Every finding on record at Longhorn Village

Based on observation, interview and record review the facility failed to ensure residents had the right to organize and participate in resident groups in the facility for 32 of 32 residents reviewed for resident rights.1. The facility failed to ensure resident council met on a regular basis.2. The facility failed to ensure a private space was provided for resident council meetings and failed to take reasonable steps to make residents aware of upcoming meetings in a timely manner.3. The facility failed to ensure the resident council met without (invited) staff present.These failures could place residents at risk of not being able to organize resident groups without interference to discuss and offer suggestions about facility policies and procedures affecting care, treatment and quality of life, support each other and plan and participate in activities.An observation and interview of the private dining room on 05/13/26 at 10:18 a.m. revealed there were six residents sitting in a chair or wheelchair. The Activities Director told the six residents they were attending a resident council meeting and handed out a typed piece of paper to each resident. The Activities Director said resident council met once a month. She also said she arranged resident council meetings. The state surveyor asked the Activities Director if she could leave the private dining room so the residents could meet without staff present. The Activities Director said, I knew you were going to say that. I know I'm not supposed to be present during resident council meetings, but I stay because I do not want to leave the residents unsupervised, just in case if they fall or need something. The state surveyor asked the six residents if they invited the Activities Director to attend the resident council meeting. The residents nodded their heads left to right (no) and some said, No. The state surveyor asked the residents if they wanted the Activities Director to be present during the resident council meeting. The Activities Director told the state surveyor and the residents she would leave the private dining room. During a group interview with six confidential residents on an undisclosed date and an undisclosed time., the residents revealed resident council did not meet on a regular basis and said, But we would like to meet once a month. They said they did not know they had a resident council before 05/12/26 (the day before). They also said the Activities Director told them on the morning of 05/13/26 that there was a resident council meeting they could attend. They said they did not know who the designated staff person was for assisting and working with resident council. The residents said the facility did not help with arrangements for resident council meetings. They said the facility did not inform them in advance where and when the previous and upcoming meetings were held. The residents said they did not know they could meet without staff present, if they desired. An observation of the 05/13/26 white, dry erase board next to the nursing station on 05/13/26 at 10:43 a.m. revealed the times for each resident event in the facility. Resident council was not listed. An observation of the May 2026 resident activities calendar posted in resident rooms on 05/13/26 at 1:44 p.m. revealed all resident activities on a daily basis. Resident council was not listed. During an interview with RN H on 05/13/26 at 2:19 p.m., the RN H revealed she did not know how often, where, and when resident council met. She also said the Director of Nursing arranged resident council meetings. She said the white, dry erase board next to the nursing station and resident activities calendar posted in each resident room informed residents in advance of where and when there were meetings. During an interview with CNA J on 05/13/26 at 2:25 p.m., the CNA J revealed she did not know how often, where, and when resident council met. She also said the Activities Director arranged resident council meetings. She said the white, dry erase board next to the nursing station informed residents of when and where daily activities and events took place. She also said the Activities Director also would come to some of the residents in the facility and informed them in person of when and where resident council meetings took place. During an interview with CNA D on 05/13/26 at 2:39 p.m., the CNA D revealed she did not know how often, where and when resident council met. She also said she did not know who arranged resident council meetings. During an interview with the DON on 05/14/26 at 2:20 p.m., the DON revealed she did not know how often, where and when resident council met. She said the Activities Director arranged the resident council meetings. During an interview with the SW on 05/14/26 at 3:08 p.m., the SW revealed the Activities Director arranged a resident council meeting once a month. He said he did not know where resident council met. He said resident council could meet without staff present if they desired. He also said he did not know resident council meetings were not arranged on a regular basis. He said he knew it was important for resident council to meet on a regular basis without staff present if they desired, had a private space to meet, be aware of upcoming meetings in a timely manner and said, It was their right to have the meetings so they could voice their concerns and so we know what we can do to fix those concerns.During an interview with the ADM on 05/14/26 at 3:31 p.m., the ADM revealed resident council meetings were held monthly. She said the Activities Director brought the residents together for resident council meetings. She also said she was not aware resident council meetings were not held monthly. She said she thought the residents' activities calendar and white, dry erase board at the nurse's station was how residents were informed of upcoming meetings. She also said she did not know the residents' activities calendar and white dry erase board did not include resident council meetings. During an interview with the AD on 05/14/26 at 4:39 p.m., the AD revealed no one informed her resident council meetings were not held once a month, residents did not have a private space to meet, residents were unaware of upcoming meetings, and residents could meet without staff present if they desired. She said she knew it was important for resident council to meet on a regular basis without staff present if they desired, had a private space to meet, be aware of upcoming meetings in a timely manner and said, We want to create an atmosphere where residents feel safe and can talk freely on issues they have. Record review of the facility's, undated, Federal Nursing Home Resident Rights, reflected, The resident had the right to personal privacy and confidentiality of his or her personal and clinical records. (1)Person privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups. Record review of the facility's, undated, Statement of Resident's State Rights, reflected, You have a right to: 7) complaint about the facility and to organize or participate in any program that presents residents' concerns to the administrator of the facility.

Based on observation, interview and record review the facility failed to ensure a resident had a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 32 residents' bedrooms (Resident #4) reviewed for a homelike environment. 1. The facility failed to ensure Resident #4's room did not have a hole in the wall. 2. The facility failed to ensure Resident #4's bathroom toilet's water did not run continuously. These failures could place residents at risk of not having a safe, comfortable, and homelike environment with comfortable sound levels.Record review of Resident #4's admission Record, dated 05/14/26, reflected a female who was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #4 was her own responsible party. Resident #4's medical diagnoses included senile degeneration of the brain (a progressive, age-related decline in mental function and brain cell health), dementia (a decline in mental abilities severe enough to interfere with daily life), insomnia, and she received hospice services. Record review of Resident #4's Annual MDS, dated [DATE], reflected she had 12/15 BIMS, which indicated she had moderate cognitive impairment. Record review of Resident #4's care plan, revised 03/28/26, reflected she was on sedative/hypnotic therapy related to difficulty sleeping. Staff were required to implement nonpharmacological interventions, which included providing a quiet environment. An observation and interview of Resident #4's room on 05/12/26 at 10:10 a.m. revealed there was a hole in her wall next to her recliner in her room. Resident #4's bathroom toilet consistently ran and made an unwanted, loud noise in the bathroom. Resident #4 revealed the hole in her wall next to her recliner in her room used to be bigger. She said she could not recall when she first noticed the hole in her wall and when the hole first appeared in her wall. She also said the hole in her wall was a little bit of a hole now. She said the hole in her wall did not bother her. She also said none of her visitors had concerns or issues about the hole in her wall. During an interview with Resident #4 on 05/13/26 at 1:33 p.m., Resident #4 revealed her toilet in her bathroom consistently ran water because the cap was stuck in the toilet. She said the staff were aware of her toilet running water and made an unwanted noise and did not pay attention to it. She also said she sometimes notified staff about her toilet making unwanted noise. She said the Maintenance staff did not look at or repair her toilet. She said the toilet making unwanted noise bothered and caused her to not be able to sleep at night. She said she felt irritated and tired because the toilet consistently made unwanted noise. She also said staff also did not pay attention to the hole in her wall. She said the Maintenance staff repaired the hole in her wall when it was a bigger hole, but they did not repair the small hole. During an interview with RN H on 05/13/26 at 2:16 p.m., RN H revealed she did not receive any concerns or issues about toilets making consistent, unwanted noise and holes in walls of residents' rooms. She said she would file a work order and submit it to the maintenance staff if there were any physical environment issues. She also said she knew it was important to ensure residents had a safe and comfortable environment and said, It's important because resident safety. Residents could be at risk of an accident or fall. During an interview with CNA J on 05/13/26 at 2:25 p.m., CNA J revealed maintenance staff repaired physical environment concerns or issues. She said she would notify maintenance staff if she observed or received any physical environment concerns or issues. She said she did not observe or receive any concerns or issues about residents' toilets making unwanted noise in their rooms and residents' walls having holes in their rooms. During an interview with CNA D on 05/13/26 at 2:39 p.m., CNA D revealed maintenance staff repaired physical environment concerns or issues. She said she would notify the charge nurse if she observed or received a physical environment concern or issues. She explained the charge nurses filed and submitted work orders to maintenance and maintenance repaired the physical environment concerns or issues. She said she knew it was important for residents to have a safe and comfortable environment and said, To prevent injury or falls and for accident prevention measures. During an interview with RN I on 05/13/26 at 2:52 p.m., RN I revealed nurses filed and submitted work orders for physical environment concerns or issues. She said the maintenance staff then repaired and resolved the physical environment concerns or issues. She also said she did not observe or receive any physical environment concerns or issues from residents. She said she did not observe any holes in the walls of residents' rooms. She also said she did not observe any residents' toilets making consistent, unwanted noises in residents' rooms. During an interview with the the MD on 05/14/26 at 12:09 p.m., the MD revealed he oversaw maintenance and housekeeping. He said the staff notified the receptionist whenever there was a physical environment concern or issue, the receptionist or designee filed and submitted the work order, and maintenance received and assigned the work orders. He also said all residents, families, staff and maintenance staff had an electronic application to independently file work orders. He said the maintenance staff did not perform daily rounds to ensure residents had a safe and comfortable environment. He explained the nursing staff performed daily rounds to ensure residents had a safe and comfortable environment. He said the maintenance staff monitored the work order logs every 10-15 minutes daily. He also said the maintenance staff entered notes whenever they completed the work orders. He said he followed-up with maintenance staff to ensure work orders were completed. He also said there were no work orders related to holes observed in walls in residents' rooms. He said toilets making consistent, unwanted noise were common and got repaired right away. He also said he was unsure if he received any work orders related to Resident #4's room. He said he knew it was important for residents to have a safe and comfortable environment and said, It's their home. We (staff) need to know when things were wrong. We rely on nursing staff to file and submit work orders. We have two maintenance staff. It's to improve and maintain quality of life. Residents could become agitated when physical environment concerns or issues were unresolved or not repaired.During an interview with TN K on 05/14/26 at 1:29 p.m., TN K revealed either residents or CNAs reported physical environment concerns or issues. She said the nurses filed work orders and notified the maintenance staff of physical environment concerns or issues. She also said she could switch residents to another room if the physical environment concern or issue placed them in danger. She said she expected staff to round often on residents' rooms to ensure residents had a safe and comfortable environment. She also said she did not observe or receive any concerns or issues about residents having holes in their walls in their rooms and residents' toilets consistently making unwanted noise in their rooms. She said she knew it was important to ensure residents had a safe and comfortable environment and said, Because this is their home. Residents should be comfortable in their home. Residents could be at risk of losing sleep and become irritated. During an interview with the DON on 05/14/26 at 2:20 p.m., the DON revealed she expected staff to notify the Concierge and said, So physical environment concerns or issues could be addressed as soon as possible. She said the Concierge, Receptionist, maintenance staff and security staff knew how to file and submit work orders. She said she expected the receptionist to file and submit work orders because the Concierge was out from 05/11/26 through 05/15/26. She also said she did not receive any longstanding physical environment work orders and was not aware of any holes in residents' room walls and toilets making unwanted noise before 05/12/26. She said she was informed there were holes in residents' walls the night of 05/13/26, performed an audit, and found there were two other residents' rooms who had holes in walls. She also said she knew it was important to ensure residents had a safe and comfortable work environment and said, To decrease risk of injuries, exposure, contaminants and respiratory issues. To also ensure there are no electric trip or fire hazards. Residents could be at risk of cognitive deficits, falls and decrease in care participation. During an interview with the SW on 05/14/26 at 3:08 p.m., the SW revealed all staff were responsible for notifying maintenance staff about physical environment concerns or issues. He said all managers filed and submitted work orders. He also said he learned of the hole in two residents' room walls in November or December 2025. He said he did not receive any other inquiries about physical environment. He also said he knew it was important to ensure residents had a safe and comfortable environment and said, Generally, this was their home. Once they come here, they should be comfortable, and that all comes down to safety. It's an order. During an interview with the ADM on 05/14/26 at 3:31 p.m., the ADM revealed anyone who observed physical environment concerns or issues should report to the charge nurse, manager on duty, Concierge, and the leadership team. She said she expected staff to notify the maintenance staff and file physical environment work order concerns or issues daily. She also said the staff also discussed physical environment concerns or issues during stand-up meetings. She said she learned of holes in residents' walls on 05/13/26. She explained she was aware of the holes in residents' walls in January 2026 . She also said she knew it was important to ensure residents had a safe and comfortable environment and said, This is their home. To be happy with their place of living. Residents could be at risk of dissatisfaction with their living environment and become frustrated with a running toilet making unwanted noise. I would be frustrated if I heard a toilet running all night. Record review of the facility's Grievances from April 2025 through May 2026 reflected there was no documentation related to Resident #4's room. Review of the facility's Event Logs from November 2025 through May 2026 reflected there were no physical environment related events. Record review of the facility's Work Orders from April 2026 through May 2026 reflected there were none related to Resident #4's toilet consistently making unwanted noise and Resident #4's wall having a hole. Record review of the facility's, undated, Federal Nursing Home Resident Rights, reflected The resident has a right to a dignified existence.Record review of the facility's, undated, Statement of Resident's State Rights, reflected You have the right to: (2) safe, decent, and clean conditions.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen.The facility failed to ensure food safety by not consistently monitoring, discarding expired food, not labeling and dating food items in the kitchen, and keeping chemicals out of the kitchen prep area. These failures can place residents at risk for foodborne illness. Observation in the kitchen on 5/12/2026 at 9:15 AM of REF 1 reflected the following: -Lemon juice with an expiration date of 4-12-2026-Shredded cheese in a Ziplock bag with no open or use by date. -Clear container with an unknown sauce with no open or use by date on the container. -Clear container of chopped garlic with an open date of 4-30-2026 and a use by date of 5/7/2026. -Beef base with an open date of 4-30-2026 and a use by date of 7-30-2026. The printed manufacture use-by-date of 2-4-2026. Observation in the kitchen cooking area 5/12/2026 at 11:35 AM reflected there was Cleaning chemicals being stored under the flat-top griddle in the kitchen food preparation area. An interview on 05/14/2026 at 1:43 PM with DA-E. The DA E stated that everyone was responsible for checking the dates on food in the kitchen, checking for out of date items, and it was everybody's responsibility to label and date items in the kitchen. The DA E stated that they check for out-of-date items in the kitchen daily. The DA E stated that she did not realize that there was some out-of-date items or items that were not labeled in the refrigerator. The DA E stated if she saw out-of-date items, she throws them away and notified the DM. The DA-E stated that stated that chemicals should not be kept in the food prep area. The DA E stated that She has had in this training on labeling and dating items in the kitchen. The DA E stated that the last time she had in service training was about six months ago. The DA E stated that staff have that training once a year. An interview on 05/14/2026 at 1:57 PM with DA G. The DA G stated that it is everyone in the kitchen's responsibility to Label and date food items in the kitchen. The DA G stated that If she sees an item that was not labeled or dated correctly, or out of date then she will remove that item and discard it into the trash. The DA G stated that she would then tell the DM about the outdated item that was thrown away. The DA G stated that she has had in service training on labeling and dating food items in the kitchen. The DA G stated that They have in service training on labeling and dating one time a year. The DA G stated that She has had in service training on labeling and dating a few months ago. The DA G stated that she does not know the policy for keeping chemicals in the kitchen food prep area.An interview on 05/14/2026 at 1:57 PM with CK A. The CK A stated that everyone should be labeling and dating food in the kitchen. The CK A stated that all food items should be labeled. The CK A stated that the refrigerator was checked daily when he was working. The CK A stated that he was not aware of the food items that were not labeled or out of date. The CK A stated that there could be a Food-borne illness or death if residents are served food items that are out of date. The CK A stated that stated that chemicals are supposed to be stored in the mop room and not in the food prep area. The CK A stated that he did not know the policy of not having chemicals stored in the food prep area. The CK A stated that he has had in-service training on labeling & dating and infection control. An interview on 05/14/2026 at 2:06 PM CK B stated that everyone was responsible for labeling and dating food in the kitchen. The CK B stated that food was rotated daily when it was brought from the main kitchen. The CK B stated all food should be labeled and dated in the kitchen. The CK B stated that they use the first out where old food goes in front and new food goes in the back. The CK B stated that that he did not know chemicals could not be in the food prep area. The CK B stated that in the past surveys he was not told that chemicals could not be in the food prep area. The CK B stated that chemicals should be kept in the utility room. The CK B stated that residents could get sick if they consumed out of date food, ate food that hair fell into, or ate food contaminated with chemicals. The CK B stated that stated that he has in-service training on labeling and dating and infection control. The CK B stated that the last time he had in-service training was about 6 months ago. An interview on 05/14/2026 at 2:06 PM the DM stated that it was expected for all staff in the kitchen to be labeling and dating food items in the kitchen. The DM stated that Kitchen staff are to check for out of date items in the kitchen daily. The DM stated that All chemicals should be stored in the mop closet, and not in the food prep area. The DM stated that chemicals could get into food, or if residents are served food that was out of date. The DM stated that Staff are trained yearly on labeling and dating food items in the kitchen. An interview on 05/14/2026 at 3:33 PM The ADM stated that it was her expectation that all staff in the kitchen label and date food items. The ADM stated that Chemicals should not be stored in the food prep area, and the chemicals should be kept in the storage closet. The ADM stated that residents could get sick if these things are not followed. The ADM stated that all staff that work in the kitchen should be trained on labeling and dating food items in the kitchen and infection control annually. A telephone contact interview on 05/15/2026 at 10:27 AM DA G stated he was new to working at the facility. The DA G stated that all staff should be checking for out of date food in the kitchen. The DA G stated that he had in service training when he first started working at the facility. The DA G stated that he was not aware of the policy of chemicals being kept in the food prep area, because he does not work in the food prep area.Review of the facility's Poisonous and Toxic Materials policy, that was not dated, reflected.-When not in use, poisonous and toxic materials will be stored on shelves that are used for no other purpose.Review of the facility's Food Receiving and Storage policy, that was not dated, reflected.-All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).

Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized for 1 (R#17) of 32 residents reviewed for medical records.R#17 did not get treatment for her right forehead scab from 05/05/26 through 05/13/26. This failure placed residents at risk of not receiving appropriate supplies and services necessary for their needs. Review of R#17's admission Record, dated 05/12/26, reflected she was initially admitted to the facility on [DATE], readmitted to the facility on [DATE], and had a responsible party. She had medical diagnoses including right neck femur fracture, muscle weakness, difficulty walking, repeated falls, cognitive communication deficit, age-related physical debility, need for assistance with personal care, history of falling and chronic pain syndrome. Review of R#17's admission MDS, dated [DATE], reflected she had a 14/15 BIMS, which indicated she was cognitively intact. She had a fracture related to a fall before admission to the facility. Review of R#17's Care Plan, revised 05/12/26, reflected there were no notes related to applying petroleum jelly on her right forehead scab. Review of R#17's Order Summary Report, dated 05/12/26, reflected she had an active prescribed order on 05/04/26 that started on 05/05/26 in which staff were required to cleanse her right forehead scab with normal saline and apply petroleum jelly every day shift for eschar (thick, leathery layer of dead tissue that forms over deep wounds, burns or infections).Review of R#17's Medication Administration Record for May 2026 reflected staff documented cleaning her right forehead scab with normal saline and applied petroleum jelly every day shift from 05/05/26 through 05/11/26. There was no entry documented on 05/12/26 at 12:12 p.m. RN H documented she provided treatment to R#17 on 05/12/26 at 1:12 p.m. An observation and interview of R#17 on 05/12/26 at 9:46 a.m., R#17 had a scab on the upper right side of her forehead. R#17 revealed she slipped and fell at home and broke her hip in two places before she was admitted to the facility. She said her physician wanted petroleum jelly applied to her right forehead scab to soften it and so it would naturally heal. She also said staff were assigned to monitor her right forehead scab and keep it lubricated. She said she learned from staff on 05/11/26 that she was supposed to receive treatment for her right forehead scab and that it should be improving. She said staff were not providing treatment to her right forehead scab. She said her right forehead scab caused her discomfort and was itchy as a result of staff not providing her treatment. During an interview with RN H on 05/12/26 at 1:31 p.m., RN H revealed she documented in R#17's electronic medication administration record that she provided treatment to R#17. She said she monitored R#17's right forehead scab. She said she did not clean R#17's scab with normal saline, did not apply petroleum jelly and said, There were certain days staff were required to clean and apply petroleum jelly on her right forehead scab. The order was not every day. I'm following the order.During an interview with R#17 on 05/12/26 at 1:32 p.m., R#17 revealed the RN did not come into her room to monitor, clean with normal saline, and apply petroleum jelly to her right forehead scab. She said she felt disappointed because staff were not providing her with the treatment, staff were not following her physician's order and said, It's itchy and uncomfortable. My hair is also getting stuck in the scab because they are not putting the ointment on it. During an interview with R#17 on 05/13/26 at 1:56 p.m., R#17 revealed her scab was oozing and sticky. She said she felt put out because the staff should have been providing her with treatment. She also said she learned from staff that they did not have the treatment available when she informed them that her right forehead scab was bothering and bugging her.During an interview with TN K on 05/14/26 at 1:29 p.m., TN K revealed she knew it was important to follow physician's orders and said, residents could be at risk of infection and become septic if staff did not follow treatment orders. Physician creates the order and treatment nurses administered the treatment. During an interview with the DON on 05/14/2026 at 2:20 p.m., the DON revealed treatment nurses administered treatment orders. She said she learned from staff that there was no petroleum jelly supply available at the facility for R#17. She also said staff were expected to notify the supply coordinator when treatment supplies were unavailable. She explained the supply coordinator was not informed of the lack of petroleum jelly at the facility. She said it was important to have treatment supplies available at the facility and said, Residents could be at risk of delay in healing process with wound. She said staff were expected to document in the electronic medication administration record whenever they provided treatment. She said she was not aware that staff documented they were providing R#17's treatments. During an interview with the ADM on 05/14/26 at 3:31 p.m., the ADM revealed she was not aware that staff documented they provided R#17's treatment when the treatment was not provided . Review of the facility's Charting and Documentation policy, 2001, reflected, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.3.Documentation in the medical record will be objective, complete, and accurate.Review of the facility's Charting Errors and/or Omissions policy, revised December 2006, reflected, Accurate medical records shall be maintained by this facility.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (R#17) of 32 residents reviewed for treatment and care. The facility failed to provide treatment to R#17's right forehead scab from 05/05/26 through 05/13/26. This failure could place residents at risk of not receiving needed care and services that are resident-centered. Review of R#17's admission Record, dated 05/12/26, reflected she was initially admitted to the facility on [DATE], readmitted to the facility on [DATE], and had a responsible party. She had medical diagnoses including right neck femur fracture, muscle weakness, difficulty walking, repeated falls, cognitive communication deficit, age-related physical debility, need for assistance with personal care, history of falling and chronic pain syndrome. Review of R#17's admission MDS, dated [DATE], reflected she had a 14/15 BIMS, which indicated she was cognitively intact. She had a fracture related to a fall before admission to the facility. Review of R#17's Care Plan, revised 05/12/26, reflected there were no notes related to applying petroleum jelly on her right forehead scab. Review of R#17's Order Summary Report, dated 05/12/26, reflected she had an active prescribed order on 05/04/26 that started on 05/05/26 in which staff were required to cleanse her right forehead scab with normal saline and apply petroleum jelly every day shift for eschar (thick, leathery layer of dead tissue that forms over deep wounds, burns or infections).Review of R#17's Medication Administration Record for May 2026 reflected staff documented cleaning her right forehead scab with normal saline and applied petroleum jelly everyday shift from 05/05/26 through 05/11/26. There was no entry documented on 05/12/26 at 12:12 p.m. Registered Nurse documented she provided treatment to R#17 on 05/12/26 at 1:12 p.m. An observation and interview of R#17 on 05/12/26 at 9:46 a.m., R#17 had a scab on the upper right side of her forehead. R#17 revealed she slipped and fell at home and broke her hip in two places before she was admitted to the facility. She said her physician wanted petroleum jelly applied to her right forehead scab to soften it and so it would naturally heal. She also said staff were assigned to monitor her right forehead scab and keep it lubricated. She said she learned from staff on 05/11/26 that she was supposed to receive treatment for her right forehead scab and that it should be improving. She also said she observed staff were not providing treatment to her right forehead scab. She said her right forehead scab caused her discomfort and was itchy as a result of staff not providing her treatment. During an interview with RN H on 05/12/26 at 1:31 p.m., RN H revealed she documented in R#17's electronic medication administration record that she provided treatment to R#17. She said she monitored R#17's right forehead scab. She also said she did not clean with normal saline and apply petroleum jelly and said, There were certain days staff were required to clean and apply petroleum jelly on her right forehead scab. The order was not every day. I'm following the order.During an interview with R#17 on 05/12/26 at 1:32 p.m., R#17 revealed the Registered Nurse did not come into her room, monitor, clean with normal saline, and apply petroleum jelly to her right forehead scab. She said she felt disappointed because staff were not providing her with the treatment, staff were not following her physician's order and said, It's itchy and uncomfortable. My hair is also getting stuck in the scab because they are not putting the ointment on it. During an interview with R#17 on 05/13/26 at 1:56 p.m., R#17 revealed her scab was oozing and sticky. She said she felt put out because the staff should have been providing her with treatment. She also said she learned from staff that they did not have the treatment available when she informed them that her right forehead scab was bothering and bugging her.During an interview with RN H on 05/13/26 at 2:07 p.m., RN H revealed she could not recall when she was most recently in-serviced on physician orders. She said she knew to notify the nurse practitioner whenever she observed any concerns or issues with physician's orders. She also said she knew it was important to follow physician orders and said, Because if medication was not being given, you have to follow-up. We will not know the effectiveness of the order. Residents could be at risk of experiencing a bad or side effect. During an interview with CNA J on 05/13/26 at 2:25 p.m., CNA J revealed the nurses cleaned and treated residents' skin issues. She said she notified the nurse if she observed a change in residents' skin condition. She also said she knew it was important to follow physician's orders and said, It's very important. Residents could be at risk of a skin condition worsening, spreading or getting infected. During an interview with CNA D on 05/13/26 at 2:39 p.m., CNA D revealed the LVNs or Wound care nurses monitored and treated residents' skin conditions. She said she knew it was important to follow physician's orders and said, To prevent infection from occurring. During an interview with RN I on 05/13/26 at 2:52 p.m., RN I revealed the nurses and treatment nurses treated residents' skin conditions. She said there were no residents who complained of skin issues going untreated. She also said she knew it was important to follow physician's orders and said, Because we do not want residents to have infection, do not want their cut or wound to get worse, and want it to heal. During an interview with TN K on 05/14/26 at 1:29 p.m., TN K revealed she knew to notify the physician and pharmacy whenever she was missing an order or needed clarification for an order. She said she knew it was important to follow physician's orders and said, Different residents could take medications for different things. It could be fatal if you don't follow the orders. We also have to follow the orders and know where to put it in. Residents could be at risk of infection and become septic if staff did not follow treatment orders. Physician creates the order and treatment nurses administered the treatment. During an interview with the DON on 05/14/2026 at 2:20 p.m., the DON revealed treatment nurses administered treatment orders. She said residents' physician orders were reflected on the electronic treatment administration record. She also said she defined day shift as working from 6:00 a.m. through 2:00 p.m. She said she knew it was important to follow physician's orders and said, We want to make sure that we follow the orders because we do not want to cause harm or additional harm to the resident. She also said she learned from staff that there was no petroleum jelly available to R#17. She also said staff were expected to notify the supply coordinator when treatment supplies were unavailable. She explained the supply coordinator was not informed of the lack of petroleum jelly at the facility. She said it was important to have treatment supplies available at the facility and said, Residents could be at risk of delay in healing process with wound. She said staff were expected to document in the electronic medication administration record whenever they provided treatment. She also said staff were expected and should be following physician's written orders. She said it was important to document treatment provided to residents and said, If you don't document it. You don't know if it was completed. Residents could be at risk of infection and a delay of wound healing. She said she was not aware that staff documented following physician's orders and were not following the order. During an interview with the ADM on 05/14/26 at 3:31 p.m., the ADM revealed treatment nurses provided treatment to residents' skin conditions. She said staff reviewed physician orders to determine what treatment to give to the resident. She said day shift was working from 6:00 a.m. through 2:00 p.m. She also said she knew it was important to follow physician's orders and said, To keep residents safe from infection and to prevent their skin from getting worse. She said was not aware that staff documented providing treatment to a resident according to their physician order and did not provide the treatment. Review of the facility's Medication and Treatment Orders policy, revised July 2016, reflected, Orders for medications and treatments will be consistent with principles of safe and effective order writing.

Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 (R #9) of 32 residents reviewed for medication storage. A red pill was on the ground in the hallway in front of R#9's room on 05/12/26. This failure could place residents at risk their medications not being safe and secure. Review of R#9's admission Record, dated 05/14/26, reflected she was admitted to the facility on [DATE] and she was her own responsible party. She discharged from the facility on 05/12/26 to home. She had medical diagnoses including permanent atrial fibrillation (irregular heartbeat), muscle weakness, dysphagia (difficulty swallowing), unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, cognitive communication deficit and need for personal care assistance. Review of R#9's admission MDS, dated [DATE], reflected she had a 14/15 BIMS, which indicated she was cognitively intact. Review of R#9's Care Plan, initiated 04/25/26, reflected no notes related to how to administer her medications. Review of R#9's Medication Administration Record for May 2026 reflected Medication Aide administered routine medications to R#9 on 05/12/26. An observation and interview of R#9's hallway on 05/12/26 at 10:19 a.m. revealed there was a circular red pill on the ground in front of R#9's closed room door. During an interview with RN H on 05/12/26 at 10:23 a.m., the surveyor notified RN H of the circular red pill on the ground in the hallway in front of R#9's door. RN H revealed the pill might be an iron or multivitamin pill. She said she did not know whether R#9 received her pill because the medication aides administered routine medications to residents from 6:00 a.m. through 2:00 p.m. and from 2:00 p.m. through 10:00 p.m. She said R#9's medication administration record showed R#9 was administered the pill. She said R#9 took the medication because she had cancer, low red blood cell count, and for vitamin deficiency. She said the MA was scheduled to administer routine medications to R#9 and other residents on her hallway on 05/12/26 from 6:00 a.m. through 2:00 p.m. During an interview with MA L on 05/12/26 at 11:18 a.m., MA L revealed she was working on 05/12/26 from 6:00 a.m. through 2:00 p.m. and from 2:00 p.m. through 10:00 p.m. She said she also worked on 05/11/26 from 6:00 a.m. through 2:00 p.m. She also said she completed training on medication administration annually and whenever the facility's pharmacist visited the facility to go over medications with staff once every 3rd of the month. She said the MAs administered routine medications. She said R#9 received her iron medication on the morning of 05/12/26. She said she did not know how a circular red pill ended up on the floor in the hallway in front of R#9's room door. She explained that she did not observe a circular red pill on the floor when R#9 received her medication on 05/10/26 and 05/11/26. She said she supervised and ensured R#9 successfully swallowed the medication. She said she knew it was important to supervise residents when administering medications and said, Sometimes residents could drop the medication, not take it or have a hard time swallowing it if you leave the medication with them. Stuff could happen if residents did not take the medication. You also never know if another resident wandered into the room and picked up the medication that fell on the ground if staff left the room without supervising the medication administration. During an interview with R#9 over the phone on 05/13/26 at 1:38 p.m., R#9 revealed the staff did not stay the entire time when they administered her medications to her. During an interview with the DON on 05/14/26 at 2:20 p.m., the DON revealed staff were in-serviced on medication administration annually. She said she most recently in-serviced staff on the topic in October 2025. She said the MAs and nurses administered medications to residents. She said she expected staff to supervise resident during medication administration. She said the circular red pill found in the hallway in front of R#9's room was a routine iron medication, which could place residents at risk of a change in condition and low iron levels. She said she knew it was important to supervise medication administration and said, To make sure medications were taken and the resident did not have difficulty taking the medication. Residents could be at risk of a change in condition and side effects by staff not monitoring medication administration. During an interview with the ADM on 05/14/26 at 3:31 p.m., the ADM revealed the MAs, LVNs and RNs administered medications to residents. She said staff were trained on medication administration annually and as needed and completed competency evaluations. She also said staff would supervise residents during medication administration and said, It depended on their cognition, effects, and type of medication. She also said she was not aware the medications were found on the floor before 05/12/26. She said she knew it was important to supervise residents who needed supervision during medication administrations and according to protocols and said, For the safety of the residents. Residents' health could go in a different way or have a change in condition. Nurses and the DON oversaw and ensured medication administration by audits. Review of the facility's Administering Medications policy, 2001, reflected, Medications are administered in a safe and timely, and as prescribed.

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 6 of 10 residents (Resident #40 and 5 unidentified residents on 100 hall) reviewed for infection control. RN H did not change contaminated gloves and wash her hands prior to exiting Resident #40's room and touched doorknob, nursing cart, and nursing computer when documented Resident #40's Accu-Check results. These failures could place the residents at risk of infection transmission, sepsis, and hospitalization.1. Record review of Resident #40's face sheet, dated 05/14/2026, reflected [AGE] year-old female admitted on [DATE] with a diagnosis of Type 2 Diabetes Mellitus (a chronic metabolic disorder where the body either resists insulin or doesn't produce enough of it, leading to high blood sugar).Record review of Resident #40's admission MDS assessment, dated 05/13/2026, reflected BIMS' score of 15 - intact cognition. Record review of Resident #40's initial care plan, dated 05/10/2026, reflected a focus Diabetes Mellitus 2 with interventions included Administer diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness.Record review of Resident #40's order summary report, dated 05/14/2026, reflected an order for Accu-checks before meals and at bedtime for diabetes mellitus with start date on 05/07/2026.Observation of Resident #40's Accu check (blood glucose monitors used for managing diabetes) on 04/13/2026 at 11:45 a.m. revealed RN H completed Accu check for Resident #40 and did not remove contaminated gloves before leaving Resident #40's room, touching the nursing cart, computer ( when accessed the information about sliding scale and documented results of Accu check), and while sanitizing the glucometer (a portable medical device used to measure the concentration of blood sugar). RN H did not sanitize Resident #40's table after completing Accu check and removing supplies used for Accu check. During an interview on 05/13/2026 at 11:51 a.m., RN H stated that she had an in-service on hand hygiene and infection control sometimes last month and she thought she changed gloves after completing Accu check for Resident #40 but forgot to wash or sanitize hands before leaving Resident #40's room. RN H stated she sanitized Resident #40's table before placing Accu check supplies but did not sanitize it after removing supplies being placed on the clean paper towel. She stated that not washing hands and changing gloves according to the facility's policy could lead to cross contamination and infection control issues that could negatively affect residents. During an interview on 05/12/2026 at 12:52 a.m., CNA C stated that she had an in service on hand hygiene and infection control a few months ago. She stated that she did not sanitize her hands between passing residents' lunch trays, and she was supposed to do it according to the training. She could not explain why did not sanitize her hands. She stated that if proper hand hygiene and infection control policy was not followed, it could negatively affect residents due to cross contamination. During an interview on 05/14/2026 at 2:39 p.m., DON stated that in-serviced on hand hygiene and infection control are provided to staff annually and on continues basis including reeducation of health care staff as needed. She stated that she was responsible as the DON and infection preventionist for monitoring staff followed the proper hand hygiene and infection control. She stated that she and experienced charge or treatment nurses performed spot monitoring weekly and randomly watched the nursing staff performing direct resident care. She stated that hands need to be washed between passing meal trays to residents according to their policy. She stated that hands need to be sanitized or washed between glove changes, before exiting residents' room and contaminated gloves disposed of before touching clean supplies to prevent cross contamination. During an interview on 05/14/2026 at 4:53 p.m., ADM stated that she had an in-service on hand hygiene and infection control 6 months ago. She stated that all staff get the infection control training at hire and annually during skill training and check offs. ADM stated that nursing management including DON who was also an infection preventionist and charge nurses were responsible for overseeing the staff adhering to proper infection control protocol and educating staff in need of additional training. She stated that hands should be washed during peri care, before touching anything in residents' environment, between gloves change, and before leaving resident's room. She stated that if not following proper infection control policy could negatively impact residents due to their vulnerable status. Record review of Compliance Rounds Expectations for all healthcare staff, dated 4/2026, revealed Infection control: Monitor hand washing between residents.Record review of Handwashing/Hand hygiene policy, revised on 10/2023, revealed Indications for Hand Hygiene: c. after contact with blood, body fluid, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; g. immediately after glove removal. 5. The use of gloves does not replace hand washing/hand hygiene.3. B. Observation on 5/12/2026 at 12:30 PM. DA F was passing out food to the residents during the lunch service. While passing out food to the resident he was not sanitizing his hands in between getting each tray of food for the resident. DA F was grabbing bowls of soup from the top inside part of the bowl where the bowl.

Based on observation, interview and record review the facility failed to ensure residents had the right to examine the results of the most recent survey of the facility conducted by Federal or State Surveyors and any plan of correction in effect with respect to the facility for 32 of 32 residents reviewed for the right to review survey results. The facility failed to post the results of the facility's most recent survey in a prominent and readily accessible place to residents, family members, legal representatives, and the public. This failure could place residents at risk of not being able to examine survey results without having to ask. During a group interview with six confidential residents on an undisclosed date at an undisclosed time, the residents revealed they did not know where the survey results were and available to read. During an observation and interview of the front entrance on 05/13/26 at 10:52 a.m., revealed the survey results were not in a prominent and readily accessible place. There was also no posting which indicated where the survey results were. The state surveyor asked the Receptionist where the survey results were. The Receptionist revealed she did not know where the survey results were and said, Let me ask the Administrator. During an interview with the DCS on 05/13/26 at 11:01 a.m., the DCS revealed the survey results were at the Receptionist's desk at the front entrance. The DCS picked a binder that was tucked behind the Receptionist's desk at the front entrance. The binder contained the facility's survey results. During an interview with RN H on 05/13/26 at 2:19 p.m., RN H revealed she did not know where the survey inspection results were. During an interview with CNA J on 05/13/26 at 2:25 p.m., CNA J revealed she did not know where the survey inspection results were. During an interview with CNA D on 05/13/26 at 2:39 p.m., CNA D revealed she did not know where the survey inspection results were. During an interview with the DON on 05/14/26 at 2:20 p.m., the DON revealed she expected staff to go to the Receptionist's desk at the front entrance for the survey inspection results. She said staff should know where the survey inspection results were. She also said she most recently in-serviced staff on where to locate the survey inspection results after the last survey. She said she was not aware staff did not know where the survey inspections results were. She also said she knew it was important to know where the survey inspection results were and said, To advocate for resident safety. This was the residents' home and to make sure they were safe, comfortable and their needs were being met. Residents could be at risk of delay in having needs and care met. During an interview with the SW on 05/14/26 at 3:08 p.m., the SW revealed her, the Administrator and the DON knew where the survey inspection results were. He said he did not know staff were unaware where the survey inspection results were. He also said he knew it was important to know where the survey inspection results were and said, It's important because we have to know in case residents asked for those resources.During an interview with the ADM on 05/14/26 at 3:31 p.m., the ADM revealed the survey inspection results were available at the Receptionist's desk at the front entrance. She said the Receptionist and leadership team should know where the survey inspection results were. She also said she did not know staff were unaware where the survey inspection results were. She said she knew it was important to know where the survey inspection results were and said, So residents feel like they have options and feel like they have other options. During an interview with the AD on 05/14/26 at 4:39 p.m., the AD revealed the survey inspection results were in the Administrator's office. She said the residents did not have access to the Administrator's office and would have to contact the Administrator to get the survey inspection results. She also said she knew it was important to know where the survey inspection results were and said, It's their right to have that information.Record review of the facility's, undated, Federal Nursing Home Resident Rights, reflected Examination of survey results. A resident has the right to:(1)Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. The facility must make the results available for examination in a place readily accessible to residents, and mist post a notice of their availability.

Based on observation, interview, and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately to the administrator of the facility and to the State Survey Agency, for one Resident (Resident #1) of three residents reviewed for abuse/neglect. The facility failed to report to the administrator of the facility and to the State Agency that Resident #1's family on 02/04/25 had alleged that a CNA had pinched and been rough with Resident #1. This failure could place residents at risk for continuation or repetition of abuse, or abuse becoming more widespread. Findings included: Review of Resident #1's MDS reflected that Resident #1 was a [AGE] year old female resident admitted to the facility on [DATE] with diagnoses in part including metabolic encephalopathy (a change in how the brain works due to an underlying condition that can result in confusion, memory loss, or loss of consciousness), heart failure (the heart doesn't pump blood as well as it should), hypertension (elevated blood pressure), dysphagia (difficulty swallowing), and pneumonia (infection in the lungs). Resident #1's BIMS score was six, indicating severe cognitive impairment. In an interview and observation on 03/04/25 at 3:05 pm, Resident #1's family stated a while back (she did not know the date), she and her mother were eating lunch in the dining room and her mother pointed at a CNA and stated that the CNA had been rough with her and had pinched her. The family reported that an unknown person in the dining room (not facility staff) told her it was true. Resident #1's family reported that she notified the DON at the time and thought the aide may have been fired. Resident #1 opened her eyes but did not respond to interview questions. In a review of the facility grievance log from December 2024 through February 2024, a grievance dated 02/04/25 and signed by the AIT stated that a family member, reported that [CNA A] has been rough with her [Resident #1], per patient. When moved to the dining room today her mother said, don't pinch me and the resident sitting across from her said she did pinch her. The action plan included to, remove the resident from the CNA's assignment and do not assign the resident to the [CNA A] permanently. A review of TULIP reflected no events reported for this allegation between 10/04/24 and 02/03/25 indicating the allegation of abuse was not reported to Health and Human Services. A review of Resident 1's progress notes for the week surrounding 02/04/25 (date of grievance) revealed no progress notes or skin or other assessments regarding the reported incident. In an interview on 03/05/25 at 9:05 am, CNA A reported that about 1.5 months ago she was informed by the DON that Resident #1's family had reported that Resident #1 had reported that she was rough with her during care and had pinched her while in the dining room. CNA A reported the DON informed her she would no longer be working with Resident #1. She denied having pinched or been rough when providing care to Resident #1. In an interview on 03/05/25 at 10:14 am, DON stated that she completed the investigation in February 2025 in which Resident #1's family mentioned to her that someone in the dining room had stated that CNA A had pinched Resident #1. She stated she interviewed CNA A who denied having pinched or been rough with Resident #1 and reported others were present in the dining room. She stated they conducted a skin assessment, she believed it should be in the electronic medical record, and Resident #1 did not have any injuries. She stated Resident #1's family did not want CNA A to work with Resident #1 anymore. She reported that the facility does not usually do progress noted on this type of incident because it was in-house. Instead, they do a grievance and that was what she did. She reported that CNA A was not suspended but was removed from Resident #1's care. The DON reported that, If there is an allegation, we talk, interview, and investigate, and if there is really an abuse, we report it. In this case we did not report it to the state because we did not find it to be abuse. If we suspect abuse, we report it to the administrator. The DON stated she reported the allegation to the administrator the next morning in report. In an interview on 03/05/25 at 10:49 am, NP B stated that about a month ago she was made aware that there was an allegation of roughness by a CNA with Resident #1. She stated she did not know what that roughness entailed or where the incident might have occurred. She stated she was never informed of any allegation that Resident #1 was pinched. She stated she was told there was no injury, and she does not remember any injuries but that she did not need to do an assessment or any documentation of the incident. In an interview on 03/05/25 at 10:57 am, the AIT stated that Resident #1's family told the DON on 02/04/24 that at lunch Resident #1 had told her that CNA A had pinched her, and she had completed a grievance report. She reported the DON did her investigation with the resident and the aid. She stated that she had just had a meeting with the administrator and now realizes the incident needed to have been reported to the state. She reported that everyone was responsible for reporting abuse but that the Director or the Administrator do the state reports. She stated the risk of not reporting an allegation of abuse is the risk of it happening again or being widespread and affecting other residents. She stated CNA A is being suspended today (03/05/25) pending investigation outcome. In an interview on 03/05/25 at 11:25 am, the ADM stated she just found out about the situation with Resident #1. She reported she was not notified of the allegation of abuse. She stated she heard within the past hour that the Resident #1's family member had reported to the AIT, that Resident #1 head told her family member that she had been pinched and in passing there was another resident that said yes, the CNA did pinch Resident #1. She stated she was told that the DON did a skin assessment and the daughter requested to not have the CNA as a caregiver. ADM reported she was upset with her team and had just educated them on abuse, what are the types, when and who to report abuse to. She stated that she contacted the Director who also stated she was not notified of the incident. She reported the team should have notified one of us. She stated if she had been notified, she would have asked if the skin assess was complete, sent CNA A home pending investigation, reinterviewed the resident, and completed a self-report for the state. ADM reported the DON told me she did the skin assessment but that she did not document it. ADM stated the risk of an allegation of abuse not being reported is that if it truly happened it could continue to happen or could happen to other residents. She stated that the alleged perpetrator, CNA A, has been placed on suspension immediately pending outcome investigation. In an interview on 03/05/25 at 11:59 am, the Director stated that today (03/05/25) was the first time that she had heard that Resident #1 was pinched, and she was currently doing a self-report. She stated she would have expected the staff to notify her at the time of the incident. She reported if she had been notified, she would have reported it within the appropriate timeframe to the state and started the internal investigation as pinching was a form of physical abuse. She reported that when there was an allegation of physical abuse a physical assessment should be documented in the electronic medical record. She stated the risk of failing to report an allegation of abuse would be potential further risk for abuse. Review of TULIP records noted this allegation was received by Health and Human Services as a facility self-report on 3/5/2025 at 12:45 PM. This allegation of abuse was investigated by this surveyor and there was not sufficient evidence to substantiate this allegation of abuse regarding pinching and/or roughness. No injury or trauma to Resident #1 was determined. The facility policy dated April 2014 and titled, 2 EXHIBIT C ABUSE PREVENTION POLICY stated that, Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment and that, Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation. The document notes that, Any allegations of abuse will be reported to the Administrator immediately and to the State Department of Health and the resident's representative as soon as possible within 24 hours. The policy also stated, The administrator or designee will review the report. The administrator or designee is then responsible for forwarding a final written report of the results of the investigation and of any corrective action taken to the State Department of Health within five working days of the reported incident.

Based on interview and record review, in response to an allegation of abuse, the facility failed to have evidence that all alleged violations were thoroughly investigated, and to prevent further potential abuse while the investigation was in progress for one (Resident #1) of three residents reviewed for abuse. The facility failed to thoroughly investigate an allegation that a staff member had been rough with and pinched Resident #1 and failed to suspend the alleged perpetrator on 02/04/25. This failure could place resident's at risk for continued abuse, unidentified injuries or trauma, and the spread of abuse to other residents. Findings included: Review of Resident #1's MDS reflected that Resident #1 was a [AGE] year old female resident admitted to the facility on [DATE] with diagnoses in part including metabolic encephalopathy (a change in how the brain works due to an underlying condition that can result in confusion, memory loss, or loss of consciousness), heart failure (the heart doesn't pump blood as well as it should), hypertension (elevated blood pressure), dysphagia (difficulty swallowing), and pneumonia (infection in the lungs). Resident #1's BIMS score was six, indicating severe cognitive impairment. In an interview and observation on 03/34/25 at 3:05, Resident #1's family reported a while back (she did not know the date), she and her mother were eating lunch in the dining room and her mother pointed at a CNA and stated that the CNA had been rough with her and had pinched her. The family reported that an unknown person in the dining room (not facility staff) told her it was true. Resident #1's family reported that she notified the DON at the time and thought the aide may have been fired. Resident #1 opened her eyes but did not respond to interview questions. In a review of the facility grievance log from December 2024 through February 2024, a grievance dated 02/04/25 and signed by the Administrator in Training (AIT) stated, daughter reported that [CNA A] has been rough with her mom, per patient. When moved to the dining room today her mother said, don't pinch me and the resident sitting across from her said she did pinch her. The action plan included to, remove the resident from the CNA's assignment and do not assign the resident to the [CNA A] permanently. A review of TULIP reflected no events reported for this allegation between 10/04/24 and 02/03/25 indicating the allegation of abuse was not reported to HHS. A review of Resident 1's progress notes for the week surrounding 02/04/25 (date of grievance) revealed no progress notes regarding the reported incident. There were no injury assessments, trauma assessments, or skin assessments. These progress notes did not indicate that the nurse practitioner, the physician, or the family had been notified of the allegation. In an interview on 03/05/25 at 9:05 am, CNA A reported that about 1.5 months ago she was informed by the DON that Resident #1's family had reported that Resident #1 had reported that she was rough with her during care and had pinched her while in the dining room. CNA A reported the DON informed her she would no longer be working with Resident #1. She denied having pinched or been rough when providing care to Resident #1. In an interview on 03/05/25 at 10:14 am, DON stated that she completed the investigation in February 2025 in which Resident #1's family mentioned to her that someone in the dining room had stated that CNA A had pinched Resident #1. She stated she interviewed CNA A who denied having pinched or been rough with Resident #1 and reported others were present in the dining room. She stated they conducted a skin assessment, she believed it should be in the electronic medical record, and Resident #1 did not have any injuries. She stated Resident #1's family did not want CNA A to work with Resident #1 anymore. She reported that the facility does not usually do progress noted on this type of incident because it was in-house. Instead, they do a grievance and that was what she did. She reported that CNA A was not suspended but was removed from Resident #1's care. The DON reported that, If there is an allegation, we talk, interview, and investigate, and if there was really abuse, we report it. In this case we did not report it to the state because we did not find it to be abuse. If we suspect abuse, we report it to the administrator. The DON stated she reported the allegation to the administrator the next morning in report. In an interview on 03/05/25 at 10:49 am, NP B reported that about a month ago she was made aware that there was an allegation of roughness by a CNA with Resident #1. She stated she did not know what that roughness entailed or where the incident might have occurred. She stated she was never informed of any allegation that Resident #1 was pinched. She stated she was told there was no injury, and she does not remember any injuries but that she did not need to do an assessment or any documentation of the incident. In an interview on 03/05/25 at 10:57 am, the AIT reported that Resident #1's family told the DON on 02/04/24 that at lunch Resident #1 had told her that CNA A had pinched her, and she had completed a grievance report. She reported the DON did her investigation with the resident and the aid. She stated that she had just had a meeting with the administrator and now realizes the incident needed to have been reported to the state. She reported that everyone is responsible for reporting abuse but that the Director or the Administrator do the state reports. She stated the risk of not reporting an allegation of abuse is the risk of it happening again or being widespread and affecting other residents. She stated CNA A is being suspended today (03/05/25) pending investigation outcome. In an interview on 03/05/25 at 11:25 am, the ADM reported she just found out about the situation with #. She reported she was not notified of the allegation of abuse. She stated she heard within the past hour that the daughter reported to the AIT, that Resident #1's daughter had been pinched and in passing there was another resident that said yes, the CNA did pinch her. She stated she was told that the DON did a skin assessment and the daughter requested to not have the CNA as a caregiver. She reported she was upset with her team and had just educated them on abuse, what are the types, when and who to report abuse to. She stated that she contacted the Director who also stated she was not notified of the incident. She reported the team should have notified one of us. She stated if she had been notified, she would have asked if the skin assess was complete, sent CNA A home pending investigation, reinterviewed the resident, and completed a self-report for the state. ADM reported the DON told me she did the skin assessment but that she did not document it. She reported the risk of not completing an assessment would be that an injury might not be identified. ADM stated the risk of an allegation of abuse not being reported is that if it truly happened it could continue to happen or could happen to other residents. She stated that the AP, CNA A, has been placed on suspension immediately pending outcome investigation. In an interview on 03/05/25 at 11:59 am, the Director stated that today (03/05/25) was the first time that she had heard that Resident #1 was pinched, and she was currently doing a self-report. She stated she would have expected the staff to notify her at the time of the incident. She reported if she had been notified, she would have reported it within the appropriate timeframe to the state and started the internal investigation as pinching is a form of physical abuse. She reported that when there is an allegation of physical abuse a physical assessment should be documented in the electronic medical record and that not doing this could result in an injury being missed. She stated the family and the nurse practitioner and/or the physician should be notified. She stated the risk of failing to report an allegation of abuse would be potential further risk for abuse. Review of TULIP records noted this allegation was received by Health and Human Services as a facility self-report on 3/5/2025 at 12:45 PM. This allegation of abuse was investigated by this surveyor and there was not sufficient evidence to substantiate this allegation of abuse regarding pinching and/or roughness. No injury or trauma to Resident #1 was determined. The facility policy dated April 2014 and titled, 2 EXHIBIT C ABUSE PREVENTION POLICY stated that, Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment and that, Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation. The policy also stated, The administrator or designee will review the report. The administrator or designee is then responsible for forwarding a final written report of the results of the investigation and of any corrective action taken to the State Department of Health within five working days of the reported incident. The policy also stated, All incidents will be documented, whether or not abuse occurred, was alleged or suspected. This policy further stated, Employees of this community who have been accused of abuse, neglect, or mistreatment will be immediately suspended until the results of the investigation have been reviewed by the administrator or designee.

Based on observation, interview. and record review, the facility failed to ensure they did not employ an individual who was found guilty of a criminal offense barring employment by a court of law for 1 (MA A) of 9 employees reviewed for abuse and neglect. The facility did not ensure MA A was disqualified from working in the facility when her criminal history, searched on 04/18/24 indicated a criminal conviction (on 03/05/24) barring employment in a nursing facility. MA A worked in the facility from 04/24/24 through 07/12/24. This noncompliance was identified as PNC. The deficient practice began on 04/24/24 and ended on 07/12/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for possible abuse, neglect, or exploitation. Findings included: Record review of the employee file for MA A reflected she was hired on 04/24/24. Her initial criminal history check was completed on 04/18/24 and reflected a misdemeanor conviction for an offense that barred employment. During an interview on 10/07/24 at 9:56 AM, the DCS stated MA A was terminated the day after the facility was made aware that a misdemeanor conviction for the offense barred the MA from employment. She stated the facility downloaded the list of barrable offenses from the state website and all the HR staff were trained on barrable offenses and background checks. During an interview on 10/07/24 at 2:58 PM, the HRD described the hiring process. She stated once the application was completed and signed, it was forwarded to the department manager for consideration and interview. If the manager wanted to hire, HR was notified. She stated one of the HR generalists would run the background checks. The checks included the Nurse Aide Registry, the Employee Misconduct Registry, criminal background, and others. She stated they ran the background check on MA A, and she saw the conviction on the record. She stated she believed because the offense was a misdemeanor, she was eligible for employment. She stated the HR department had training and reviewed the barrable offenses on the list. She stated she learned any conviction for the listed offenses made the person not eligible to work in the facility. She stated, since the training, if there is any conviction of any kind, the generalists sent it to her for final review. She stated employee files were audited by two staff to ensure they were accurate and completed. She stated the audits were reviewed at the QAPI meetings. During an interview on 12/19/24 at 10:39 AM, the HRD stated as soon as they learned MA A's conviction was barrable, they downloaded the list of barrable offenses (State of Texas, Health & Safety Code, Chapter 250 subsection 250.006 Convictions Barring Employment). She stated the conviction was a misdemeanor and she was specifically looking for a felony. She stated it was a mistake, a misunderstanding. She stated each employee in the HR department now had a copy of the list for reference. She stated she and the other two staff in the department had training about the barrable offenses, provided by the Nurse Consultant and the DCS on 07/15/24. During an observation and interview on 12/19/24 at 10:57 AM, HRE B was seated at her desk. Posted on the wall to her left, a copy of the barrable penal code list was observed. She stated she initiated background checks on new employees. She stated if the person had not lived in the state for the last five years, there was a different background check conducted that pulled information from other states. She stated if there was any conviction on the report, she compared it with the list then it was reviewed by the HR director for final approval. She stated she had training on the barrable offense list in July of this year. During an observation and interview on 12/19/24 at 11:03 AM, HRE C was sitting at her desk. On the wall behind the desk, a copy of the barrable penal code list was observed. She stated she conducted background checks. She stated she first had to make sure the application was signed because she could not proceed without the signature. She stated if any background check came back with a conviction, she sent it to the HRD for review. During an interview on 12/19/24 at 1:30 PM the ADM, stated she was out of town when the facility learned that MA A had a barrable offense but she was notified. She stated MA A was terminated and the HR staff were trained by the Nurse Consultant and the DCS. She stated it was her expectation that any conviction on the background check was reviewed by the HR manager. She stated employee file audits are a topic at their QAPI meetings. She stated background checks must be accurate as a wrong spelling or wrong number could give information on the wrong person. Immediate Response: - DCS and administration aware. - Downloaded and printed list of barrable offenses. - MA A was terminated. - HR department was trained on background checks and barrable offenses. - Audits of employee files conducted by two staff. Actions: 07/11/24 - DCS and HRM downloaded and printed the barrable offense list. Each of the three HR staff were given a copy of the list. 07/12/24 - MA A was terminated. 07/15/24 - HRM and the two HR employees trained on background checks and barrable offenses. Conclusion: Confirmed. MA A worked at the facility from 04/24/24 through 07/12/24 with a conviction for a barrable offense. Review of 9 undated personnel files, including MA A, reflected required background checks, reference checks, and orientation training on abuse/neglect/exploitation, resident rights, and dementia care. The background checks were completed prior to the date of hire. The audit sheets reflected initials from two HR staff. Review of the facility Abuse prevention policy updated November 2016 reflected in part . This community will not knowingly employ any individual convicted of resident abuse, neglect, or misappropriation of property. The community will not knowingly employ any direct care staff convicted of any of the crimes listed in the State Criminal History of Nurse Aides an Other Unlicensed Employees, or with a finding of abuse listed on the Nurse Aide Registry or criminal history background check. Prior to a new employee starting a work schedule, this community will: 1.1 initiate a reference check from previous employers, in accordance with community policy. 1.2 Obtain a copy of the state license . 1.3 If applicant is a nursing assistant, obtain a copy of the person's state nurse aide registry report from the state department. 1.4 Obtain a limited criminal history. Review of in-services conducted reflected the HR staff were in-serviced on background checks and barrable offenses on 07/15/24. This noncompliance was identified as PNC. The deficient practice began 04/24/24 and ended on 10/12/24. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Server A, Server B and Dietary Manager) of 3 staff members reviewed in that: The facility failed to ensure Server A, Server B and the Dietary Manager performed hand hygiene when serving residents during lunch service. This failure placed residents at an increased risk of exposure to infections to include COVID- 19, decreased quality of life or hospitalization s. Finding include: An observation on 08/26/2024 at 12:14 PM revealed Server A, Server B exiting the dining room and serving residents. Server A was observed with gloves on while serving residents and touching door of kitchen when returning to the kitchen from the dining room. An observation on 08/26/2024 at 12:18 PM revealed the DM entering and exiting kitchen serving food to residents without performing hand hygiene. An observation on 08/26/2024 at 12:19 PM revealed Server A and Server B exit kitchen to dining room to serve residents without performing hand hygiene. An observation on 08/26/2024 at 12:20 PM revealed no hand sanitizer or hand washing sink immediately outside or inside of the kitchen. An observation on 08/26/2024 at 12:25 PM revealed Server A wearing gloves and place plate on tray and exiting kitchen to serve residents. Further observation revealed Server A returned to kitchen with the same gloves and placed other plates on tray for residents. An observation on 08/26/2024 at 12:56 PM revealed Server A replaced gloves without performing hand hygiene. Server A was observed touching door handle when exiting kitchen. Server A returned to kitchen and removed gloves, but no hand hygiene was performed before Server A provided a cup to nursing staff for resident. An observation on 08/26/2024 at 1:01 PM revealed Server A was wearing gloves in the dining room and cleaned up dirty dishes. An observation on 08/26/2024 at 1:03 PM revealed Server A removed dirty gloves and grabbed a new pair of gloves to put on without performing hand hygiene. Further observation revealed Server A put on one glove and dropped one glove on the floor and pick it up and put it on without performing hand hygiene. During an interview on 08/26/2024 at 12:56 PM, Server A stated that she was usually responsible for placing plates on trays and serving residents in the dining room. She stated that when staff entered and exited the kitchen or when they touched something they were supposed to clean their hands. She stated that before gloves were put on and when they were taken off staff were supposed to perform hand hygiene. Server A did not answer when asked why she did not perform hand hygiene when exiting and reentering the kitchen. During an interview on 08/26/2024 at 1:02 PM, Server B stated staff were supposed to wash their hands when they entered the kitchen and stated staff were supposed to wash hands in between any tasks performed. He stated he did not wash his hands when re-entering kitchen because he was busy. During an interview on 08/26/2024 at 1:05 PM, the DM she stated staff were supposed to wash their hands when they came in to dining room and when they re-entered the kitchen. The DM stated staff were also supposed to wash their hands or perform hand hygiene after they exit the kitchen and serve meals. She stated they were not supposed to wear gloves in dining room only if they are preparing food. She stated if staff are wearing gloves while serving, they were not correct. The DM stated when staff enter the kitchen, they were supposed to wash their hands at hand washing sink. During an interview on 08/26/2024 at 2:42 PM with the ADM, she stated that staff were expected to wash their hands prior to serving and any time they needed to wash their hands. She stated staff were supposed to wash their hands or perform hand hygiene when handling resident plates and put gloves on to deliver trays. The ADM stated staff were supposed to wash their hands or perform hand hygiene after they change glove. The ADM stated that If they are touching the door handle staff should have washed their hands before serving another resident. The ADM stated that it was not expected that staff wash hands in between serving residents if they did not touch anything. The ADM stated if staff got new gloves and dropped the gloves on the floor they were supposed to throw away the gloves and perform hand hygiene. Review of facility in-service dated 07/21/2024 was completed for the topic of handwashing and glove usage in food service. In-service included policy titled Handwashing and Glove Usage in Food service dated in 2016. The policy reflected hand washing was the most important way to stop the spread of infection. Food handlers were supposed to wash their hands after clearing tables or busing dirty dishes, after leaving and returning to the kitchen/prep area and after touching any other surfaces. In-service included that single-use gloves should be used when handling ready-to eat food. Further review reflected hands should be washed before putting gloves on. Review of the facility's policy titled Handwashing/Hand Hygiene policy dated October 2023 reflected staff are trained regarding the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Staff are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, resident and visitors. Further review revealed hand hygiene is indicated after touching a resident's environment. Hand hygiene should be performed before applying gloves.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchen reviewed. There were unsealed bags containing dairy products in the refrigerator. 3 of 3 steam table wells had a whitish yellow substance in them. There was a heavily dented large metal colander. There were containers of spices open to air. This failure could place residents at serious risk for complications from food contamination. The findings were: Observation during the initial tour of the kitchen on 01/23/24 at 10:00 am revealed, 2 unsealed gallon bags in the refrigerator and open to air; one contained butter, the other cheese. The steam table wells had a whitish yellow substance caked on their bottoms, and 2 had a whitish yellow substance caked inches up the sides of 3 of 3 wells. The well in the center had what appeared to be bits of food floating in murky water. There was a heavily dented large metal colander that was being used for service according to the COOK. 10 of 29, 28oz containers of spices were open to air. Interview with the COOK on 01/23/24 at 10:15 am revealed one of the unsealed bags in the refrigerator contained a large amount of butter and the other one, a large amount of shredded cheese. The COOK stated the bags should be sealed to keep the food fresh and to keep the food from possibly becoming cross contaminated. The COOK stated the residents could get sick from cross contamination. The COOK stated the heavily dented large metal colander was being used for service. The COOK stated the dented colander, or any other heavily dented pans, should not be used for service because the dents could collect bacteria in them and make the residents sick. The COOK stated the spices should not be open to air because they could clump or go bad. Return observation visit to the kitchen on 01/25/24 at 11:45 am revealed 1 of 3 steam table wells remained crusted on the bottom and sides with a whitish substance and bits of what appeared to be food floating in murky water. There were 2 of 29, 28oz containers of spices open to air. Interview with the DM on 01/25/24 at 11:45 am stated the cleaning lists showed the steam table wells were cleaned daily. The DM stated the steam table wells did not look clean. The DM stated residents could potentially get sick. The DM stated the spices and anything in the refrigerators should not be open to air. References: Food equipment standards, Food Equipment, Certification and Classification convey that equipment certified for conformance to a recognized American National Standard by an American National Standards Institute (ANSI) accredited certification program is deemed to comply with the equipment sanitation provisions contained in Food Code Chapter 4, Parts 4-1 of the Food Code, Section 4-205.10. 4-202.11 Food-Contact Surfaces. (A) Multiuse FOOD-CONTACT SURFACES shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections (3) Free of sharp internal angles, corners, and crevices (4) Finished to have smooth welds and joints

Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents, Resident #8, reviewed for care plans in that: -Resident #8's care plan was not revised quarterly. This failure could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings included: Record review of Resident #8's Face Sheet reflected an [AGE] year-old female, with an original admitted [DATE]. Diagnoses included Dementia (Decline in cognitive abilities that impacts a person's ability to perform everyday activities), Anxiety (An unpleasant state of inner turmoil and includes feelings of dread over anticipated events), Psychotic Disturbance (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and mood disturbance (mood is distorted or inconsistent with your circumstances and interferes with your ability to function). Record review of Resident #8's MDS quarterly assessment dated [DATE] reflected a BIMS score of 00 indicating severe cognitive impairment. Record review of Resident #8's care plan initiated [DATE] indicated the next review date was [DATE]. During an Interview on [DATE] at 3:00 PM with the DON she stated the MDS coordinator and the ADON handled most care plans. The DON stated Resident #8's care plan should have been updated. The DON said they missed it. The DON stated possible negative outcomes for Resident #8 could be anything not captured in the care plan. During an interview on [DATE] at 3:10 PM with the Director of Clinical Services, she said they were very overwhelmed at the time. She said they were in the middle of an outbreak. The Director of Clinical Services said the DON, the Director of Clinical Services, the Nurse manager and the ADON all check MDS coordinator's work. She said they do not have a double check system. During a telephone interview on [DATE] at 9:00 AM with the MDS coordinator she said Resident #8's care plan was expired. She said There was a lot going on when it was due. She said they were in the middle of a covid outbreak. She stated the dietician updated her part on [DATE] and the rest of the team should have updated their parts. She stated that the care plan should be reviewed to discuss medical changes, other changes, and status. She said they had the last meeting with the resident representative on [DATE]. She stated the reason to update the care plan was to ensure they talked about significant changes. She stated if it does not happen, they could miss something. She said they do not need to go by the schedule. She stated the care plan could be updated at any time if there was a significant change. She said it depends on the resident's status and the medical status. She stated the care plan was scheduled to be updated every quarter. She said if it they do not update the care plan, they could miss something. Record review of the Care Plans Policy (Revised [DATE]); Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 11.d The interdisciplinary team reviews and updates the care plan at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observations, interviews, and record review, the facility failed to accommodate residents' food preferences for 2 of 8 residents (Resident #3 and #16) reviewed for food preferences. 1.The facility failed to honor Resident #3's preferences for no condiments. 2.The facility failed to honor Resident #16's preference for her dislike of mustard. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: 1. Record review of Resident #3's face sheet dated 01/23/24 revealed an [AGE] year-old female with diagnoses including dementia, senile degeneration of brain (reflects a long history of not understanding), abnormal weight loss, protein-calorie malnutrition, dysphagia (difficulty swallowing), and adult failure to thrive (a syndrome of global decline). Record review of Resident #3's MDS assessment dated [DATE] indicated she was rarely understood and sometimes understood simple, direct communication. Resident #3 had a BIMS score of 0 with memory problems and was cognitively severely impaired. Resident #3 had a feeding tube as well as a regular diet and required assistance with all ADL tasks. Resident #3 was on Hospice. Record Review of Resident #3's Care Plan dated 01/24/23 indicated Resident #3 required tube feeding related to her inability to meet nutrition/hydration needs through oral intake-date initiated 02/01/23 and revised 05/07/23. Resident #3's care plan also included Resident #3 had a nutritional/hydrational problem related to mental disorders, dementia, poor consumption of meals and received tube feedings daily. Resident #3 was able to feed herself in her room. She liked: hamburger plain, ice cream, cheesecake, cookies, mac and cheese, grilled cheese, and lemon-lime sodas. Record Review of Resident #3's physician orders dated 01/25/23 documented a regular diet with cut meats and (thin) regular consistency. Physician orders dated 03/03/23 documented tube feed 1 can once a day for supplement, on 02/03/23-flush g-tube with 300ml of water 3 times a day for hydration. Record review of Resident #3's family request sheet dated 02/05/23 had no condiments-plain for hotdogs and hamburger-plain-no condiments, lettuce, tomato, pickle, or anything. Record review of Resident #3's undated electronic food preferences revealed Likes: . plain hot dog, plain hamburger . Record review or Resident #3's daily menus dated 01/23/24, 01/24/24, and 01/25/24 did not indicate any preferences, likes or dislikes, nor any preferences, likes or dislikes on the Every Day menus. Observation and interview with Resident #3 on 01/23/24 at 1:49 pm revealed a hot dog with mustard & ketchup and Resident #3 stated she hated condiments and did not want the hot dog. 2.Record review of Resident #16's face sheet had an initial admission of 07/15/22 and most recent admitted d 08/28/23 revealed a [AGE] year-old female with diagnoses including heart failure, protein-calorie malnutrition, stage 3 kidney disease, cognitive communication deficit, high cholesterol, a-fib (a type of arrhythmia, or abnormal heartbeat), dementia, unsteadiness on her feet, and anxiety. Record review of Resident #16's MDS assessment dated [DATE] indicated she had no communication deficits, and her BIMS score was 14, indicating no cognitive impairment. Resident #16 required 1-2-person assistance for mobility and transfers. Resident #16 was in a wheelchair. Resident #16 was in hospice. Record Review of Resident #16's Care Plan dated 08/28/23 indicated Resident #16 Loves milk to drink, date initiated 10/13/23, moderate protein-calorie malnutrition date initiated 09/09/23, with interventions such as able to make food and fluid needs known to staff, date initiated 01/25/24, usually eats off every-day menu, date initiated 01/25/24, regular diet with cut meats and thin liquids, date initiated 09/12/23, staff helps Resident #16 fill out menus. Resident #16 usually changes her mind for lunch and dinner once food is delivered in dining room and will order off Every-Day Menu. Or if eating in room CNA will come to kitchen asking for alternate meal if she changes her mind once delivered in her room. Staff honors food preferences. Sometimes just sits in dining room not touching meal for extended time and then will eat. Sometimes just picks at food or eats very slowly. Not a big eater. Will drink Ensure at times if eats poorly. Drinking supplements date initiated 01/25/24. Record Review of Resident #16's physician orders dated 10/07/23 documented a daily supplement drink, on 09/06/23 a different supplement drink three times a day, on 08/28/23 regular diet with cut meats and (thin) regular consistency. Record review of Resident #16's undated electronic food preferences revealed mustard in her dislikes. Record review or Resident #16's daily menus dated 01/23/24, 01/24/24, and 01/25/24 did not indicate any preferences, likes or dislikes, nor any preferences, likes or dislikes on the Every-Day menus. Observation and interview on 01/23/24 at 2:28 pm, Resident #16 was observed with an uneaten hamburger on her tray in her room. She stated it had mustard all over it and she was not going to eat it because she has requested only light mayonnaise. Resident #16 stated she was quite upset because this happened all the time. Interviews with CNAs A and B on 01/24/24 at 10:40 am revealed they sometimes helped residents with their menus daily. They stated they did not refer to the resident's preference sheets nor knew where to locate them. They stated the daily menus were generic, and they circled what the resident chose from the list, or circled the always menu, that was printed on the back of the daily menus. Interview with the DM on 01/25/24 at 8:54 am provided preference cards and a diet information sheet dated 02/05/23 from the family of Resident #3. The DM stated Resident #3 had a favorite of Asian food, and when they present it, she told them she didn't want it. If they give her time, she will eat it 100%. The DM stated they address this (preferences) in the care plan. She stated she documented new admits likes and dislikes in the electronic record and the diet roster. The DM stated she did not know if the staff referred to the preference sheets in the electronic record. The DM stated she was responsible for making sure the staff and the residents were honoring the resident's preferences. The DM stated the nursing staff helped with the menus daily and the kitchen staff just goes by what was on the daily menu without comparing it to the resident's preference sheets. The DM stated she believed the nursing staff was filling in condiments and such without actually asking the residents what they preferred. Interview with the DCS on 01/25/2024 at 3:26 pm stated residents had choices of dining in their room or in the dining room and they got snacks throughout the day. The DCS stated residents had options and staff documented what they (the resident's) want, and the residents can get whatever they want. She stated, it (food preferences) was a very liberal plan here, not rigid at all. They DCS stated she did not have a clue as to how residents were getting condiments or any food they did not want. The DCS stated this was a problem. The DCS stated nutritional issues could arise with residents not eating the food they did not like. The DCS stated the resident's had a right to choose what they want and do not want to eat. Record review of the Every Day menu revealed All beef hot dog (mustard/mayo/ketchup/relish). Hamburger w fries (lettuce/tomato/onion/mustard/mayo/ketchup A facility policy on resident food preferences was requested, but not provided.

Based on observation, interview, and record review, the facility failed to treat each resident with dignity and respect and care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for eight of twelve residents (Resident #1, Resident #2, Resident #18, and Resident #20, and four anonymous residents) reviewed for resident rights, in that: The facility failed to: A.) allow Resident #1 and Resident #2, who were able to communicate and on a pureed diet, have the ability to choose their meals. B.) allow Resident #18 and Resident #20, AnonRes# 1, AnonRes #2, AnonRes#3, and AnonRes#4 who were on a regular diet, have the ability to choose their meals. These failures placed residents at risk for an undignified existence due to the lack of the right of self-determination. Findings included: A.) Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's most recent MDS, dated [DATE], reflected a BIMS of 10, indicating a mild cognitive impairment. Review of Resident #1's physician's diet order, dated 8/13/21, reflected the following: Pureed (Level 4) texture, thin (regular) consistency Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's most recent MDS, dated [DATE], reflected a BIMS of 10, indicating a mild cognitive impairment. Review of Resident #2's physician's diet order, dated 3/13/21, reflected the following: Pureed (Level 4) texture, Mildly Thick (Nectar) consistency, Pleasure feedings of pureed textures only During an observation and interview on 9/28/21 at 8:40 AM, revealed DA I delivered Resident #2 his breakfast tray. The Surveyor asked to see his meal ticket, reflecting no food options were circled. DA I stated Resident #2 was on a puree diet, so he did not get a choice. He stated the residents who have a pureed diet just get whatever the cook had prepared. During an observation and interview on 9/28/21 at 8:42 AM, revealed Resident #1 and Resident #2 eating their breakfast which were identical. Resident #1 stated he had never chosen what he ate for meals. He stated it would be nice to be able to have the choice, instead of eating whatever was put in front of him. Resident #2 agreed and stated he did not know that was an option. During an interview on 9/28/21 at 8:46 AM, CNA B and CNA C both stated they assisted residents with filling out their meal tickets. They both stated residents that were on a puree diet did not get a choice. When they were asked why that was the case, they stated, That's a good question. During an interview on 9/28/21 at 1:02 PM, Resident #2's family member stated she was not aware he had the choice of what meals he was served. She stated he would love to be able to choose his meals and have an option every day. B.) Review of Resident #18's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's most recent MDS, dated [DATE], reflected a BIMS of 5, indicating a severe cognitive impairment. During an interview on 9/30/21 at 10:10 AM, Resident #18 stated sometimes the aides will ask her which meal option she wanted , but most of the time they just circled a meal on her meal ticket without asking her. Review of Resident #20's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's most recent MDS, dated [DATE], reflected a BIMS of 12, indicating no cognitive impairment. During an interview on 9/29/21 at 9:54 AM, Resident #20 stated she had no idea she had an option to choose another meal. She stated she just ate whatever was put in front of her. She stated she would love to be able to make her own choice regarding her meals daily. Observation on 9/29/21 at 11:22 AM, revealed Resident #20 asking a staff member if she really had a choice for meals. She told the staff member she had never been told that she had an option, and she was glad to know that she did. During a confidential interview on 9/29/21 at 10:28 AM with eight residents and one resident's family member, four of the eight residents stated they have never been asked which meal they wanted. They stated they were not aware there was an option. They stated they just ate whatever was put in front of them. They were not aware they could ask for something different if they did not like what they were served. They stated they would love to have the option, and it would make them feel like they still had control of something in their lives. The resident's family member that was in attendance stated his wife was not asked what she wanted to eat, she was given and ate whatever was put in front of her. During an interview on 9/30/21 at 9:40 AM, Cook A stated there was usually two meals prepared for the residents that were on a pureed diet. She stated there were some foods that were easier to puree than others. She stated if there was not anything circled on a resident's meal ticket, she would ask a dietary aide which meal or option the resident would prefer. During an interview on 9/30/21 at 11:43 AM, the ADM stated she expected all residents, that had the ability cognitively to choose their meal, should have the right to choose their meal and food options. She stated the aides should be assisting residents with filling out their meal tickets daily. She stated if a resident is on a pureed diet and was cognitively able to choose what they would like to eat, they should also be given the choice of what they want to eat. She stated if for the residents that were not cognitively able to choose their meal preference, the families were involved in familiarizing the staff of the residents' preferences. She stated it was important for all residents to be able to utilize their right of choices. Review of the facility's Resident Food Preferences Policy, revised July of 2017, reflected the following: 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain personal hygiene for one (Resident #19) of six residents reviewed for ADLs, in that: The facility failed to provide showers to Resident #19 in compliance with his shower schedule. This deficient practice placed residents at risk of a decline in their sense of well-being, neglect of hygiene, and feeling of self-worth. Findings included: Review of Resident #19's undated face sheet reflected a [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's most recent MDS, dated [DATE], reflected a BIMS of 10, indicating a mild cognitive impairment. Review of Resident #19's most recent care plan, dated 9/14/21, reflected he had an ADL self-care performance deficit and was totally dependent on one staff to provide bath/shower per schedule (every Thursday) and as necessary. Review of Resident #19's bathing tasks in his electronic medical record reflected he had not received a shower in the past 30 days, from 8/30/21 to 9/28/21. During an observation and interview on 9/28/21 at 9:45 AM, Resident #19's his scalp was greasy, and the back of his hair was disheveled. He stated he had not received a shower in weeks because he prefers a male, and the facility had not had a full-time male aide in quite some time. He stated he did not think it was much to ask for one shower a week. He stated not receiving showers made him feel dirty and gross. During an interview on 9/29/21 at 1:50 PM, Resident #19's friend, FR G stated she was aware he had not been showered in a long time. She stated his preference was for only males to bathe him. She stated Resident #19's other friend (FR H) always attended his care plan meetings, so she would know more if the issue/concern had been discussed with the staff. During an interview on 9/30/21 at 10:04 AM, Resident #19's friend, FR H stated she attended all of his care plan meetings, usually via a video conference call. She stated the staff were well aware that Resident #19 preferred a male for bathing. She stated she would expect that if they did not have a male working full-time, that they call in a male agency staff member. She stated it was unacceptable for him to go weeks without receiving a shower. During an interview on 9/30/21 at 9:30 AM with the DON, he stated his expectations were that residents were bathed three times a week or according to their bathing preferences. He stated their electronic medical chart system populates data and an alert would pop up if a resident had not received a shower, unless they had refused. He stated if a resident refused a shower, he would expect the aide try again at another time of the day or ask another staff member to re-approach. He stated he was aware that Resident #19 preferred a male for bathing. When he was told that according to his bathing task log, it would appear he had not received a shower in over a month. He stated that the aides were probably documenting wrong, as there had been a male aide that worked the weekend prior (9/24 - 9/25). When asked why he had not attempted to shower Resident #19, he stated he was not sure. He stated it was important for the residents to receive a shower at least 3 times a week to prevent skin breakdown, rashes, or a lack of dignity. During an interview on 9/30/21 at 10:02 AM with CNA A, she stated Resident #19 preferred a male aide for showers. She stated she and the other female aides did not offer him showers because they knew he would refuse. She stated they did not inform the charge nurse because they were also aware he would only allow a male to shower him. During an interview on 9/30/21 at 11:43 with the ADM, she stated her expectations were that residents were offered a shower according to their preferences in order to meet their needs. She stated if a resident refuses a shower, it should be documented as such. She stated the charge nurses, and ultimately the nurse management team, should be over-seeing that showers are being completed and documented. She stated she was aware that Resident #19's preference was a male when it came to bathing. She stated she was not aware he had not been receiving a shower. She stated it was important for residents to receive showers regularly to help prevent skin breakdown. Review of the facility's staffing sheets for the month of September reflected a male aide worked on the weekend of 9/24/21 - 9/25/21. Review of the facility's In-Service Education Report, dated 9/24/21, reflected that staff should be documenting showers. If a resident refused a shower the CNA must notify their charge nurse of the refusal and chart it in their electronic medical chart (A bed bath counts as a shower and needed to be charted as such). The charge nurses must go see why the resident refused the shower, offer an alternative, and complete a progress note documenting what they discussed with the resident.

Based on interview, observation, 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 to help prevent the development and transmission of communicable diseases and infection for the residents in the facility for three of four staff members (MA E, CNA C, and LVN F) reviewed, in that: A.) MA E failed to sanitize the vital signs machine before and after taking the blood pressure of three residents in three separate rooms. B.) CNA C failed to discard dirty wipes and use clean wipes during peri care for Resident #13 as she used the same wipe for three-five swipes before discarding. C.) LVN F failed to change her gloves between cleaning the wound and applying the dressing when providing wound care to Resident #13. She did not use a clean piece of gauze to dry the wound after using the same piece of gauze to cleanse the wound. These failures placed residents at risk for cross-contamination and the spread of infection. Findings included: A.) Observation on 9/28/21 at 7:18 AM revealed MA E taking the vital signs machine (without observation of sanitization of the machine) out of a resident room and into another resident room. He then took the VSM out of that resident room and into another resident room (without observation of sanitization of the machine). During an interview on 9/28/21 at 8:26 AM with MA E, he stated he sanitized the VSM at the beginning of his shifts. When asked about sanitizing the VSM between residents, he stated he usually did, and pointed to a pack of aloe personal wipes. When asked if the wipes were on the EPA approved list, he did not answer. When told he was observed taking the VSM in and out of three resident rooms without sanitizing the machine, he stated he usually cleaned it between residents. During an interview on 9/30/21 at 12:07 PM with LVN G, Charge Nurse, she stated it was not acceptable to use personal wipes to sanitize equipment because they do not contain and germicidal or sanitizing agents. Equipment should be cleaned between each resident contact. During an interview on 9/30/21 at 11:44 AM with the ADM, she stated using aloe personal wipes were not adequate for sanitizing equipment between residents. She stated it was her expectations were that the equipment be sanitized between residents with actual sanitizing wipes to kill germs and potentially stop the spread of infection. Review of the facility's In-Service Education Report, dated 7/29/21, reflected the following: ATTENTON ALL HEALTHCARE STAFF This is a reminder that ALL equipment that is used on more than one resident (V/S machine, glucometer, etc) MUST be cleaned/wiped down between resident use in order to prevent the spread of infections. . Use the Purple top wipes if available (2 min drying time), or use the Lysol blue top wipes, Lysol yellow bag wipes (4 minute drying time). Review of the facility's Cleaning and Disinfection of Resident-Care Items and Equipment Policy, revised October of 2018, reflected the following: 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: . c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical resident-care items include bedpans, blood pressure cuffs . (2) Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location). . 7. Intermediate and low-level disinfectants for non-critical items include: a. Ethyl or [MEDICATION(S)] alcohol; b. Sodium hypochlorite (5.25-6.15% diluted 1:500 or per manufacturer's instructions); c. Phenolic germicidal detergents; d. [MEDICATION(S)] germicidal detergents; and e. Quaternary ammonium germicidal detergents B.) Review of Resident #13's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's MDS, dated [DATE], reflected he had a severe cognitive impairment and is rarely understood. Review of Resident #13's care plan, dated 7/15/21, reflected he required extensive assistance of a two-person physical assist during incontinent care. Observation on 9/28/21 at 7:40 AM revealed CNA B and CNA C entering Resident #13's room to perform peri care. CNA C performed hand hygiene and donned gloves. She un-taped the resident's brief and rolled it down. She grabbed a wipe from the wipe-warmer and wiped front creases and suprapubic area (three swipes with one wipe). She then grabbed another wipe from the warmer and used it to clean the penis and head of the penis (five swipes for one wipe). She put on clean gloves, removed the brief, and turned the resident on his left side. She used one wipe for four swipes and grabbed a new wipe. She wiped the resident's rectal area and there was a brown smear on the wipe. She folded the wipe in half and wiped again which also had a brown smear. She folded the wipe in half again and wiped his rectal area and changed gloves. CNA B and CNA C assisted Resident #13 to his wheelchair using a mechanical lift. CNA C picked up some trash off the floor and threw it in the trash can. She grabbed a wipe from the wipe-warmer with the same gloves and proceeded to clean his face with the wipe. During an interview on 9/28/21 at 7:58 AM with CNA C, she stated she changed her gloves frequently but admitted she had not washed her hands or used hand sanitizer between glove changes. She stated that she was supposed to sanitize or wash between glove changes. She stated she had heard of the phrase One wipe, one swipe, but denied she had used a wipe for more than one swipe. She did acknowledge the folding of the wipe when there was a brown smear, but stated she used the clean part when re-swiping the area. During an interview on 9/30/21 at 10:08 AM with the DON, he stated wipes should be used only once and then thrown away. He stated gloves should be changed in between clean and dirty. Review of the facility's Perineal Care Policy, revised October of 2010, reflected it did not address the use of wipes, but rather the use of a washcloth and water. C. Review of Resident #13's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 9/29/21 at 9:38 AM revealed RN F performing wound care on Resident #13. LVN F gathered supplies and dated the dressing. She entered the room, performed hand hygiene, and donned gloves. CNA D held up Resident #13's leg. LVN F removed the old dressing which had some drainage, no odor detected. The center of the wound was open, smaller than the size of a dime. The edges were macerated, peri-wound slightly elevated. LVN F removed her gloves, performed hand hygiene, and put on new gloves. She grabbed a piece of gauze and rinsed the wound with saline, wiped with the now saline-moist gauze. She then folded the piece of gauze and used the same gauze to pat dry the wound. She then put the collage powder on the dressing and applied the dressing to the wound without removing her gloves to put on new gloves. During an interview on 9/29/21 at 9:48 AM with LVN F, she stated she had been in-serviced on hand hygiene. When asked about times gloves should be changed during wound care, she stated she had changed gloves multiple times. When asked if she had ever been told to change gloves between the dirty and clean tasks, she was not sure what that meant. When asked if she should have changed gloves after cleaning the wound, since the gloves were then potentially contaminated from the dirty would, before patting the wound dry, she stated she had not seen any contamination on her gloves because she was touching only the gauze and her gloves had never touched the wound. She was asked if using the same piece of gauze to clean the wound, now the dirty gauze and clean wound, and then patting it dry was acceptable because that could potentially make the wound dirty again. She stated she had folded the gauze and used a dry piece of the gaze not the wet part that she had cleaned the wound with. RN F admitted she could see how not changing gloves between dirty and clean could spread infections or germs. She stated using the same piece of gauze could cause contamination of the spreading of germs. During an interview with on 9/30/21 at 10:08 AM with the DON, he stated LVNF should hae used a clean gauze to dry the wound. He stated she should have changed gloves in between cleaning the wound and applying medication to the wound. He stated this deficient practice could cause cross-contamination. Review of the facility's Dressings, Dry/Clean Policy, revised September of 2013, reflected the following: 16. Use dry gauze to pat the wound dry.

Based on interview and record review the facility failed to ensure resident was free from neglect for 1 of 7 residents reviewed for neglect (Resident #3). A. CNA A failed to report to nursing staff resident #3 was in pain and needed pain medications. This failure had the potential to affect 43 residents who resided on Halls 100 and 200 if the facility staff failed to provide pain medications when the resident requested the medications. Findings include: A. Record review Resident #3 admission record revealed a admission date of [DATE] with the following [DIAGNOSES REDACTED]. Record review of Resident #3's Minimum Data Set ((MDS) dated [DATE] Section C reflected a Brief Interview for Mental Status (BIMS) of 14 which indicates resident mental status as cognitively intact. Observation and interview with Resident #3 was not available, Resident #3 discharged home on[DATE]. Surveyor called Resident #3 on 3/8/17 at 12:02 PM and left a message, resident has not returned the phone call. In an interview on 3/8/17 at 3:15 p.m. the Administrator (ADM) stated the weekend supervisor (WSPV) notified her that Resident #3 was neglected by nurses for not giving her pain meds when requested. The administrator stated she spoke with Resident #3 and she stated she was having pain on 1/27/17 and requested pain medications. The Administrator stated Resident #3 stated she told CNA A she needed some pain meds and thought CNA A told the nurses on duty. The ADM stated Resident #3 said it took so long for someone to bring her some pain medications she decided to walk to the nurse's station and ask for pain meds herself. Resident #3 stated to ADM she told the WSPV she felt helpless and neglected on 1/27/17 during the 2-10 shift. ADM stated RN B, LVN C were suspended and then counseled on the expectations of responding to residents. ADM stated CNA A was suspended, counseled, and then terminated due to verbal abuse to Resident #2. ADM stated she still did not know if CNA A informed RN B and LVN C about Resident #3 needing pain medications. ADM stated she decided to suspend and counsel all three employees involved, unfortunately CNA A was terminated for another incident. In an interview on 3/8/17 at 2:30 PM Registered Nurse (RN) B stated she remembers Resident #3 coming to the nurse's station to request some pain medications. RN B stated she told Licensed Vocational Nurse (LVN) C to give Resident #3 some pain medications. RN B stated LVN C gave Resident #3 two [MEDICATION NAME]-[MEDICATION NAME] tablets 10-325 milligrams (mg) as needed (PRN) around 4:00 PM. RN B stated LVN C also give Resident #3 some more pain meds later that evening. RN B stated CNA A never told her Resident #3 was requesting pain medications prior to Resident # 3 coming to the nurses station. Review of Resident #3's Medication Administration Record [REDACTED] [MEDICATION NAME]-[MEDICATION NAME] tablet 10-325 mg. Give 1 tablet by mouth every 4 hours as needed for pain - moderate hold for sedation. [MEDICATION NAME]-[MEDICATION NAME] tablet 10-325 mg. Give 2 tablet by mouth every 4 hours as needed for pain - moderate hold for sedation. [MEDICATION NAME] Tablet 10-325 ([MEDICATION NAME]-[MEDICATION NAME]) Give 2 tablet by mouth in the morning for pain give 2 tabs by mouth (po) daily (Q) in the morning 30 minutes prior to therapy. Tylenol Tablet 325 mg give 1 tablet po Q 4 hours PRN for pain. Tylenol Tablet 325 mg give 2 tablet po Q 4 hours PRN for pain In a phone interview on 3/8/17 at 2:48 A.M. LVN C stated she was told by RN B to give Resident #3 some medication for pain. LVN C stated she remembered Resident #3 being at the nurse's station requesting some pain medication. LVN C remembers giving Resident #3 some Flexiril (muscle relaxer) and Senna (stool softener) along with her 8:00 P.M. pain meds because she was complaining of having muscle spasms and constipation. LVN C stated she does remember CNA A telling her Resident #3 was complaining of constipation, but never stated Resident #3 was in pain and requesting pain meds. Record review of WSPV's written statement on 1/28/17 reflected the following: Spoke with CNA A that work day. CNA informed me she was in another resident's room shortly after arriving to the floor for the 2-10 shift and heard a light go off, she proceeded to Resident #3's room and Resident #3 requested a pain pill. CNA A informed me she went and asked a Certified Medication Aide (CMA) if Resident #3 had anything scheduled and there was nothing due until the evening. CNA A went back to inform Resident #3 she didn't have anything scheduled and Resident #3 stated she could have something every four hours. CNA A stated she told the resident those are your PRN meds, I will let the nurse know. CNA A stated to WSPV she told RN B and LVN C Resident #3 wanted some pain medication. WSPV stated CNA A stated Resident #3 spoke with her again and Resident #3 wanted to speak to the Nurse Practitioner (NP) about her pain meds. CNA A stated she informed RN B and LVN C about Resident #3 wanting pain meds and wanting to speak to the NP. CNA A stated both nurses were at the nurse's station when she told them what Resident #3 wanted. Then later around dinner time CNA A answered Resident #3 call light again, and Resident #3 stated she wanted to talk to the nurses or she was going to call 911. Attempted phone interview on 3/8/17 at 2:07 PM with CNA A was not successful a message could not be left because CNA's mailbox was full, and there was no other number for contact. Attempted phone interview on 3/8/17 to WSPV was not successful, surveyor asked ADM to give WSPV her number so WSPV could call back. WSPV called surveyor on 3/10/17 (Saturday) surveyor was not available to answer phone call. Surveyor called WSPV back on 3/13/17 and left a message. Review of CNA A personnel chart reflected a Separation Notice dated 1/31/17, CNA A was terminated due to confirmation of alleged verbal abuse. Record review Conversation forms for RN B and LVN C reflected both were counseled on 2/3/17 and 2/6/17 in regards to expectations of responding to residents. Review of the facility's policy and procedure titled Abuse Prevention Policy undated, reflected the following: Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. Neglect is defined as failure to provide goods and services necessary to avid physical harm, mental anguish, or mental illness. The facility undated healthcare census list reflected 43 residents who resided on Halls 100 and 200 who were cared for by CNA A.

Based on interview and record review the facility failed implement writtten policies to ensure resident was free from neglect for 1of 7 residents reviewed for neglect (Resident #3). A. CNA A failed to report to nursing staff resident #3 was in pain and needed pain medications. This failure had the potential to affect 43 residents who resided on Halls 100 and 200 if the facility staff failed to provide pain medications when the resident requested the medications. Findings include: A. Review of the facility's policy and procedure titled Abuse Prevention Policy undated, reflected the following: Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. Neglect is defined as failure to provide goods and services necessary to avid physical harm, mental anguish, or mental illness. Record review Resident #3 admission record revealed a admission date of [DATE] with the following [DIAGNOSES REDACTED]. Record review of Resident #3's Minimum Data Set ((MDS) dated [DATE] Section C reflected a Brief Interview for Mental Status (BIMS) of 14 which indicates resident mental status as cognitively intact. Observation and interview with Resident #3 was not available, Resident #3 discharged home on[DATE]. Surveyor called Resident #3 on 3/8/17 at 12:02 PM and left a message, resident has not returned the phone call. In an interview on 3/8/17 at 3:15 p.m. the Administrator (ADM) stated the weekend supervisor (WSPV) notified her that Resident #3 was neglected by nurses for not giving her pain meds when requested. The administrator stated she spoke with Resident #3 and she stated she was having pain on 1/27/17 and requested pain medications. The Administrator stated Resident #3 stated she told CNA A she needed some pain meds and thought CNA A told the nurses on duty. The ADM stated Resident #3 said it took so long for someone to bring her some pain medications she decided to walk to the nurse's station and ask for pain meds herself. Resident #3 stated to ADM she told the WSPV she felt helpless and neglected on 1/27/17 during the 2-10 shift. ADM stated RN B, LVN C were suspended and then counseled on the expectations of responding to residents. ADM stated CNA A was suspended, counseled, and then terminated due to verbal abuse to Resident #2. ADM stated she still did not know if CNA A informed RN B and LVN C about Resident #3 needing pain medications. ADM stated she decided to suspend and counsel all three employees involved, unfortunately CNA A was terminated for another incident. In an interview on 3/8/17 at 2:30 PM Registered Nurse (RN) B stated she remembers Resident #3 coming to the nurse's station to request some pain medications. RN B stated she told Licensed Vocational Nurse (LVN) C to give Resident #3 some pain medications. RN B stated LVN C gave Resident #3 two [MEDICATION NAME]-[MEDICATION NAME] tablets 10-325 milligrams (mg) as needed (PRN) around 4:00 PM. RN B stated LVN C also give Resident #3 some more pain meds later that evening. RN B stated CNA A never told her Resident #3 was requesting pain medications prior to Resident # 3 coming to the nurses station. Review of Resident #3's Medication Administration Record [REDACTED] [MEDICATION NAME]-[MEDICATION NAME] tablet 10-325 mg. Give 1 tablet by mouth every 4 hours as needed for pain - moderate hold for sedation. [MEDICATION NAME]-[MEDICATION NAME] tablet 10-325 mg. Give 2 tablet by mouth every 4 hours as needed for pain - moderate hold for sedation. [MEDICATION NAME] Tablet 10-325 ([MEDICATION NAME]-[MEDICATION NAME]) Give 2 tablet by mouth in the morning for pain give 2 tabs by mouth (po) daily (Q) in the morning 30 minutes prior to therapy. Tylenol Tablet 325 mg give 1 tablet po Q 4 hours PRN for pain. Tylenol Tablet 325 mg give 2 tablet po Q 4 hours PRN for pain In a phone interview on 3/8/17 at 2:48 A.M. LVN C stated she was told by RN B to give Resident #3 some medication for pain. LVN C stated she remembered Resident #3 being at the nurse's station requesting some pain medication. LVN C remembers giving Resident #3 some Flexiril (muscle relaxer) and Senna (stool softener) along with her 8:00 P.M. pain meds because she was complaining of having muscle spasms and constipation. LVN C stated she does remember CNA A telling her Resident #3 was complaining of constipation, but never stated Resident #3 was in pain and requesting pain meds. Record review of WSPV's written statement on 1/28/17 reflected the following: Spoke with CNA A that work day. CNA informed me she was in another resident's room shortly after arriving to the floor for the 2-10 shift and heard a light go off, she proceeded to Resident #3's room and Resident #3 requested a pain pill. CNA A informed me she went and asked a Certified Medication Aide (CMA) if Resident #3 had anything scheduled and there was nothing due until the evening. CNA A went back to inform Resident #3 she didn't have anything scheduled and Resident #3 stated she could have something every four hours. CNA A stated she told the resident those are your PRN meds, I will let the nurse know. CNA A stated to WSPV she told RN B and LVN C Resident #3 wanted some pain medication. WSPV stated CNA A stated Resident #3 spoke with her again and Resident #3 wanted to speak to the Nurse Practitioner (NP) about her pain meds. CNA A stated she informed RN B and LVN C about Resident #3 wanting pain meds and wanting to speak to the NP. CNA A stated both nurses were at the nurse's station when she told them what Resident #3 wanted. Then later around dinner time CNA A answered Resident #3 call light again, and Resident #3 stated she wanted to talk to the nurses or she was going to call 911. Attempted phone interview on 3/8/17 at 2:07 PM with CNA A was not successful a message could not be left because CNA's mailbox was full, and there was no other number for contact. Attempted phone interview on 3/8/17 to WSPV was not successful, surveyor asked ADM to give WSPV her number so WSPV could call back. WSPV called surveyor on 3/10/17 (Saturday) surveyor was not available to answer phone call. Surveyor called WSPV back on 3/13/17 and left a message. Review of CNA A personnel chart reflected a Separation Notice dated 1/31/17, CNA A was terminated due to confirmation of alleged verbal abuse. Record review of Conversation forms for RN B and LVN C reflected both were counseled on 2/3/17 and 2/6/17 in regards to expectations of responding to residents. The facility undated healthcare census list reflected 43 residents who resided on Halls 100 and 200 who were cared for by CNA A.