostridium Difficile Colitis(inflammation of the colon caused by bacteria), Chronic Obstructive Pulmonary Disease ( a group of lung diseases that block airflow and make it difficult to breathe), Unspecified Atrial Fibrillation( the heart's upper chambers beat chaotically and irregularly), and Gastro-esophageal reflux ( a digestive disease in which stomach acid or bile irritates the food pipe lining). Record review of Resident #1's Annual MDS assessment, dated 01/17/2024, revealed a BIMS score of 12, which indicated moderate cognitive impairment. Record review of Resident #1's Care Plan, last reviewed 01/18/2024, revealed a Focus: The resident has + C.Difficile results. Date initiated 01/18/2024. Record review of Resident #1's Medical assessment dated [DATE] revealed the resident was on a CONTACT ISOLATION: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry. Date Initiated: 01/18/2024 Observation on 02/01/2024 at 1:52 p.m. revealed Resident #1's hallway had Resident #1's room set up with 3-drawer cart outside of door, filled with masks, face shields, gowns, and gloves. Further observation revealed there were trash bins for doffing face masks and shields, hand sanitizer and signs on the wall and doors regarding isolation precautions. Observation on 02/01/2024 at 1:52 p.m. revealed PTD present in Resident #1's room, who was in isolation, wearing only a surgical mask that was pulled down around PTD's chin. Further observation revealed PTD exiting the room and returning to the Physical Therapy room where other residents and staff were present. PTD touched residents call light on bedside table, while he helped her to raise the head part of the bed for Resident #1. In an interview with PTD and the DON on 02/01/2024 at 02:14 p.m., the PTD stated he was only going in their real quick to assist Resident #1 with her bed because she asked him for help. PTD acknowledged he had received infection control training and using PPE. The DON informed PTD that no matter the length of time that he was in an isolation room, any person must follow the orders that are on the wall on what to wear when entering a room with precautions. The DON further revealed all staff were trained on infection control and isolation precautions, knew the procedures and risk of spreading the infection to themselves and other residents. She stated PTD should have been aware of the PPE set up in the hall and would provide PTD with further in-service training immediately. Record review for an in-service training on infection control provided on 02/01/2024 was signed by PTD. Record review of the Infection Prevention and Control Program, updated May 13, 2023, provided by the DON as part of the facility Infection Control Procedures, revealed, a section Personal Protective Equipment; Health Care P rovider who enter the room of a patient with suspected or confirmed Clostridium Difficile Colitis infection should adhere to Standard Precautions). Record review of the facility's policy titled, Infection Control Plan: Overview, updated 05/2023, revealed, Preventing Spread of Infection: The facility will require staff to Donn and Doff PPE before and after contact with resident who needs isolation to prevent the spread of infection to others in the facility.

Based on interviews, record reviews, and observations, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of six residents (Resident #1) reviewed for quality of care. Facility staff failed to check Resident #1's meal tray and provided Resident #1 with a mechanical soft textured diet instead of pureed textured diet as order by physician. Resident #1 was sent to emergency room due to change of condition and was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in the identification of Immediate Jeopardy (IJ) on 3/30/2022 at 4:33p.m. The immediacy was lifted on 4/01/2022 at 4:42pm, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as a pattern until interventions were put in place for all residents who required specilaized textured diets as ordered by their physician, and to ensure the safety of residents from serious injury and even death. This failure placed residents at risk for serious injury and even death by not receiving the proper specialized textured diet and services needed. Findings included: Record review of Resident #1's face sheet dated 03/29/22 documented an [AGE] year-old male admitted on [DATE] with a re-admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] indicated Resident #1 BIMS score was 8 (moderate cognitive impairment), required extensive assistance for bed mobility. Resident #1 required supervision for eating. Other health conditions included shortness of breath or trouble breathing when lying flat. Record review of Resident #1's Care plan dated 03/02/22 documented: -Resident #1 is at risk for potential nutritional problem as evidence by receives NAS (no added salt) Pureed textured Diet; Regular Liquids Consistency. -The resident will comply with recommended diet daily through review date. -Intervention: -Monitor intake and record q (every) meal, Monitor/document/report as needed any signs or symptoms of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. - Provide and serve diet as ordered. Record review of the Order Summary Report dated 03/30/22 for Resident #1 indicated orders: NAS (No Added Salt) diet Pureed texture, regular liquids consistency, yogurt with meals: Add fortified pudding snacks between meals. Record review of Nursing progress notes on 03/28/22 at 6:29p.m documented: During dinner noted that resident was given a regular diet instead of his puree diet and tray was taken and exchanged for correct diet, however resident was coughing and coughed up a moderate amount of phlegm. vital signs wnl (within normal limits). RP notified. MD notified. N.O. z-pack as directed, robitussin 10ml Q6 hours prn. If aspiration is suspected or resident status declines send to emergency room . Resident denies any pain discomfort or SOB. Will continue to monitor during this shift. Record review of Nursing progress notes on 03/28/2022 at 7:15p.m documented: Resident was noted to have been given the wrong diet (regular) when he is a puree diet. Resident had some coughing and coughing up phlegm, but no food particles noted. Resident instructed to stay in sitting position or lay with head of bed up for a while. his vital signs were within normal limits, he denied any pain discomfort or shortness of breath. Food tray was taken away and replace with correct diet tray. call light in place. will continue to monitor during this shift. Record review of Nursing progress notes on 03/28/2022 at 8:02p.m. documented: Resident complaining of SOB (shortness of breath) unable to obtain O2 reading, BP 76/30, per MD send to ER for eval and treat. Record review of Nursing progress notes on 03/29/2022 at 4:34 p.m. documented: Received call from nurse at [local]-emergency room , resident admitted to room [ROOM NUMBER] for Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility's in-service sheet Daily Meeting Agenda dated 3/29/22 documented: Trays are not to leave dining room until checked by nurse. No exceptions!! Sign in revealed 7 charge nurse signatures. Record review of the facility's in-service sheet Daily Meeting Agenda dated 3/29/22 documented: Reviewing dietary cards/trays for accuracy on current diet textures. Sign in revealed 8 charge nurse signatures. In an interview with the DON and Administrator on 03/30/22 at 9:50 A.M he revealed on 03/28/22 the administrator was notified, that Resident #1 had an incident with a meal and was doing fine but he was given no specifics. Later that evening the administrator got a call that the resident had been sent out to hospital. On the morning of 03/29/22 before breakfast, the administrator found out Resident #1 was sent in the wrong tray with mechanical soft food instead of the ordered puree diet. He revealed, after Resident #1 ate the mechanical soft food tray, he was noted with coughing. That is when LVN A noticed the food on the tray was not the right texture. The administrator stated he immediately began verifying that the staff were checking trays for every meal. He revealed he went to breakfast himself to make sure a nurse was checking trays. And he attended every meal after to ensure nurses were checking meal trays. During the startup meeting at 9:30 AM on 03/29/22, the administrator discussed the incident about Resident #1 and were working on brainstorming a solution and interventions to put into place. The administrator revealed the management team were working on the in-servicing and re-education for staff. The DON revealed they were making interventions such as making sure the managers were present at every meal, especially for dinner to double check the trays that go to the residents. The kitchen was going to double check the trays to make sure the residents get the right diets. He revealed LVN A was suspended pending further investigation, all nurses were to be re-educated about checking the trays completely because it is their responsibility. In an interview with the Dietary manager on 03/30/22 at 10:30 A.M she revealed the evening staff that prepared and served dinner on 03/28/22 had maintenance in the kitchen working on something that caused them to feel distracted. She revealed Cook A and Dietary Aide C made a mistake of the food texture for Resident #1 during checking trays prior to sending to the nurses to be checked. She revealed, Cook A reads tray cards and prepare the plates to match the diet correctly. Dietary Aide C should have been on the other side double checking the plate and tray card have the correct diet. Dietary manager revealed Dietary Aide C was helping on the food line instead of checking trays. She stated, once the trays go to the charge nurses, the charge nurses are to check the trays prior to handing them to the residents. She revealed it's really a team effort to read the tray cards to make sure they put the right diet on the right residents tray. She was currently in servicing and will have a meeting with her staff today at 1 PM about diet textures, tray line job duties, and safety of checking trays. In a telephone interview with LVN A on 03/30/22 at 10:53AM she revealed she was so busy on 03/28/22, she was unable to check hall trays before they were sent to the residents. She revealed, when the nurse assigned to checking trays is busy or something comes up, staff will find another nurse to help check the halls trays, but the hall trays were passed out to the residents by the CNAs before the nurses could check the trays. LVN A revealed she had been trained on checking meal cards for residents before passing them to the residents. She stated, Resident #1 had eaten 25% of the plate which was flour tortilla, ground beef, and shredded cheese, before she heard him coughing from the hallway. She went to check on Resident #1 when she noticed the resident coughing up what appeared to be mucous. She revealed everything else on the tray was puree except the main course. She monitored Resident #1 and received orders from the MD for preventative measures. She revealed she notified the administrator and ADON B. LVN A stated, it is important to check hall trays before they are passed to the residents, to make sure the resident gets the right diet that is ordered to prevent the resident from choking or a possible allergic reaction. In an interview with ADON B on 03/30/22 at 11:30 A.M, she revealed she oversaw schedules and assigned a charge nurse to check breakfast, lunch, and dinner. She makes sure there is a nurse on the schedule to verify and check the correct diet is on the tray for the residents for breakfast, lunch, and dinner. She revealed, she did that to make sure the residents are getting the right food and diet that is ordered by the physician. She revealed its best practice and part of the nurse's job description to check meal cards that have the resident's ordered diet and compare it to the food trays to make sure the resident is getting the correct diet. She stated, it's important to check meal trays to ensure that the resident will not choke, aspirate, or have an allergic reaction. Record review of the facility's Daily position sheet dated 03/30/22 documented day, evening, and night shift employees, along with the name of the charge nurse assigned to breakfast, lunch and dinner duty. In an interview with DON on 03/30/22 at 11:42AM, she revealed there is no policy on tray checking for the nurses. She revealed nurses are trained during the hiring process to check meal trays before the tray gets passed to the residents. DON stated, during the hiring process the manager showing the new nurse around, will show them how they are assigned to checking meals but there is no check off sheet for training. She stated, It's an unwritten job description for the nurses to check food trays and meal cards as assigned during breakfast, lunch, and dinner before the trays are passed to the residents. She revealed all nurses know who is assigned to tray checking due to the schedule at the nurses' station. She revealed, it's important to check meal trays and meal cards, to make sure the residents receive the correct diet and meal textures because the resident can aspirate and choke. In an interview with Cook A on 03/30/22 at 12:38p.m she revealed Dietary Aide C was on the food line helping him on 03/28/22, so he is unsure who prepared the food plate for Resident #1. He revealed he always checks the tray cards and reads the diets on the trays to serve the residents the correct diets on their plates. He revealed he made the food plates to match the food cards and handed the plate to Dietary Aide C to put the food plate on the correct tray with the correct card. He is unsure how the resident got the wrong food, or where it was missed. Cook A stated, there are 4 trays in front of him at one time and he would look at the meal card for diet type and check for allergies then he will prepare all 4 plates and pass it to his dietary aide as another set of eyes to put the food on the correct tray. He revealed it's important to make sure the resident gets the right diet to ensure the resident doesn't choke or have an allergic reaction. In an interview with Dietary Aide C on 03/30/22 at 1:05PM she revealed he was placing resident's food plates on the food trays on 03/28/22. He revealed, Cook A made the plate and handed him the plate to put on the tray. He stated, he put the plate on the tray and did not check Resident #1 meal card and diet because he thought Cook A had checked to make sure the food plate and meal card matched. He revealed it's the job of everyone in the kitchen to double check the resident's meal card and food plate to make sure the resident gets the right diet, but the kitchen staff missed that tray. He stated after the kitchen staff pass the trays to the nurses, he believes it the nurse's job to check the trays to make sure everything is correct before the tray gets to the resident. He revealed it's very important to check the food plate with the resident's meal card, to prevent issues with the residents, and to prevent choking. Dietary Aide C revealed he was just in-serviced today on checking meal card and food plates. In an interview with the Administrator on 03/30/22 1:40P.M he revealed there has not be an incident like this for the three years he has worked at the facility. He revealed there is no policy for checking the meal trays or meal cards, but it's a daily assignment for the charge nurses. He revealed it is the assigned nurse that is in charge of verifying the meal cards and meal trays to ensure the appropriate diets and textured meals are served to the residents. The administrator revealed they have a monitoring system in place, but it was not carried out on 03/28/22. He stated all the nurses were being re-educated about checking meal trays and would have a back-up nurse to be in the kitchen to receive the meal trays and check them, if the assigned nurse can't make it. He revealed the Dietary Manager was working on formalizing a duty plan for the dietary aides. The plan will ensure meal trays are double checked before the trays leave the kitchen. The nurse managers will stay for the dinner meal to check the trays. The administrator revealed it is the charge nurse's responsibility to check the trays and pass the tray to the CNAs to give to the residents. The nurses should be looking at the resident's meal card and observing the food texture is correct, the likes and dislikes, and the allergies are correct. It's important to check the meal trays prior to serving to the resident because they want to make sure they are following the physician orders, prevent choking, prevent allergic reactions, or a negative outcome. In an interview with CNA D on 03/30/22 at 4:44 p.m., she revealed on 03/28/22 during her 2pm-10pm shift, she was assigned to the hall Resident #1 was located on. She revealed she was working during the incident with Resident #1. CNA D stated, she was helping another resident, when she heard the trays arrive to the hall. By the time she exited the room she was in, hall trays were already being passed by other CNAs. She was able to assist in passing only two trays and she did not pass Resident #1 his tray. She revealed she passed hall trays to the residents because she assumed the LVN A had checked hall trays since the tray cart was on the 200-hall being passed. CNA D revealed it was the charge nurses and managers on duty's job to check food trays before passing them to staff. The staff passing the trays to the residents should uncover and set up food trays for the resident and peek at the food to make sure it's the same as the resident's meal card diet. Record review of Dietary's undated Tray line checklist and menu compliance policy documented: -3. Be aware of what steps to take before each meal to ensure that the trays are accurate, menu are followed, and food quality is maintained. Due to the above failure, the facility Administrator was notified of the IJ on 3/30/22 at 4:33p.m.; they were given the IJ template; and a plan of removal was requested. Received the Plan of Removal [POR] from Administrator via email on 03/31/22 at 8:56 AM. Confirmed with the Administrator on 03/31/22 at 9:15 AM about reviewing the facility's Plan of Removal. The facility provided a Plan of Removal which revealed the following: o On 3/29/22 all nurses were re-educated regarding checking each resident's tray card to ensure that the diet is served as ordered. o On 3/29/2022 administrator ensured that no meal since the incident has gone without all residents' trays being checked by a nurse prior to serving to residents. o On 3/29/2022, during morning Start-up Meeting with the Management Team, administrator discussed the incident and brainstormed to develop procedures to help ensure that each resident's tray card is checked by a nurse to ensure that the diet is served as ordered. o On 3/29/2022, during morning Start-up Meeting with the Management Team, Administrator reiterated that the manager on duty is to ensure that the nurse assigned dining room duty is in the dining room and that they review tray cards to trays prior to trays being served or sent to the hallways. o On 3/29/2022, during morning Start-up Meeting with the Management Team, Administrator discussed with dietary manager that trays are not to be sent out until a nurse has reviewed the trays. o On 3/29/2022, administrator met with the cook who was serving the night of the incident to discuss what went wrong and how we can ensure that it does not happen again. This discussion included root cause analysis and developing ideas for actions to implement in the plan of correction for the incident. o On 3/31/2022, nurse managers developed a schedule to assign a back-up nurse for each meal to make sure each resident's tray card is reviewed to ensure that the diet is served as ordered. o Re-educated CNAs on 3-30-22 to set up tray when delivered and observe that diet card and meal served match. o Re-educated CNAs on 3-30-22 not to serve meal trays before a licensed nurse has checked the tray. The nurse on dining room duty will check the carts in the dining room and communicate to the CNAs when the trays have been checked and are available to be taken to the halls or delivered to the residents in the dining room. o Dietary cooks and aides re-educated on 3/30/22 regarding checking each resident's tray card to ensure that the diet is served as ordered. o Re-educated dietary personnel on 3/30/22 to hold trays until nurse has checked them. o Dietary manager will audit tray line for accuracy at least weekly and re-educate staff as needed. o Dietitian will continue to audit tray line for accuracy at least monthly, re-educate staff as needed and provide administrator with a report upon exit. o Dietary staff will be in-serviced quarterly regarding tray cards and diets. o Managers on duty in-serviced on 3-30-22 on making sure nurse is checking each resident's tray card to ensure that the diet is served as ordered. o Director of nursing and nurse managers audited all meal tickets with Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . o Dietary manager will audit all meal tickets with Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . o All dietary department employees have been re-educated on 3-30-22. All managers on duty have been in-serviced on 3-30-22. o Re-education of all nurses and CNAs will be completed by 3-31-22. o Any nursing staff and dietary staff who were not on duty and unable to attend the required in-services will be re-educated before the start of their next shift. On 3/30/2022, an ad hoc Quality Assurance Performance Improvement Meeting was held with the Management Team to discuss the incident and procedures to help ensure that each resident's tray card is checked by a nurse to ensure that the diet is served as ordered. Elements of the above plan were discussed along with plans to implement. Surveyor Verification of Plan of Removal was as follows: During monitoring for POR an observation on 04/1/22 at 7:20 AM revealed dietary staff and Dietary managers were reading meal cards prior to serving the food onto a plate. The plates were noted being double checked by Dietary manager for accuracy before placing the food cart at the front of the kitchen near the door. LVN K was noted at the kitchen door to receive food cart. LVN K compared meal cards to the food and beverages placed on the tray. After, LVN K passed the cart to staff that consisted of CNAs, Nursing staff, and managers, who pushed the cart to the halls to be passed to residents. During an observation on 04/1/22 at 7:51AM food trays were being passed by staff on hall 300. It was revealed CNA F was checking the meal card and food plates and was noted setting up tray for multiple residents. In an interview on 04/1/22 at 8:26 AM with the Administrator. He revealed the DON and nurse managers on 3/30/22 had audited all residents tray cards to resident's diet orders and verified all ordered diets are printed correctly on the resident's tray cards. Record review on 04/01/22 of facility's Daily Meeting Agenda on 3/29/22 documented: Mandatory- trays are not to leave dining room until checked by nurse. no exceptions!! sign in documented 7 nurses in attendance. Record review on 04/01/22 of facility's Daily Meeting Agenda on 3/30/22 documented: Mandatory- If you don't have hall duty, must be in dining room to help pass hall trays, trays should not be passed out until nurse checks them. All people that require assistance must be up in dining room unless approved to be in room. Sign in revealed 14 CNAs in attendance. Record review on 04/01/22 of facility's Daily Meeting Agenda on 3/30/22 documented: Mandatory- Charge nurses must be in dining room to check trays (if assigned) prior to leaving the kitchen, how to properly read meal cards. If you are assign dining room duty, prioritize time and be there. No exceptions!! If you can't go to dining room. Find another nurse to go to dining room. Sign in revealed 6 charge nurses in attendance. Record review on 04/01/22 of facility's Daily Meeting Agenda on 3/30/22 documented: Mandatory- Ensure that nurses are checking tray cars to ensure proper diets are being served and ensure that a nurse is in the dining room. Sign in revealed 13 CNAs in attendance. In an interview with DON on 04/01/22 at 9:20AM revealed there are 15 charge nurses employed at the facility, and all expect 1 have been re-educated on checking meal cards and trays for accurate diets. The charge nurse that has not been re-educated was not answering calls and has not showed up for work. DON revealed all staff who have not been re-educated on checking meal cards and trays for accurate diets, will be re-educated before they return for their next shift. Record review of the facility's Daily position sheet dated 03/31/22 and 04/01/22 documented day, evening, and night shift employees, along with the name of the charge nurse assigned to breakfast, lunch, and dinner duty. It also noted a backup nurse for breakfast, lunch, and dinner duty. Record review on 04/01/22 of dietary's Food and Nutrition services in-service sign in sheet dated 3/30/22 documented presenter: Dietary Manager. Topic: Tray line checklist and menu compliance. Dietary supervisor in-serviced all dietary staff on the importance of accurately reading tray cards. Dietary supervisor noted that the responsibility of ready tray cards accurately lies on all staff who are working during the meal service in the kitchen, which includes Dietary supervisor, cook, dietary aides, and dishwashers. Dietary supervisor also went over the dangers of sending out inaccurate diet/diet textures to residents which can cause them to choke, aspirate, or even death. Dietary supervisor informed all staff that trays should not go out of kitchen until a nurse is at the door to check and ensure all tray cards are accurate. Signed by 8 dietary staff. Record review on 04/01/22 of dietary's Food and Nutrition services in-service sign in sheet dated 3/30/22 documented presenter: Dietary manager. Topic: Diet Textures, L2-Mechanical, L3 advance, puree diets. Signed by 7 Dietary staff. On 03/31/22 and 04/01/22 beginning at 9:40 am 8 nurse staff from different shifts were interviewed on effectiveness of in-services on reviewing dietary cards/trays for accuracy on current diet texture, Charge nurses must be in dining room to check trays (if assigned) prior to leaving the kitchen, and how to properly read meal cards. All 8 staff responded being knowledgeable on checking meal tray cards and resident meal trays for accuracy. On 4/01/22 beginning at 11:10 a.m. 6 dietary staff were interview on effectiveness of in-services on importance of accurately reading tray cards, the responsibility of reading tray cards accurately lies on all staff who are working during meal service in the kitchen, and the dangers of sending out inaccurate diet/diet textures to resident. All 6 staff responded being knowledgeable on checking meal trays and meal cards for accuracy. On 4/01/22 at 4:42 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as a pattern until interventions were put in place for all residents who required specialized textured diets as ordered by their physician, and to ensure the safety of residents from serious injury and even death.

Based on interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one of five residents (R#1) reviewed for accidents in that: The facility failed to provide supervision to R#1 when R#1 fell nine times in a six-month period. This deficient practice could place residents who require supervision at risk of accidents or injury. The findings were: Record review of R#1's Admission Record, dated 01/28/2021, revealed R#1 was an [AGE] year-old female and was admitted to the facility on [DATE]. R#1 was re-admitted on [DATE]. R#1's [DIAGNOSES REDACTED]. Record review of R#1's quarterly MDS, dated [DATE], revealed R#1: -cognitive status was severely impaired, -required total assistance of one-person physical assist for bed mobility, locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair), locomotion off unit (how resident moves to and returns from off unit locations, e.g., areas set aside for dining, activities or treatments.), dressing, eating and personal hygiene. -uses wheelchair as mobility device, -had two falls with no injury since admission or re-entry, Record review of R#1's Care Plan, revised 01/18/21, revealed a problem, -8/29/20-fall with injury; skin tear to right upper extremity, -9/15/20-unwitnessed fall no injuries, -10/30/20-Unwitnessed fall; fell from w/c trying to pick up a donut off the floor, -11/26/20-Fall, no injury, -12/07/20-Fall- no injury, -12/27/20- Fall with discoloration to right hand, -1/4/21-Witnessed fall w/o injury, -1/15/21-Witnessed fall with injuries. Interventions included; -9/15/20-neuro checks, PT screening referral, -10/30/20-to be seen by PT services, -11/26/20-neuro checks, -12/7/20-resident completed PT services- -12/27/20-continue with low bed with floor mat for safety, concave mattress for safety, -1/15/21- send to ER for evaluation and treatment neuro checks, large frontal scalp hematoma and small area of soft tissue injury at the bridge of nose, -1/18/21-implement tilt & recline w/c for safety, -1/22/21-monitor hematoma to forehead daily until resolved. Record review of the facility policy titled Fall Risk revised December 2017 indicated; Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff will identify interventions to reduce the risk of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on the assessment of the nature or category of falling. Record review of form titled Fall Risk Evaluation for R#1 dated 11/26/20 indicated a score of 13 which was categorized as high risk for falls. Record reviewed of form titled Fall Risk Evaluation for R#1 dated 01/15/21 indicated a score of 15 which was categorized as high risk for falls. Record review of Incident Reports for R#1 indicated; -8/27/21- resident found sitting on the floor on her bottom, leaning against her bed. No injuries noted at time of accident. -08/29/20-resident found sitting on floor against roommate's plastic shelve containers. Noted with skin tear and purple discoloration to right forearm. -9/15/20-resident found on floor by bathroom. No injuries noted. -10/04/20-received left hip x-ray results from x-ray showing evidence of left femoral neck fracture. Received orders to send to ER. -10/30/20-resident found sitting in front of her wheelchair, next to her bed. No injuries noted. -11/26/20-resident found sitting on floor by dining table with w/c behind her with brakes unlocked. No injuries noted. -12/07/20-resident found sitting on floor in front of dining table, w/c behind her with brakes unlocked. No injuries noted. -12/27/20-resident found sitting on her bottom at her doorway looking out of room, leaning against door. No injuries noted. -01/04/21-resident observed by nurse standing in doorway starting to fall, nurse immediately ran to help but was unable to reach her. Resident had a fall, landing on her right hip. Resident crying with facial grimacing while being assessed, sent to ER. Sustained right hip injury. X-ray results made on left hip instead of right hip. No fracture to right or left hip was found. -01/08/21-noted resident with skin tear. -01/15/21- cook notified nurse of a fall in dining room. Upon assessment, noted resident lying on floor on her back by the table, laceration to the nose and forehead. Received orders to send out to ER. Investigation indicated dietary cook notified nurse resident had fallen in the dining room. Observation of R#1's bedroom on 01/27/21 at 8:35 a.m. revealed resident not in room. Low bed against the bed with bolsters on each end, with a floor mat on floor. Observation on 01/27/21 at 3:52 p.m. revealed R#1 in her bed. Deep laceration to head with dark discoloration surround the laceration were visible. R#1 appeared confused and did not respond to surveyor greeting. Interview on 01/28/21 at 1:44 p.m. with Dietary Cook B revealed he reported to charge on 01/15/21 that R#1 was on the dining room floor. Dietary Cook B said Dietary Aide C went into kitchen to tell him that a resident was on the floor. Dietary Cook B said he ran to tell the charge nurse at nurse's station. Interview on 01/28/21 at 2:02 p.m. with Dietary Aide C revealed she was in the dining room picking up dirty dishes to take to into the kitchen around 6:20 p.m. on 01/15/21. Another resident asked her to bring him some sugar and she went into kitchen and as she returned into dining room, she saw R#1 standing by her wheelchair and fall down to the floor. No other staff member was in the dining room with residents. Dietary Aide C said she was not assigned to be with residents in the dining room. Interview on 01/28/21 at 2:10 p.m. with the DON revealed Dietary Cook B had told her that Dietary Aide C had seen the resident fall. A CNA was outside the dining room in the patio with glass doors facing the dining room. On 01/28/21 at 4:50 p.m. the DON said she could not remember who the CNA was outside the patio by dining room. The DON said CNA was on her break and she was smoking and looking into dining room through glass doors. The DON said beginning January she had started assigning staff to be in the dining room when residents were in the dining room. The DON said she did not know who had been assigned on 01/15/21 to be with residents while in the dining room. The DON said she didn't know if this CNA was assigned to supervise the residents in the dining room at time of incident. The DON was unable to provide information regarding her plan to assign supervision to resident while they were in the dining room. On 01/28/21 at 10:53 a.m. interview with ADON/LVN A revealed the DON and she would update all care plans as needed. ADON/LVN A stated when a resident had a fall, interventions were developed and implemented on the care plans. R#1's care plan had been updated and revised with new interventions and were listed in her care plan. New interventions had included, PT services, neuro-checks, UA collected, implement tilt and recline wheelchair. On 01/28/21 at 11:43 a.m. interview with the DON revealed modifications to R#1's wheelchair was made. A different wheelchair was provided with a tilted seat back and the back-rest tilts back to help sitting better to prevent her from standing but able to propel in her wheelchair. Anti-tippers were installed for when resident tries to stand, the wheelchair will not slide from under her. We referred R#1 to therapy for a custom wheelchair but that took time to receive. The cushion on her wheelchair was changed. The DON said they were trying to modify R#1's wheelchair to prevent her falls and injuries. Interview on 01/28/21 at 8:49 a.m. with CNA D revealed when R#1 was in bed, she made sure her bed was low and a mat on the floor. CNA D said she would re-direct R#1 since she tries to get up from chair. R#1's wheelchair had anti-roll back. Anti-rolls did not prevent R#1 from getting up but does prevent wheelchair from rolling back if she attempts to get up. Staff usually take resident to dining room and most times there is someone there with residents. CNA D said she tried to keep an eye on resident because she has had several incidents of falls. On the last fall R#1 sustained a laceration and received stitches on her injury. On 01/28/21 at 3:13 p.m. interview with CNA E revealed R#1 did try to get up a lot and had had several falls. R#1 attempts to get up from her new wheelchair, when in dining room. Staff must be in the dining room always when a resident is in the dining room. On 01/28/21 at 3:00 p.m. interview with CNA F revealed there should always be someone supervising residents while in the dining room.

Based on interview and record review, the facility failed to ensure that all alleged violations involving neglect were reported immediately to the State Survey Agency, for one Resident (R#1) of five residents reviewed for neglect. The facility did not report to the State Survey Agency when R#1 sustained a laceration to the forehead. This failure could place residents at risk of neglect. The findings were: Record review of the facility policy titled Abuse, Neglect and Exploitation Policy revised on December 2017 indicated Suspected violations and all substantiated incidents of abuse will be reported to appropriate state agencies and other entities or individuals as may be required by law within the first 2 hours. Should a suspected violation or substantiated incident of neglect, injuries of unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility, i.e. Texas Department of Aging and Disability Services. Record review of form titled Fall Risk Evaluation for R#1 dated 11/26/20 indicated a score of 13 which was categorized as high risk for falls. Record reviewed of form titled Fall Risk Evaluation for R#1 dated 01/15/21 indicated a score of 15 which was categorized as high risk for falls. Record review of R#1's Admission Record, dated 01/28/2021, revealed R#1 was an [AGE] year-old female and was admitted to the facility on [DATE]. R#1 was re-admitted on [DATE]. R#1's [DIAGNOSES REDACTED]. Record review of R#1's quarterly MDS, dated [DATE], revealed R#1: -cognitive status was severely impaired, -required total dependence on one-person physical assist for bed mobility, locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair), locomotion off unit (how resident moves to and returns from off unit locations, e.g., areas set aside for dining, activities or treatments.), dressing, eating and personal hygiene. -uses wheelchair as mobility device, -had two falls with no injury since admission or re-entry, Record review of R#1's Care Plan, revised 01/18/21, revealed a problem, -1/15/21-Witnessed fall with injuries. Interventions included; -1/15/21- send to ER for evaluation and treatment neuro checks, large frontal scalp hematoma and small area of soft tissue injury at the bridge of nose, -1/18/21-implement tilt & recline w/c for safety, -1/22/21-monitor hematoma to forehead daily until resolved. Record review of Incident Reports for R#1 indicated; -01/15/21- cook notified nurse of a fall in dining room. Upon assessment, noted resident lying on floor on her back by the table, laceration to the nose and forehead. Received orders to send out to ER. Investigation indicated dietary cook notified nurse resident had fallen in the dining room. Observation of R#1's bedroom on 01/27/21 at 8:35 a.m. revealed resident not in room. Low bed against the bed with bolsters (vinyl-covered pillows that provide a secure position in bed) on each end, with a floor mat on floor. Observation on 01/27/21 at 3:52 p.m. revealed R#1 in her bed. A laceration to head with dark discolorations surrounding the laceration were visible. R#1 cognitive status was severely impaired and did not respond to surveyor greeting. Interview on 01/28/21 at 1:44 p.m. with Dietary Cook B revealed he reported to charge on 01/15/21 that R#1 was on the dining room floor. Dietary Cook B said Dietary Aide C went into kitchen to tell him that a resident was on the floor. Dietary Cook B said he ran to tell the charge nurse at nurse's station. Interview on 01/28/21 at 2:02 p.m. with Dietary Aide C revealed she was in the dining room picking up dirty dishes to take to into the kitchen around 6:20 p.m. on 01/15/21. Another resident asked her to bring him some sugar and she went into kitchen and as she returned into dining room, she saw R#1 standing by her wheelchair and fall to the floor. No other staff member was in the dining room with residents. Dietary Aide C said she was not assigned to be with residents in the dining room. On 01/28/21 at 4:50 p.m. the DON said she could not remember who the CNA was outside the patio by dining room. The DON said the CNA was on her break and she was smoking and looking into dining room through the glass doors. The DON said beginning January she had started assigning staff to be in the dining room when residents were in the dining room. The DON said she did not know who had been assigned on 01/15/21 to be with residents while in the dining room. On 01/28/21 at 3:13 p.m. interview with CNA E revealed R#1 did try to get up a lot and had had several falls. R#1 attempts to get up from her new wheelchair, when in dining room. Staff must be in the dining room always when a resident is in the dining room. On 01/28/21 at 3:00 p.m. interview with CNA F revealed there should always be someone supervising residents while in the dining room. On 01/28/21 at 1:28 p.m. interview with the Administrator/Abuse Prohibitionist revealed that resident's fall on 01/15/21 had been witnessed by Dietary Staff and he knew what had caused the injury of laceration to forehead. The Administrator/Abuse Prohibitionist said he did not have reasons to suspect neglect. He knew R#1 had several falls. The Administrator said he did not see a reason to report the incident to state office. On 01/28/21 at 4:50 p.m. interview with the Administrator/Abuse Prohibitionist revealed he did not report the incident because it was a witnessed fall by Dietary Aide C. We did investigate and questioned Dietary Cook B and Dietary Aide C. Dietary Aide C stated she saw the resident stand up from wheelchair and fall. Dietary Aide C was in the dining room at time of the incident picking up dishes from tables and based on these interviews that neglect had not occurred. Dietary Aide C was not assigned to monitor the residents that were in the dining room. Other CNAs were taking residents back to their rooms when resident fell .

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents, for three Residents (R#2, R3, R#4,) of seven residents reviewed for supervision. The facility did not provide supervision for residents in the physical therapy department. R#2, R#3, and R#4 were left unattended while doing exercises in the therapy department. This failure could place all residents receiving therapy in the therapy department at risk for injuries. The findings were: 1) Record review of R#2's Admission Record, dated 01/09/20 revealed R#2 was a [AGE] year-old female who was readmitted to the facility on [DATE]. R#2's [DIAGNOSES REDACTED]. Record review of R#2's Minimum Data Set (MDS) assessment, dated 11/18/19, revealed R#2: -had moderately impaired cognition, -required extensive assistance from staff with bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene, -had no range of motion impairment of upper and lower extremities, -received Speech-Language Pathology and Audiology Services, start date 11/13/19, -received Occupational Therapy, start date 11/13/19, and -received Physical Therapy, start date 11/13/19. Record review of R#2's Order Summary, dated 01/09/20 revealed: -Active order Physical Therapy (PT) clarification: Continue PT services at five times per week, times one - week order date 01/08/2020 -Active order PT clarification: Continue PT services at five times per week, times four weeks order dated 12/11/2019 -Active order PT clarification: continue PT services for five times per week, times four weeks . Order dated 11/13/2019 Record review of R#2's care plan, dated 11/12/19 and edited 12/31/19, revealed: Focus: Resident is at risk for impaired physical mobility r/t (related to) [MEDICAL CONDITION]. Interventions included: .PT, OT treatment as ordered . Record review of R#2's Occupational Therapy - Therapy Progress Report, dated 01/02/20 at 9:36 a.m., revealed: Assessment Summary: -Background - Precautions: Fall Risk, History (hx) of [MEDICAL CONDITION], anxiety, flight risk. -Supervision OT/assistant supervision . electronically signed by OT. Record review of R#2's Therapy Progress note, dated 01/08/20 at 2:38 p.m., revealed: Assessment Summary: -Background - Precautions: Depression, Anxiety, Diabetes Mellitus two (DM2), Restless Leg Syndrome (RLS), Fall Risk, flight risk/exit seeking, confusion, disorientation. -Supervision - PT/assistant supervision . electronically signed by PT. 2) Record review of R#3's Admission Record, dated 01/09/20 revealed R#3 was an [AGE] year-old female who was readmitted to the facility on [DATE]. R#3's [DIAGNOSES REDACTED]. There was no MDS assessment for R#3. Record review of R#3's Order summary, dated 01/09/20 revealed: -OT clarification order: DX: Right upper extremity fracture, requested [DIAGNOSES REDACTED]. OT plan of care seven times per week times four weeks . start date 01/03/2020 end date 01/31/2020. -PT clarification order: PT seven times per week times four weeks .start date 01/03/2020. Record review of R#3's care plan, dated 01/07/20, revealed: -The resident is at risk for falls -The resident has impaired visual function, wears glasses -The resident has a pathological bone fracture of right Humerus r/t status [REDACTED]. Record review of R#3's Occupational Therapy-Therapy Progress Report, dated 01/09/20 at 10:50 a.m., revealed: Assessment Summary: -Background - Precautions: Fall Risk, right upper extremity non-weight bearing, right upper extremity in sling, no- weight bearing right upper extremity, no range of motion to right upper extremity until orders received from doctor. -Supervision OT/assistant supervision . Electronically signed by OT. Record review of R#3's unsigned Therapy Progress note, date of service 01/03/20 to 01/09/20 revealed: Assessment Summary: -Background - Precautions: Right Upper Extremity non-weight bearing and no range of motion, mild cognitive declines, fall risk and history. -Supervision PT/assistant supervision . 3) Record review of R#4's Admission Record, dated 01/09/20 revealed R#4 was an [AGE] year-old male who was admitted to the facility on [DATE]. R#4's [DIAGNOSES REDACTED]. Record review of R#4's MDS assessment, dated 12/25/19, revealed R#4 was cognitively intact, required extensive assistance with bed mobility, transfers, and toilet use, and had no range of motion impairment for upper and lower extremities. Record review of R#4's Order summary, dated 01/09/20 revealed: -OT clarification order: DX: aspiration pneumonia, congested heart failure, chronic obstructed [MEDICAL CONDITION] disease, requested [DIAGNOSES REDACTED]. OT plan of care seven times per week times four weeks . start date 12/24/19 end date 01/21/2020. -PT clarification order: PT seven times per week times four weeks .start date 12/23/19. Record review of R#4's care plan, dated 12/13/19 with a revision 01/01/20, revealed: (R#4) has an ADL self-care performance deficit . Interventions included PT/OT evaluation and treatment. Record review of R#4's Occupational Therapy-Therapy Progress Report, dated 01/06/20 at 5240 p.m., revealed: Assessment Summary: -Background - Precautions: Fall Risk, pacemaker/defibrillator implant, oxygen at two liters per minute per nasal canula. -Supervision OT/assistant supervision Electronically signed by OT. Record review of R#4's Therapy Progress note, date of service 01/06/20 revealed: Assessment Summary: -Background - Precautions: fall risk, weakness, pacemaker/defibrillator implant. -Supervision PT/assistant supervision . electronically signed by PT. Observation on 01/09/20 at 8:25 a.m., revealed the Director of Rehab (DOR) was in the Speech Therapy Department, near the nurses station. The DOR stated he was available for interview at this time and walked with surveyor to a conference room near the front lobby of the facility. On 01/09/20 at 8:45 a.m., surveyor and the DOR concluded the interview and walked to the PT Department. Upon entering, the following was observed: -R#2 was seated in a wheelchair (w/c) with the back of the w/c up against the left wall. R#2 was utilizing step exerciser. -R#3 was seated in a w/c on the left side of the doorway. R#3 was utilizing a left hand pedal exerciser. -R#4 was facing the wall directly in front of the door to PT, utilizing the top of a stationary bicycle. -There was no staff present in the PT Department. In an interview on 01/09/20 at 8:45 a.m., when asked if residents were supervised in the PT department, the DOR stated, Someone from the department is to be in here. In an interview on 01/09/20 at 8:50 a.m., the COTA stated residents were not to be left alone in the therapy department. The COTA said she had left the therapy department to do in-room patient care and thought the DOR was in the department. The COTA said, of the three residents in the department, one was her patient, one was the DOR's patient and one was the PTA's patient. In an interview on 01/09/2020 at 8:52 a.m., the PTA said residents were not to be left alone in the therapy department, The PTA said she had left the therapy department to do in-room patient care and thought the DOR was in the department. The PTA acknowledged that one of the residents in the department unattended was her patient. In an interview on 01/09/20 at 9:01 a.m., the DON said she was not sure if residents needed to be supervised while in the PT department. The DON said surveyor would need to ask PT staff because PT was their own entity. In an interview on 01/09/20 at 9:05 a.m., the Administrator said he did not know if staff needed to be present while residents were in the PT department. The Administrator said he was not aware of a policy on supervision. In an interview on 01/09/20 at 9:41 a.m., the DOR stated facility protocol was that staff were present when residents utilized PT equipment. The DOR said the door was locked when patients were not in the PT department, No one has access to the department unless on therapy. In an interview on 01/10/20 at 12:55 p.m., the DON stated there was not a written policy on supervision.

Based on observation, interviews and record review, it was determined that the facility failed to ensure one Resident (R#1) of one resident with an ostomy received services that met professional standards. The facility did not have ostomy supplies available to meet R#1's needs as per Physician's Admission Order. R#1's [MEDICATION NAME] leaked urine onto his skin causing pain, redness, and maceration to the stoma site and surrounding area on his abdomen. R#1 was transferred to the hospital due to pain and irritation. The facility did not clarify Physician order [REDACTED].#1's sutures, and R#1 suffered pain and infection due to the sutures becoming embedded in his skin and requiring surgical removal. These failures affected one resident with special needs and placed two current residents with ostomies at risk for not receiving the specialized services and treatments which could cause complications and a decline in their health status. The findings were: Texas Administrative Code, Title 22, Part 11, Chapter 217, Standards of Nursing Practice: 217.11 The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; . (N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment; . 217.12. Unprofessional Conduct. The unprofessional conduct rules are intended to protect clients and the public from incompetent, unethical, or illegal conduct of licensees. The purpose of these rules is to identify unprofessional or dishonorable behaviors of a nurse which the board believes are likely to deceive, defraud, or injure clients or the public. Actual injury to a client need not be established. These behaviors include but are not limited to: (1) Unsafe Practice - actions or conduct including, but not limited to: (A) Carelessly failing, repeatedly failing, or exhibiting an inability to perform vocational, registered or advanced practice nursing in conformity with the standards of minimum acceptable level of nursing practice set out in Rule 217.11; (B) Carelessly or repeatedly failing to conform to generally accepted nursing standards in applicable practice settings; . (2) Failure of a chief administrative nurse to follow appropriate and recognized standards and guidelines in providing oversight of the nursing organization and nursing services for which the nurse is administratively responsible . (4) Careless or repetitive conduct that may endanger a client's life, health, or safety. Actual injury to a client need not be established. Review of R#1's face sheet revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R#1 was age 75. Review of R#1's Brief Interview for Mental Status from the Minimum (MDS) data set [DATE] revealed a score of 14 out of 15 points on Cognition (interviewable) and that he was able to make his needs known. Review of R#1's Notification of Pending Resident Admission indicated he was to be admitted to the facility on [DATE] for short term rehabilitation Medicare; Skilled PT (Physical Therapy) and OT (Occupational Therapy) to eval (evaluate). The notification also indicated R#1 would need [MEDICATION NAME] urinary bags. In an interview on 09/25/15 at 2:00 p.m., Licensed Vocational Nurse, (LVN) A said that she completed the assessment on R#1. LVN A said that R#1 was expected to be discharged from the hospital on [DATE] but his discharge was delayed until 08/20/15. Review of hospital After Visit Summary dated 08/20/15 revealed R#1 had undergone a Radical Cystectomy with Ideal Conduit (urinary diversion). In an interview on 09/24/15 at 4:00 p.m., R#1 said that he has had a [MEDICATION NAME] for over [AGE] years. R#1 said when he arrived at the facility, the nurses started using a brand of [MEDICATION NAME] supplies which were different than those that he usually used. R#1 said that the [MEDICATION NAME] bags were small, four to five inches wide and four to five inches long, and he used bags that were much longer. R#1 said that the glue on the ostomy wafer (bag and adhesive base plate) would not stick to his skin because it would get wet. R#1 said that all of the urine came out right away when he drank something. R#1 said he could not sleep and the urine leakage turned his skin red from top to bottom. In the interview on 09/24/15 at 4:00 p.m., R#1 said he could not eat at the nursing home as the smell of the urine made him feel too bad, and he also had pain in his stomach. R#1 said that his pain when he arrived at the nursing home was a 6 or 7, but it got worse. Hospital Discharge instructions dated 08/20/15 revealed Keep wound clean and dry. May apply dressing as needed BID (twice daily) to keep lower part of incision dry and clean; and For worsening symptoms/changing condition/problems or questions: Call the (hospital) Health Access Center . Review of admission orders [REDACTED]#4605) twice a month and prn; Empty [MEDICATION NAME] q (every) shift; Apply dry dressing to Suprapubic fold BID (twice a day) ; Apply [MEDICATION NAME] 100,000 units/gram powder to redness on incision site to suprapubic area BID X 7 d (seven days); Monitor staples to incision site QD (daily). Review of Medicare Nurse's Notes dated 08/20/15 revealed R#1's skin assessment included 9 staples to incision site below [MEDICATION NAME] site; Noted with redness, orders for [MEDICATION NAME] Powder BID; [MEDICATION NAME] bag connected to catheter bag extended to strap on leg. Review of R#1's [MEDICATION NAME] Care Plan dated 08/20/15 revealed Has [MEDICATION NAME]/risk for infection and/or skin breakdown, with interventions that included Notify MD (physician)/Family of any changes of skin R/T (related to) [MEDICATION NAME] and Notify MD/Family if S/S (signs/symptoms) occur. In an interview on 09/25/15 at 2:00 p.m., LVN A said that she completed the Admission Assessment for R#1 and on 08/20/15 she sent a communication note to all department heads that R#1 was coming into the facility on [DATE]. LVN A said that Central Supply, (CSUP) E, was advised via this communication note that R#1 needed [MEDICATION NAME] bags. In an interview on 09/24/15 at 2:20 p.m., CSUP E said that the procedure to obtain ostomy supplies for incoming residents was that the manager who brought in the patient put a slip in CSUP E's box a day or so before the patient arrived. CSUP E said that they only had one size of [MEDICAL CONDITION] bag and if they had to order ostomy supplies it could take up to three days, although they could get emergency supplies from the local hospital if needed. In the interview on 09/24/15 at 2:20 p.m., CSUP E showed surveyor a box of Natura [MEDICATION NAME] # 6 with [MEDICATION NAME] pouch # 5 and said that this was the type of [MEDICATION NAME] supplies that they were first using for R#1's [MEDICATION NAME]. Review of Medicare Nurses Notes dated 08/24/15 at 1:00 a.m. revealed R#1 was in bed and the [MEDICATION NAME] bag was leaking and was changed twice, but continued to leak out, and Will pass on in report that res (resident) may need a larger [MEDICATION NAME] bag. Review of 24 hour report dated 08/24/15 and 08/25/15 revealed under the follow up column that R#1 needed a larger [MEDICATION NAME] wafer. In an interview on 09/24/15 at approximately 3:00 p.m., Physical Therapist Assistant, (PTA) D, said R#1 refused therapy at the beginning because of abdominal pain and leakage from his [MEDICATION NAME] and PTA D said he brought it to the attention of CSUP E , for two or three days requesting [MEDICATION NAME] supplies that worked better. PTA D said CSUP E showed the nurse who was applying the [MEDICATION NAME] bag how to use a new wafer for the [MEDICATION NAME] after several days and R#1 did not have problems with leakage from the [MEDICATION NAME] site after that. Review of Physical Therapy Treatment Encounter Note dated 08/25/15 revealed Patient refused to continue due to pain at the abdominal region next to his [MEDICATION NAME] bag. Nurse was call(ed) and Nurse Practitioner ordered pain med and xrays. Poor tolerance to treatment today. Review of Physical Therapy Treatment Encounter Note dated 08/27/15 revealed Patient not able to finish session due to problems with his [MEDICATION NAME], leaking causing for him to get soil(ed), Patient verbalize(d) is very frustrated; Spoke with charge nurse central supply and charge nurse from afternoon shift; they worked on this matter and changed the bags and part of the [MEDICATION NAME]. Patient later afternoon was doing well no c/o (complaint of) of any leaks so far. In an interview on 09/24/15 at 10:30 a.m., LVN F said that she applied [MEDICATION NAME] powder to R#1's incision twice daily as his treatment nurse. She said that he moved the [MEDICATION NAME] around and it would leak. She said that it was difficult to put the [MEDICATION NAME] powder in the fold of R#1's abdominal skin. LVN F said that she came in one day and found that there was a lot of leakage from his [MEDICATION NAME] and R#1 covered it with a towel and refused to let her do a complete change, would only allow the wafer and stoma paste change. In an interview on 09/25/15 at 2:40 p.m., LVN G said that the [MEDICATION NAME] wafer that she was having to use was too small for R#1's opening in his skin. LVN G said that R#1's opening was oblong shaped and the wafer had a round opening so the bag would leak due to the wafer not fitting properly. LVN G said that the first day she worked with R#1 the [MEDICATION NAME] was leaking and she asked CSUP E for larger wafers. LVN G said that she asked for the larger wafers a second and third day and CSUP E said I'm waiting. LVN G said CSUP E showed her (LVN G) how to use [MEDICAL CONDITION] wafers and it worked well, but it had been three or four days that R#1 stayed wet off and on from the leakage. Review of Medicare Nurses Notes dated 08/27/15 revealed R#1's [MEDICATION NAME] was leaking and the nurse replaced it with a new [MEDICATION NAME] kit, and Bandage changed as well d/t (due to) saturated with urine (incision site). R#1 was complaining of moderate pain and was given prn Tylenol #3 for pain. In an interview on 09/25/15 at 2:20 p.m., CSUP E said that LVN G complained to her (CSUP E) that the [MEDICATION NAME] was leaking but it appeared that LVN G was not using the wafer and the ostomy bag correctly. CSUP E said she showed LVN G how to apply the wafer correctly and the leakage stopped. CSUP E said that she had given LVN G a [MEDICAL CONDITION] wafer that was larger than the original wafers that were used and this seemed to work better. CSUP E said that she ordered some ostomy kits, [MEDICATION NAME] # , that had the wafers attached to them, on 08/27/15. Review of Purchase Order dated 08/27/15 revealed 2 BX Pouch Ostomy 4 10/BY [MEDICATION NAME] (two piece system). In an interview on 09/25/15 at 2:30 p.m., Director of Nurses, (DON) B and CSUP E showed surveyor two wafers, both size 57mm with 2 ¼ inch opening, and said that both wafers were standard and could be used for R#1's stoma. Surveyor observed that one wafer was smaller in diameter and had less area to adhere to the skin. CSUP E said that the first wafer was the size that was used at the beginning and the larger wafer was eventually used, and said that there was no difference in the size of these wafers and bags that were used for R#1 and the wafer and bag that were in the [MEDICATION NAME] kit that was ordered by CSUP E on 08/27/15. Review of Pain Management Flow Sheet for August, 2015 revealed R#1 had pain rated at a 7 in right groin at 9:00 a.m. on 08/25/15 and was administered APAP #3; had pain rated at a 7 in right groin at 1:30 p.m. on 08/26/15 and was administered APAP #3; and had pain rated at a 6 in right groin at 1:30 p.m. on 08/28/15 and was administered APAP #3. Review of Progress Notes dated 08/25/15 revealed Family Nurse Practitioner, (FNP) C, assessed R#1 as having abdominal pain in the right lower quadrant and ordered a KUB (kidney, ureter and bladder x-ray). Review of Progress Notes dated 08/27/15 revealed FNP C assessed R#1 as having decreased right lower quadrant pain; Irritation/rash to surgical site poss (possible) 2 (secondary) leakage from [MEDICATION NAME] bag; UA (urinalysis) abnormal (chronic UTI-urinary tract infection); and TX (treatment) nurse waiting call back from surgeon to remove staples. In the interview on 09/25/15 at 2:30 p.m., DON B said that the usual practice for obtaining physician orders [REDACTED]. In an interview on 09/24/15 at 4:00 p.m., R#1 said that on 08/28/15 his wife told the nurses that R#1 had an infection and needed to see a physician. He was then taken to his physician's office on the afternoon of 08/28/15 and from there his physician told him to go to the emergency room at a local hospital. R#1 said that a surgeon at the hospital removed his staples from his incision and told him that the staples were embedded in his skin. R#1 said that he had no idea the staples were still in the incision and he felt immediate relief from the pain when the staples were removed. R#1 said that FNP C , should have done something about the staples sooner and he should have had them out in eight or nine days after the surgery, which was done on 08/10/15. R#1 said he could not move much after being in the facility for three or four days because of the pain. In an interview on 09/24/15 at 4:00 p.m., R#1 said that no one at the nursing home saw the five or six staples in his abdomen. R#1 said he had a lot of pain in the area of the staples and it was difficult for him to do therapy. R#1 said that the second time he was supposed to go to therapy, his stomach area hurt too badly and he told his wife, you need to get me out of here. R#1 said that the nurses would come once a day and put powder on the incision and would tell him, it will be all right. See what will happen next week. In an interview on 09/24/15 at 10:30 p.m., LVN F said that on the morning of 08/28/15 she observed that the redness on the incision site was down some but there was an oozing coming from inside the incision so she notified DON B. Review of physician's orders [REDACTED].Remove staples and retention sutures. And Patient transferred from scheduled MD (physician) Office visit to ER emergency room ) at MD's order. Dx (diagnosis): suture/wound infection. Review of R#1's hospital History and Physical dated 08/28/15 revealed R#1 was found to have moderately-severe [MEDICAL CONDITION] of the abdominal wall and was admitted to the hospital. Review of R#1's Hospital Consultation prepared by Physician H dated 08/28/15 revealed The area from the umbilicus inferiorly is a macerated (excessive amount of fluid remaining in contact with skin or surface of a wound for extended periods) area with multiple retaining sutures that have cut through the skin and deep in the subcutaneous tissue and he has a full complement of skin staples, some of which are totally buried in granulation tissue. There were multiple draining purulent (containing, consisting of, or being pus) sinuses of a yellow purulent fluid. Hospital Discharge Summary authentication on 09/04/15 indicated R#1 was discharged home. According to the Resident Census and Condition of Residents for 672, dated 09/22/15, there were two residents in the facility receiving ostomy care.

Based on observation, interviews and record review, the facility failed to ensure one Resident (R#1) of one resident with an ostomy received proper treatment and care. The facility did not have ostomy supplies available to meet R#1's needs. R#1's [MEDICATION NAME] leaked urine onto his skin causing pain, redness, and maceration to the stoma site and surrounding area on his abdomen. R#1 was transferred to the hospital due to pain and irritation. These failures affected one resident with special needs and placed two current residents with ostomies at risk for not receiving the specialized services and treatments which could cause complications and a decline in their health status. The findings were: Review of R#1's face sheet revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R#1 was age 75. Review of R#1's Brief Interview for Mental Status from the Minimum (MDS) data set [DATE] revealed a score of 14 out of 15 points on Cognition (interviewable) and that he was able to make his needs known. Review of R#1's Notification of Pending Resident Admission indicated he was to be admitted to the facility on [DATE] for short term rehabilitation Medicare; Skilled PT (Physical Therapy) and OT (Occupational Therapy) to eval (evaluate). The notification also indicated R#1 would need [MEDICATION NAME] urinary bags. In an interview on 09/25/15 at 2:00 p.m., Licensed Vocational Nurse, (LVN) A said that she completed the assessment on R#1. LVN A said that R#1 was expected to be discharged from the hospital on [DATE] but his discharge was delayed until 08/20/15. Review of hospital After Visit Summary dated 08/20/15 revealed R#1 had undergone a Radical Cystectomy with Ideal Conduit (urinary diversion). In an interview on 09/24/15 at 4:00 p.m., R#1 said that he has had a [MEDICATION NAME] for over [AGE] years. R#1 said when he arrived at the facility, the nurses started using a brand of [MEDICATION NAME] supplies which were different than those that he usually used. R#1 said that the [MEDICATION NAME] bags were small, four to five inches wide and four to five inches long, and he used bags that were much longer. R#1 said that the glue on the ostomy wafer (bag and adhesive base plate) would not stick to his skin because it would get wet. R#1 said that all of the urine came out right away when he drank something. R#1 said he could not sleep and the urine leakage turned his skin red from top to bottom. In the interview on 09/24/15 at 4:00 p.m., R#1 said he could not eat at the nursing home as the smell of the urine made him feel too bad, and he also had pain in his stomach. R#1 said that his pain when he arrived at the nursing home was a 6 or 7, but it got worse. Hospital Discharge instructions dated 08/20/15 revealed Keep wound clean and dry. May apply dressing as needed BID (twice daily) to keep lower part of incision dry and clean; and For worsening symptoms/changing condition/problems or questions: Call the (hospital) Health Access Center . Review of admission orders [REDACTED]#4605) twice a month and prn; Empty [MEDICATION NAME] q (every) shift; Apply dry dressing to Suprapubic fold BID (twice a day) ; Apply [MEDICATION NAME] 100,000 units/gram powder to redness on incision site to suprapubic area BID X 7 d (seven days); Monitor staples to incision site QD (daily). Review of Medicare Nurse's Notes dated 08/20/15 revealed R#1's skin assessment included 9 staples to incision site below [MEDICATION NAME] site; Noted with redness, orders for [MEDICATION NAME] Powder BID; [MEDICATION NAME] bag connected to catheter bag extended to strap on leg. Review of R#1's [MEDICATION NAME] Care Plan dated 08/20/15 revealed Has [MEDICATION NAME]/risk for infection and/or skin breakdown, with interventions that included Notify MD (physician)/Family of any changes of skin R/T (related to) [MEDICATION NAME] and Notify MD/Family if S/S (signs/symptoms) occur. In an interview on 09/25/15 at 2:00 p.m., LVN A said that she completed the Admission Assessment for R#1 and on 08/20/15 she sent a communication note to all department heads that R#1 was coming into the facility on [DATE]. LVN A said that Central Supply, (CSUP) E, was advised via this communication note that R#1 needed [MEDICATION NAME] bags. In an interview on 09/24/15 at 2:20 p.m., CSUP E said that the procedure to obtain ostomy supplies for incoming residents was that the manager who brought in the patient put a slip in CSUP E's box a day or so before the patient arrived. CSUP E said that they only had one size of [MEDICAL CONDITION] bag and if they had to order ostomy supplies it could take up to three days, although they could get emergency supplies from the local hospital if needed. In the interview on 09/24/15 at 2:20 p.m., CSUP E showed surveyor a box of Natura [MEDICATION NAME] # 6 with [MEDICATION NAME] pouch # 5 and said that this was the type of [MEDICATION NAME] supplies that they were first using for R#1's [MEDICATION NAME]. Review of Medicare Nurses Notes dated 08/24/15 at 1:00 a.m. revealed R#1 was in bed and the [MEDICATION NAME] bag was leaking and was changed twice, but continued to leak out, and Will pass on in report that res (resident) may need a larger [MEDICATION NAME] bag. Review of 24 hour report dated 08/24/15 and 08/25/15 revealed under the follow up column that R#1 needed a larger [MEDICATION NAME] wafer. In an interview on 09/24/15 at approximately 3:00 p.m., Physical Therapist Assistant, (PTA) D, said R#1 refused therapy at the beginning because of abdominal pain and leakage from his [MEDICATION NAME] and PTA D said he brought it to the attention of CSUP E , for two or three days requesting [MEDICATION NAME] supplies that worked better. PTA D said CSUP E showed the nurse who was applying the [MEDICATION NAME] bag how to use a new wafer for the [MEDICATION NAME] after several days and R#1 did not have problems with leakage from the [MEDICATION NAME] site after that. Review of Physical Therapy Treatment Encounter Note dated 08/25/15 revealed Patient refused to continue due to pain at the abdominal region next to his [MEDICATION NAME] bag. Nurse was call(ed) and Nurse Practitioner ordered pain med and xrays. Poor tolerance to treatment today. Review of Physical Therapy Treatment Encounter Note dated 08/27/15 revealed Patient not able to finish session due to problems with his [MEDICATION NAME], leaking causing for him to get soil(ed), Patient verbalize(d) is very frustrated; Spoke with charge nurse central supply and charge nurse from afternoon shift; they worked on this matter and changed the bags and part of the [MEDICATION NAME]. Patient later afternoon was doing well no c/o (complaint of) of any leaks so far. In an interview on 09/24/15 at 10:30 a.m., LVN F said that she applied [MEDICATION NAME] powder to R#1's incision twice daily as his treatment nurse. She said that he moved the [MEDICATION NAME] around and it would leak. She said that it was difficult to put the [MEDICATION NAME] powder in the fold of R#1's abdominal skin. LVN F said that she came in one day and found that there was a lot of leakage from his [MEDICATION NAME] and R#1 covered it with a towel and refused to let her do a complete change, would only allow the wafer and stoma paste change. In an interview on 09/25/15 at 2:40 p.m., LVN G said that the [MEDICATION NAME] wafer that she was having to use was too small for R#1's opening in his skin. LVN G said that R#1's opening was oblong shaped and the wafer had a round opening so the bag would leak due to the wafer not fitting properly. LVN G said that the first day she worked with R#1 the [MEDICATION NAME] was leaking and she asked CSUP E for larger wafers. LVN G said that she asked for the larger wafers a second and third day and CSUP E said I'm waiting. LVN G said CSUP E showed her (LVN G) how to use [MEDICAL CONDITION] wafers and it worked well, but it had been three or four days that R#1 stayed wet off and on from the leakage. Review of Medicare Nurses Notes dated 08/27/15 revealed R#1's [MEDICATION NAME] was leaking and the nurse replaced it with a new [MEDICATION NAME] kit, and Bandage changed as well d/t (due to) saturated with urine (incision site). R#1 was complaining of moderate pain and was given prn Tylenol #3 for pain. In an interview on 09/25/15 at 2:20 p.m., CSUP E said that LVN G complained to her (CSUP E) that the [MEDICATION NAME] was leaking but it appeared that LVN G was not using the wafer and the ostomy bag correctly. CSUP E said she showed LVN G how to apply the wafer correctly and the leakage stopped. CSUP E said that she had given LVN G a [MEDICAL CONDITION] wafer that was larger than the original wafers that were used and this seemed to work better. CSUP E said that she ordered some ostomy kits, [MEDICATION NAME] # , that had the wafers attached to them, on 08/27/15. Review of Purchase Order dated 08/27/15 revealed 2 BX Pouch Ostomy 4 10/BY [MEDICATION NAME] (two piece system). In an interview on 09/25/15 at 2:30 p.m., Director of Nurses, (DON) B and CSUP E showed surveyor two wafers, both size 57mm with 2 ¼ inch opening, and said that both wafers were standard and could be used for R#1's stoma. Surveyor observed that one wafer was smaller in diameter and had less area to adhere to the skin. CSUP E said that the first wafer was the size that was used at the beginning and the larger wafer was eventually used, and said that there was no difference in the size of these wafers and bags that were used for R#1 and the wafer and bag that were in the [MEDICATION NAME] kit that was ordered by CSUP E on 08/27/15. In an interview on 09/24/15 at 10:10 a.m., Family Nurse Practitioner, FNP C said that R#1 was picking at his [MEDICATION NAME] bag and the area around the bag was red but had no abcess when she looked at it on 08/25/15 and 08/27/15. FNP C said that R#1's wife requested that R#1 be prescribed [MEDICATION NAME] because he had been on [MEDICATION NAME] prior to his admission to the nursing facility, so an order for [REDACTED]. Review of physician's order [REDACTED].O. Apply [MEDICATION NAME] compound. Mix equal parts of A&D oint (ointment) and zinc oxide cream 460 gram tube of [MEDICATION NAME] to yield jar. Review of Pain Management Flow Sheet for August, 2015 revealed R#1 had pain rated at a 7 in right groin at 9:00 a.m. on 08/25/15 and was administered APAP #3; had pain rated at a 7 in right groin at 1:30 p.m. on 08/26/15 and was administered APAP #3; and had pain rated at a 6 in right groin at 1:30 p.m. on 08/28/15 and was administered APAP #3. Review of Progress Notes dated 08/25/15 revealed Family Nurse Practitioner, (FNP) C, assessed R#1 as having abdominal pain in the right lower quadrant and ordered a KUB (kidney, ureter and bladder x-ray). Review of Progress Notes dated 08/27/15 revealed FNP C assessed R#1 as having decreased right lower quadrant pain; Irritation/rash to surgical site poss (possible) 2 (secondary) leakage from [MEDICATION NAME] bag; UA (urinalysis) abnormal (chronic UTI-urinary tract infection); and TX (treatment) nurse waiting call back from surgeon to remove staples. Review of R#1's hospital History and Physical dated 08/28/15 revealed R#1 was found to have moderately-severe [MEDICAL CONDITION] of the abdominal wall and was admitted to the hospital. Hospital Discharge Summary authentication on 09/04/15 indicated R#1 was discharged home. According to the Resident Census and Condition of Residents for 672, dated 09/22/15, there were two residents in the facility receiving ostomy care.