Every finding on record at Parkview Skilled Care and Rehabilitation

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen (Kitchen A) reviewed for dietary services. The facility failed to allow the food processor container to air dry completely before using it to puree food on 8/4/26 and 8/5/26. This failure could place residents at risk for food contamination and foodborne illness.The findings included: Record Review of a Learn2Serve Certification certificate, dated 1/13/26, revealed the [NAME] had successfully completed the Texas Food Handler Education Training. Observations during the puree process on 8/4/26 from 11:11 AM to 11:41 AM, revealed that the [NAME] pureed carrots and cowboy beans in the food processor. After the carrots were pureed, the [NAME] transferred the food to a smaller container, then the [NAME] washed the food processor container in a 3-compartment sink and then placed the food processor container on a tray to go through a wash cycle in the dishwasher. The food processor container was removed from the tray when the wash cycle was completed. The food processor container was picked up and placed back on the machine with liquid dripping from the food processor container. Cowboy beans were added to the food processor container to puree. The cowboy beans were pureed and transferred to a smaller container. Observations during the puree process on 8/5/26 from 10:28 AM to 11:56 AM, revealed the [NAME] pureed baked chicken, cornbread, broccoli, and dinner rolls in the food processor. After the baked chicken was pureed, the [NAME] transferred the food to a smaller container. Then the [NAME] washed the food processor container in a 3-compartment sink and then placed the food processor container on a tray to go through a wash cycle in the dishwasher. The food processor container was removed from the tray when the wash cycle was completed. The food processor container was then placed on the serving table. Liquid was observed dripping from the food processor container. Cornbread was added to the food processor container and was placed on the machine to puree. The cornbread was pureed and transferred to a smaller container. Then the [NAME] washed the food processor container in a 3-compartment sink and placed the food processor container on a tray to go through a wash cycle in the dishwasher. The food processor container was removed from the tray when the wash cycle was completed and placed on the serving table with liquid dripping from the food processor container. Broccoli was added to the food processor container and was then placed on the machine to puree. The broccoli was pureed and transferred to a smaller container. Then the [NAME] washed the food processor container in a 3-compartment sink and then placed the food processor container on a tray to go through a wash cycle in the dishwasher. The food processor container was removed from the tray when the wash cycle was completed and placed on the serving table with liquid dripping from the food processor container. The [NAME] turned the food processor container upside down and shook it, liquid was observed falling out of the container. The [NAME] placed the food processor container on the serving table, added dinner rolls, and then placed it on the machine to puree. The dinner rolls were pureed and transferred to a smaller container. Observation on 8/5/26 at 12:10 PM, revealed a 5-gallon bucket of Liquid Sanitizer/Multi-use Chlorine Sanitizer/Sodium Hypochlorite Liquid Sanitizer was labeled: Keep out of reach of children. DANGER. This bucket sat next to a 5-gallon bucket of dish machine rinse additive and a 5-gallon bucket of dish machine detergent. All three buckets were stored on a shelf below the dishwasher. During an interview on 8/5/26 at 2:30 PM, the [NAME] stated she prepared lunch which included all meal textures on 8/4/26 and 8/5/26. The [NAME] stated the process of pureeing food was to first wash hands, apply gloves, place the food in the blender, add liquids as needed, and then taste for texture and flavor. The [NAME] stated after one puree she would rinse the food processor container in the dish pit and then run it in the dishwasher for sanitizing. The [NAME] stated she was to let the food processor container and all other dishes dry. The [NAME] stated then she would wash her hands, grab clean supplies for the next items to be pureed and then start the process again. The [NAME] stated all dishes were supposed to be air dry after they were sanitized in the dishwasher so that sanitizer did not get in the food. The [NAME] stated the liquid on wet dishes was sanitizer. The [NAME] stated she was trained in the sanitization and air-dry process but could not remember the last time she was trained. The [NAME] stated she was nervous and forgot to let the food processor container air dry before using it to puree the food. The [NAME] stated she was responsible for ensuring the food processor container was dry before she used it. The [NAME] stated She was aware today that she forgot to let the food processor container air-dry but was not aware she had done it yesterday as well. The [NAME] stated a potential negative outcome was cross contamination and residents could get sick. During an interview on 8/6/26 at 11:11 AM, the DM stated she had worked in the kitchen in this facility as a [NAME] prior to becoming the DM. The DM stated all dishes must be air-dry before using them to prepare food. The DM stated dishes must be dry, so the sanitizer did not get into the food. The DM stated she was aware the [NAME] was using a wet food processor container to prepare food when she observed the [NAME] puree food for the last two days. [TW13.1][AL13.2]The DM stated all kitchen staff were trained and had their food handlers training. The DM stated she was responsible for ensuring kitchen staff followed sanitation requirements. The DM stated she expected staff to follow what they learned in their courses and training and to ensure that utensils and dishes were dry. The DM stated she expected dietary staff to prevent cross contamination, complete hand hygiene, and to wear gloves as required. The DM stated a potential negative outcome was that food could get contaminated and residents could get sick. During an interview on 8/6/26 at 12:46 PM, the ADM stated all equipment in the kitchen must be air dry before it could be used to prepare food. The ADM stated she was aware when she observed the puree process that the [NAME] did not allow the food processor container to be air dry before she used it to prepare foods. The ADM stated the dietician monitored dietary staff monthly during their visits. The ADM stated all kitchen staff were trained in food preparation and sanitation. The ADM stated the DM and herself were responsible for ensuring staff followed the requirements. The ADM stated she expected staff to ensure all kitchen equipment and dishes were air dry before they were used. The ADM stated a potential negative outcome was that residents could get sick from bacteria. Record review of the facility guideline titled, General Cleaning and Sanitizing Guidelines, undated, reflected the following: There is an important difference between clean and sanitized. Both attributes are important in the food service department to maintain and health and well-being of the resident's and all others who consume food prepared and served from the food service department. Sanitizing involves reducing the number of germs or bacteria to safe level as judged by public health requirements. Sanitization occurs by enough accumulative heat or concentration of chemicals for enough time to reduce the bacterial count, including harmful bacteria, to a safe level on utensils and equipment. Whenever the food service director instructs an employee to clean equipment, a work surface, a storage area, or utensils or dishes, she/he should be sure the employee understands that the equipment must be sanitized as well as cleaned. Surfaces can look and actually be clean without being sanitized. It is the responsibility of all food service personnel to be aware of the need and the procedures of all food service personnel to be aware of the need and the procedures by which to clean and sanitize all areas of the kitchen.Sanitation can occur by means of application of heat or concentration of chemicals for enough time to reduce the bacterial count on surfaces of equipment and utensils. Common methods of sanitizing are (but not limited to): 5. Mechanical dishwasher using a chemical sanitizer, which is automatically dispensed into the final rinse according to the manufacturer's specification at temperature specified by the manufacturer. Once utensils and equipment have been cleaned and sanitized, they should be allowed to air dry; the use of towels may re-contaminate sanitized surfaces. Once equipment and utensils have been sanitized, they should be handled and stored to protect the equipment and utensil for re-contaminate.

Based on Observations, Interviews, and Record Review the facility failed to ensure residents were free from involuntary seclusion for 1 of 22 (Resident #7) residents reviewed for involuntary seclusion. The facility failed to obtain a physician order, documenting the clinical criteria met for placement in the secure/locked unit for Resident #7 on 08/04/2026. This failure could place residents at risk of isolation, decreased quality of life, and psychosocial harm. Findings included:Record review of the face sheet, dated 08/06/2026, revealed Resident #7 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included the following: Alzheimer's disease (progressive, irreversible brain disorder), dementia in other diseases classified elsewhere, severe with agitation (significant cognitive decline along with agitation), dementia in other diseases classified elsewhere, severe with psychotic disturbance (significant cognitive decline along with psychotic symptoms such as hallucinations, paranoia, suspiciousness, or delusions), insomnia (inability to sleep), anxiety disorder (mental health condition that causes excessive fear and worry), and major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest). Record review of Resident #7's quarterly MDS assessment, dated 06/25/2026, revealed Resident #7 had a BIMS score of 01, which indicated severely impaired cognition. Record review of the current care plan for Resident #7, undated, revealed a focus area that stated, The resident has impaired cognitive function/dementia or impaired thought processes r/t: DEMENTIA, ALZHEIMER'S DISEASE, Date Initiated: 03/26/2026., with the intervention and tasks that included, Promptly inform resident's primary physician and family members of any changes in cognitive status. The document included a focus area that stated, Resident is at high risk for elopement. Resident has attempted to leave the facility several times. Resident is appropriate to live on the secure unit due to benefitting from frequent staff interaction, as well as the quieter environment. This is the least restrictive environment for resident at this time. Date Initiated: 08/04/2026., with interventions and tasks that included, Consult with primary care physician and/or psychiatrist as needed. An additional focus area stated, Wander guard: At risk for elopement due to confusion and altered thought process, Date Initiated: 05/22/2026. with interventions and tasks that included, Have resident wear wander guard bracelet as ordered.Record review of the facility document titled, Secure Unit - Agreement to Reside Acknowledgement , dated 08/03/2026, stated the following: I prefer the secure unit and do not wish to move even though I have been offered in the past. I Understand that if I ever change my mind, I can move when a room off of the secure unit is available. Indicate reason for wanting to move: Elopement Risk. The document was signed by Resident #7's Responsible Party on 08/03/2026. Record review of Resident #7's physician orders, dated 08/05/2026, revealed Resident #7 did not have an active physician order for placement in a secure/locked unit. During an observation on 08/04/2026 at 11:30 AM Resident #7 was observed in the common area of the secure/locked unit. During an interview on 08/04/2026 at 12:15 PM RN B stated Resident #7 was moved to the secure/locked unit on this day, 08/04/2026, and Resident #7 was being monitored for behaviors of wandering and agitation. During an attempted interview on 08/04/2026 at 04:20 PM, Resident #7 was unable to articulate where she was currently residing or if she knew the code to open the door to the secure/locked unit. Resident #7 was not oriented with time and/ or place and was not able to be interviewed. During an observation and attempted interview on 08/05/2026 at 12:20 PM, Resident #7 was observed in the common area of the secure/locked unit. Resident #7 was not oriented with time and/or place and was not able to be interviewed. During an interview on 08/06/2026 at 11:45 AM the DON stated it was the facility's policy to obtain a physician's order prior to placing a resident in a secure/locked unit. The DON stated prior to placing a resident on the secure/locked unit, the resident was assessed to determine if they met the criteria for the unit, which included an assessment for elopement risk and monitoring for behaviors. The DON stated the facility also included the resident's family/representative and physician in the discussion to ensure all parties were involved in the decision. The DON stated Resident #7 was assessed and met the criteria for the secure/locked unit. The DON stated Resident #7 was exhibiting behaviors that they felt required more supervision, and the decision was made to move her to the secure/locked unit. The DON stated Resident #7 was overstimulated and the secure/locked unit was quieter. The DON stated Resident #7's representative was contacted and also agreed with the decision. The DON stated a consent was signed by Resident #7's representative prior to the move. The DON stated the decision to move Resident #7 to a secure/locked unit was discussed as a possibility with the resident's physician when the resident was first admitted to the facility in March 2026 and ongoing since then. The DON stated a physician's order was not obtained prior to moving Resident #7 to the secure/locked unit. The DON stated the nurse in charge of moving a resident to the secure/locked unit was responsible for obtaining and entering the physician's order prior to moving the resident. The DON stated she was responsible for obtaining the physician's order for Resident #7, but she overlooked obtaining the order. The DON stated the facility completed an audit of all residents' physician orders for the secure/locked unit weekly or bi-weekly. The DON stated the facility would have noticed the missing order when this audit was completed. The DON stated the physician's order was obtained on 08/06/2026 and entered into the Resident's chart online. The DON stated it was her expectation that the physician's order be obtained prior to moving a resident to the secure/locked unit. The DON stated it was important to obtain a physician's order prior to moving a resident to the secure/locked unit to ensure the resident's physician was aware at all times and to ensure the facility was following the physician's orders. During an interview on 08/06/2026 at 12:00 PM the ADM stated the facility's process, prior to moving a resident to a secure/locked unit, included assessing the resident, obtaining consent from the resident's family, obtaining a physician's order, and updating the resident's care plan. The ADM stated she was not aware a physician's order was not obtained for Resident #7 prior to moving the resident to the secure/locked unit. The ADM stated the DON told her she forgot to obtain the order. The ADM stated the DON and ADM were responsible for ensuring the physician's order was obtained. The ADM stated the nurse who initiated the move was responsible for obtaining the physician's order. The ADM stated the DON initiated the move for Resident #7. The ADM stated Resident #7 was moved to the secure/locked unit on 08/04/2026. The ADM stated the physician's order was obtained on 08/06/2026. The ADM stated nursing staff completed an audit of all residents' physician's orders regularly, and the ADM followed up with her own audit to ensure all orders were accurate. The ADM stated the decision to move Resident #7 to a secure/locked unit was discussed with eh resident's representative due to the resident exhibiting behaviors of wandering, and the resident was an elopement risk, The ADM stated the facility also felt the resident would benefit from a quieter environment with more supervision. The ADM stated a consent was signed by the resident's representative prior to moving the resident to the secure/locked unit. The ADM stated it was her expectation that the physician's order was obtained timely. The ADM stated it was important to ensure the order was obtained timely, so the resident's physician was aware and agreed with the decision made for residents. An attempted telephone interview was made on 08/06/2026 at 12:20 PM, to the physician for Resident #7 with no response. Record Review of the facility's policy titled Guidelines for Restraints , undated, revealed the following: PURPOSE:If a resident is evaluated and needs a physical restraint, a systematic approach will be followed to assure all areas are addressed during the initiation or change of a restraint. GUIDELINE::1) If an evaluation indicates a risk for safety, and the Interdisciplinary Team concurs that restraint usage is necessary, the resident will be evaluated for intervention, as appropriate. Recommendation will be an interdisciplinary process.a. The least restrictive device for the resident will be determined, based on individual needs.b. Orders will be obtained from the physician. c. Consent form will be presented to the resident and/or family for signature.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and maintained in accordance with currently accepted professional standards for 1 of 2 medication carts (Medication Cart 1) reviewed for storage.The facility failed to ensure CMA C ensured Medication Cart 1 was locked before walking into room [ROOM NUMBER] on 8/5/2026. This failure could result in misappropriation of medication, or medication errors.The findings include: During an observation of Hall 3 on 08/05/2026 at 11:28AM, Medication Cart 1 was found to be unlocked. The drawers 3 and 4 on the medication cart were able to be opened and contained resident's medications with no staff within sight or reach of Medication Cart 1. CMA C was observed opening the door to room [ROOM NUMBER] and exiting the room. CMA C walked to Medication Cart 1. During an interview on 08/05/2026 at 11:29AM, CMA C stated she was responsible for Medication Cart 1 at that time. She stated she was passing out medication to residents and forgot to lock it before entering room [ROOM NUMBER]. She stated a potential negative risk could be residents getting into the medication cart, or someone taking medication that is not theirs. CMA C confirmed the Medication cart 1 had not been locked. During an interview on 8/06/2026 at 11:11AM, the DON stated staff had been trained on medication carts and training is conducted monthly. She stated the training goes over medication cart cleanliness, storage, and stocking medication. She stated if staff walked away from the medication carts, and are not within reach or direct eyesight, then the medication carts need to be locked. She stated a potential negative outcome could be medication errors, or misappropriation of medication. She stated the pharmacy consultant also conducts observation rounds during their visits and monitors the medication carts and if there are any concerns. She said the consultant would discuss concerns with the DON. During an interview on 8/06/2026 at 11:30AM, the ADM stated staff are trained on medication carts annually and as needed. She stated staff should be locking the medication carts when they are not actively being used. She stated a potential negative outcome of medication carts being left open could be residents getting into the cart. Record review of facility policy titled Storage of Medication Guidelines undated revealed The purpose of this guideline is to ensure that medications are stored in a safe, secure, and orderly manner.40) compartments containing medication are locked when not in use.

Based on observations, interviews, and record reviews, the facility failed to ensure menus were followed for 1 of 2 meals observed. (Lunch meal 8/4/26) The facility failed to follow the week 5 menu for pureed lunch meals served at the facility on Tuesday 8/4/26 by not serving or substituting all food items listed on the menu. This failure could place residents that eat food from the kitchen at risk of poor intake, and/or weight loss. The findings included: Record review of the Tuesday (Day 31) Week 5 menu, dated 2026, revealed the lunch menu was mustard fried catfish, cowboy beans, steamed baby carrots, hush puppies, garnish: lemon wedge, and ambrosia.Observation on 8/4/26 at 12:15 PM of dining room revealed pureed lunch meal trays served included mustard fried catfish, cowboy beans, and steamed baby carrots. No pureed hush puppies were observed on the plates nor was there a food item served to substitute the missing hush puppies. Observation on 8/4/26 at 1:05 PM of the dining room revealed pureed lunch meal trays served in the dining room on the secured unit included mustard fried catfish, cowboy beans, and steamed baby carrots. No pureed hush puppies were observed on the plates. During an interview on 8/5/26 at 2:30 PM, the [NAME] stated she prepared and served the lunch puree meals on 8/4/26. The [NAME] stated she should have served pureed hush puppies with the lunch meal on 8/4/26. The [NAME] stated she realized the hush puppies were missing when she served the last couple of trays. The [NAME] stated she got nervous and forgot to puree the hush puppies. The [NAME] stated all ingredients on the menu add up to a certain amount of nutrition and calories and all residents were supposed to get each food group on each meal. The [NAME] stated it was important for residents to get all food items because their body needed the nutrition. The [NAME] stated she was trained in following the menu and substitutions but was not sure when her last training was. The [NAME] stated she was responsible for ensuring the hush puppies were served on the pureed food trays. She stated the negative outcome was that residents could get sick and their body could start shutting down. During an interview on 8/6/26 at 11:11 AM, the DM stated they must serve all food items listed on the menu because it was approved by the dietitian and was based on the residents' requirements of what they could and could not eat. The DM stated all textures must get everything served on the menu for that meal or the item must be replaced by an approved substitution. The DM stated she was not aware residents were not served all items listed on the menu. The DM stated the system they used to ensure menus were followed was that the resident's ticket indicated what they're supposed to get served. The DM stated the cooks were supposed to serve the items listed on the resident's meal ticket. Then the aides were supposed to check the trays to ensure all the food on the tray matched the meal ticket before they put the trays on the warming cart. The DM stated then the aide that passed the food to residents was supposed to check the meal ticket and tray before serving the tray to the residents. The DM stated staff were trained on the following menus by herself and the previous dietary manager. The DM stated herself, the aides, and the cooks were all responsible for ensuring all food items listed on the meal tickets were followed. The DM stated she expected staff to ensure the correct food items were on the trays, portions, and dietary restrictions were followed. The DM stated potential negative outcomes were that residents would not get the nutritional value they need to maintain their health, prevent hunger, and it could affect reactions from their meds and their immunity from sickness.During an interview on 8/6/26 at 11:51 AM, the DON stated all food listed on the meal tickets must be served and match the ingredients and correct texture for each resident. The DON stated she was aware of previous general complaints of missing food items by complaints from residents and that staff fixed them. The DON stated the dietary staff were responsible for serving the correct items and then the staff who served the tray was responsible for double checking the tickets and trays to ensure all food items were on the tray before it was given to the resident. The DON stated it was usually a nursing staff that served the trays to the residents. The DON stated staff were trained on following menus and checking trays as part of their new hire training. The DON stated there were also monthly staff meetings where they discussed any concerns and addressed them. The DON stated the person serving the tray to the resident was responsible for ensuring all food listed on the meal tickets were on the trays. The DON stated it was important to ensure residents met their nutrition goals. The DON stated she expected staff to ensure the food on the trays was correct. The DON stated potential negative outcomes were weight loss, fluctuations of blood sugars, and nutritional deficits.During an interview on 8/6/26 at 12:46 PM, the ADM stated dietary staff must follow the menu. The ADM stated she was not aware the menus were not followed. The ADM stated she expected the dietary staff to follow the menu and serve all items listed. The ADM stated staff were to monitor each meal served and ensure residents received all items being served for the meal. The ADM stated it was important so residents would get proper nutrition. The ADM stated staff were trained in serving trays and following menus. She stated the potential negative outcome was that residents would not receive proper nutrition.Record review of the Menu Planning Guideline, undated, revealed in part: Nutritional needs of individuals will be provided. Based on a facility's reasonable efforts, menus should reflect the religious, cultural, and ethnic needs of the population served, as well as input received from individuals and groups. Procedure: 5. Menus will be served per the posted menus and if not available temporary changes in the menu will be noted on the menu substitution sheets.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 (Resident #9) residents reviewed for infection control.The facility failed to ensure CNA B utilize EBP during wound care for Resident #9 on 8/05/2026. This failure could place residents at risk for cross contamination and infection.The Findings include: Record review of Resident #9's face sheet revealed an [AGE] year-old female originally admitted to the facility of 9/21/2022. Resident # 9 had a medical history of irritable bowel syndrome, cough, unspecified dementia, and pressure ulcer (bedsore) of sacral (triangular bone at the base of the spin) region. Record review of Resident #9's quarterly MDS dated [DATE] revealed Section C- Cognitive Patterns a BIMS score of 8 which indicated Resident #9 had moderate cognitive impairment. Record review of Resident #9's physician orders revealed Clean stage II [a shallow open sore] injury to her coccyx [tailbone]. with a start date of 8/06/2026. Physician orders revealed Initiate Enhanced Barrier Precautions (EBP)for chronic wound until wound is resolved with a start date of 8/06/2026. During a wound care observation on 8/05/2026 at 9:25AM for Resident #9, an EBP sign and PPE storage box were noted in Resident #9's room. CNA B entered the room without utilizing hand hygiene and put on gloves. CNA B assisted in turning Resident #9 onto her left side and removing her pants while LVN D provided wound care. CNA B did not utilize a gown while assisting LVN D in turning Resident #9. LVN D completed wound care and CNA B assisted Resident #9 in adjusting in bed. During an interview on 8/05/2026 at 9:33AM CNA B stated he was hired on June 2026 and did not think he had been trained on infection control. He stated he had some training on EBP and PPE. He stated PPE was used for residents when they are on contact precautions or things like that. He stated he was not aware he had to use EBP with Resident #9. He stated he had seen the EBP sign on her door but did not think it applied to her. He stated EBP was used on Residents when staff need protection from Residents' bodily fluids. He stated PPE was used to protect the staff from illnesses and disease. He stated it can help protect the Residents too, but it was primarily used for staff. He stated he had forgotten to use hand hygiene when he entered the room. He stated, I was aware of the EBP sign on the door to an extent.what I mean is, I had seen the sign on the door, but I didn't see other people using it, so I didn't think it applied to me. He stated he had been trained by multiple CNAs upon hire, and the DON had trained him but it was a classroom type setting and did not include EBP. During an interview on 8/06/2026 at 11:02AM, the DON stated she was the infection preventionist. She stated staff were trained on EBP with monthly in-services. She stated the in-services covered the EBP signs, how to identify residents who required EBP and the instructions on the EBP signage. She stated EBP was used for any resident who may have an open wound, sore, IV line, or any form of artificial opening. She stated if staff saw the signage on the door, they should be utilizing hand hygiene, gowns and gloves before assisting the resident in any of the task listed on the EBP sign and then removal of PPE and hand hygiene when complete. She stated the potential negative outcome of not using EBP could be enhanced infection risk for the residents. She stated if staff are assisting during wound care, they should be utilizing EBP as well. She stated CNA B had been trained on EBP and he had multiple staff educate him on EBP and infection control when he had been hired.During an interview on 8/06/2026 at 11:20AM, the ADM stated the DON was the infection preventionist. She stated staff are trained on EBP annually and monthly. She stated EBP was used for Residents that may have wounds, catheters, and any open areas. She stated staff should utilize gowns, gloves, and hand hygiene before and after providing Residents with care. She stated a potential negative outcome could be infection to the Resident. She stated if staff are assisting with any form of wound care, they were expected to follow EBP. Record review of facility document tilted In-service Training Report dated 7/16/2026 revealed CNA B's signature and raining included .60. EBP- wear gown/gloves and [NAME] before leaving room, Resident on EBP are labeled with A or B on the sign on the door. Record review of facility document tilted Competency Checklist for Certified and Non-certified nurse aids dated 6/26/2026 for CNA B revealed he had been trained and checked off on Infection control including the use of PPE. Record review of facility policy tilted Enhanced Barrier Precautions undated revealed, 1. Enhanced barrier precautions are used as an infection prevention and control intervention to reduce the spread of multidrug-resistant organisms to residents .3. Examples of high contact resident characteristics requiring the use of gown and gloves for EBP's include a. Dressing b. bathing c. transferring d. providing change linen e. changing briefs or assisting with toileting f. device care or use h. wound care. 4. EBPs are indicated for residents with wounds and or in dwelling medical devices.8. Standard precautions applied to the care of all residents regardless of suspected or confirmed inspections or colonization status 9. Staff are trained to care for residents on EBP 10. signs are posted on the door or wall outside the residence room indicating the type of precautions and PPE required.

Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 2 of 8 residents (Resident #74 and Resident #84) reviewed for advanced directives, in that: The facility failed to ensure Resident #74 and Resident #84 had an Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that did not have missed required information. These failures could place residents at risk for not having their end-of-life wishes honored and incomplete records.Findings included: Resident #74 Record review of Resident #74's admission record, dated [DATE], revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include: Sepsis (life-threatening infection), atherosclerotic heart disease (plaque build-up inside the blood vessels to the heart), and muscle weakness. The admission record also revealed under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #74's physician order summary dated [DATE] revealed the following order: DNR-Do Not Resuscitate with a start date of [DATE]. Record review of Resident #74's care plan, undated, revealed, Focus: DNR with a date initiated on [DATE]. Record review of Resident #74's OOH-DNR form, date retrieved on [DATE], revealed there was no physician's license number associated with the physician's signature, no date with the physician's signature and the physician had not signed the bottom of the OOH-DNR. Resident #84 Record review of Resident #84's admission record, dated [DATE], revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include: acute kidney failure (kidney problems), atrial fibrillation (irregular heartbeat) and heart failure. The admission record also revealed under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #84's physician order summary dated [DATE] revealed the following order: DNR-Do Not Resuscitate with a start date of [DATE]. Record review of Resident #84's OOH-DNR form date retrieved on [DATE] revealed in Section B, I am the patient's __Legal Guardian; __agent under Medical Power of Attorney; __or Qualified Relative (see back); and:__I attest to issuance of an Out-of-Hospital DNR by the patient by nonwritten means of communication; or__I am acting under the guidance of a prior Directive to Physicians; or__I am acting upon the known values and desires of the patient; or__I am acting in the patient's best interest based upon the guidance given by the patient's physician.All check mark areas were blank. During an interview on [DATE] at 4:05 PM, the DON stated the OOH-DNR forms were completed in the business office on admission and the clinical nurses were responsible to follow up on the forms to ensure they were correct. During an interview on [DATE] at 4:07 PM, the BOM stated she normally started the OOH-DNR forms for a resident. The BOM stated whoever completes the DNR was responsible to ensure it was correct. The BOM stated she started the OOH-DNR and someone else at the facility looked it over and took it to the physician to have signed. The BOM stated she did not know why Resident #74 and Resident #84's OOH-DNR's were incomplete. The BOM stated she did not know the last time she was trained on OOH-DNR's. The BOM stated RN A was the nurse who usually followed up on the OOH-DNR's at the facility. The BOM stated a potential risk to the residents was it was not a true DNR if the form was incomplete and it could affect the DNR status for the residents. During an interview on [DATE] at 4:12 PM, RN A stated she did not know why Resident #74's and Resident #84's OOH-DNR's were incomplete. RN A stated the ADM reviews all of the OOH-DNR forms and she would follow-up on them as well. RN A stated she did not know the last time she was trained on OOH-DNR forms. RN A stated a potential negative outcome to the residents was they could get to the hospital and them [the hospital staff] not honor it and it would be a bad outcome. During an interview on [DATE] at 11:42 AM, the ADM stated whichever staff completed the OOH-DNR was responsible to ensure the form was filled out completely. The ADM stated she double checks every OOH-DNR but was behind and had not reviewed the OOH-DNR's for Resident #74 and Resident #84 yet. The ADM stated the BOM completed about 90 percent of the OOH-DNR's at the facility. The ADM stated she had been trained on advanced directives within the past year but was unsure of the exact date. The ADM stated a potential negative outcome to the residents was a risk for not following their [the residents] wishes, or whoever made the decision. Record review of the facility policy titled, Advanced Directives/CPR/Code Status Policy, undated, reflected the following: It is the policy of [the facility] to honor and respect all resident's choice regarding advanced directives to the best of our capabilities. These choices may include, but are not limited to, accepting or refusing medical or surgical treatment. [The Facility] will assist residents and families with information regarding advanced directives.We strongly recommend all residents have a complete advanced directive with all known wishes clearly outlined. Record review of the document titled, Texas Department of State Health Services Standard Out-of-Hospital Do-Not-Resuscitate Order with a revised date of [DATE] reflected the following on Page 2 of 2: Out-of-Hospital DNR Instructions:.The original standard Texas Out-of-Hospital DNR form must be completed and properly executed.

Based on interview and record review, the facility failed to ensure care plans were developed in consultation with the resident and the resident's representative for 4 of 6 residents (Resident #66, Resident #11, Resident #51, and Resident #38) reviewed for comprehensive care plan in that: The facility failed to ensure Resident #66, Resident #11, Resident #51 and Resident #38 or the resident's representative were invited to participate in the resident's care plan meetings. This failure could place residents at risk of not receiving the interventions, treatments and care necessary for the residents to reach their highest practicable physical, mental, and psychosocial well-being by not involving the residents and/or resident's representatives in care plan meetings. Findings included: Resident #66 Record review of Resident #66's face-sheet dated 06/11/2025, revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Record review of Resident #66's quarterly MDS dated [DATE], revealed Resident #66 had a BIMS score of 15, indicative of cognitively intact. Resident #66's primary medical condition category that best describe the primary reason for admission was coded as Paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease). Other active diagnosis included Urethral discharge, Pain, Constipation (problem with passing stool), Hematuria (the presence of blood in the urine), and Type 2 Diabetes Mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood). Under section Q - participation in assessment and goal setting only the resident was coded as active participant in the assessment process. Record review revealed Resident #66's last Care Plan meeting note was undated. The Care Plan document did not include information regarding the date or time the Care Plan meeting was held, who was invited, nor who attended. In an interview on 06/11/2025 at 2:39 PM, Resident #66 stated he did not know what a care plan meeting was. Resident #66 stated he had not been invited to a care plan meeting that he could recall because, I know if there is something like that, my family member would be involved. Resident #66 stated no one had mentioned care planning meeting to him in the last year he had been in the facility. In an interview on 06/12/2025 at 10:08 AM, a family member of Resident #66 stated that the family member had not been involved in any care plan meetings for Resident #66 and no one had communicated to him for care planning meeting. The family member stated, I had to get my Resident #66 to the ER (Emergency room) for 3days due to extended stomach and vomiting some few weeks back. The family member stated he would like to be informed and involved in Resident #66's care planning meetings. The family member stated, the negative outcome of not having such meeting would be not knowing when certain things are going on around my Resident #66. Resident # 11 Record review of Resident # 11's face-sheet dated 06/11/2025, revealed a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #11's quarterly MDS dated [DATE], revealed Resident #11 had a BIMS score of 12, indicative of moderate impairment. Resident #11's primary medical condition category that best described the primary reason for admission was medically complex condition related to Fibromyalgia (a long-term condition that involves widespread body pain). Other active diagnoses included Shortness of breath, GERD - Gastro-esophageal reflux disease (a condition where stomach acid flows back up into the esophagus (the tube connecting the stomach and mouth), causing heartburn and other symptoms), Calculus of kidney (hard deposits that form in the kidneys from minerals and salts in urine), Constipation (problem with passing stool), Muscle weakness (a decrease in the strength and ability of muscles to perform their normal functions, often resulting in a reduced ability to move the body) and Essential (Primary) Hypertension (a type of high blood pressure where no specific underlying cause, such as a medical condition, can be identified). In an interview on 06/12/2025 at 10:20 AM, a family member of Resident #11 stated they had not been informed of any care plan meetings for Resident #11 and had not attended such meetings before. The family member stated, My understanding would be, if am happy with Resident #11, other than that, I really don't know if the facility has asked me to come in for care planning meetings and I have talked to one of the nurses sometime about Resident #11 when she was feeling bad. The family member stated she would like to be informed and involved in Resident 11's care planning meetings. The family member stated, the negative outcome of not having such meeting maybe the facility will not do all they said they will do that could have prevented some of Resident #11's physical decline. Record review revealed Resident #11's last Care Plan meeting note was undated. The Care Plan document did not include information regarding the date or time the Care Plan meeting was held, who was invited, nor who attended. Resident # 51 Record review of Resident # 51's face-sheet dated 06/18/2025, revealed a [AGE] year-old female admitted to the facility on [DATE]. Record review of the quarterly MDS assessment dated [DATE], revealed Resident #51 had a BIMS score of 12, indicative of moderate impairment. Resident #51's primary medical condition category that best described the primary reason for admission was coded as fractures and other multiple traumas. Other active diagnoses included anemia (low levels of healthy red blood cells to carry oxygen throughout the body), Hypertension (high blood pressure), asthma, chronic obstructive pulmonary disease, or chronic lung disease. Under section O, Special Treatments, Resident #51 received Oxygen therapy while a resident of the facility and within the last 14 days. Record review revealed Resident #51's last Care Plan meeting note was undated. However, the focus column included revisions dated 12/31/2024. The Care Plan document did not include information regarding the date or time the Care Plan meeting was held, who was invited, nor who attended. In an interview on 06/11/2025 at 03:02 PM, Resident #51 stated she had not participated or heard about any care plan meetings. Resident #51 stated, I hate to say because, I don't remember, like my family member does that and takes care of it. In an attempted interview on 06/12/2025 at 10:37 AM, Resident's family member was not accessible over the phone. Resident #38 Record review of Resident #38's face-sheet dated 06/18/2025, revealed an [AGE] year-old female originally admitted to the facility on [DATE]. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #38 had a BIMS score of 11, indicative of moderate cognitive impairment. Resident #38's primary medical condition category that best described the primary reason for admission was coded as Medically complex conditions related to Parkinson's disease without dyskinesia (progressive neurological disorder that primarily affects movement, causing symptoms like tremors, stiffness, and difficulty with balance and coordination). Other active diagnoses included Type 2 Diabetes Mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), Hyperkalemia (a condition where there is too much potassium in the blood). Resident #38 was coded as the only active participant in the assessment process in Section Q, Participation in Assessment and Goal Setting. In an interview on 06/11/2025 at 03:08 PM, Resident #38 stated 'I do not know what is care plan and I have not heard that before. She stated if the facility had such, that would be her family member and not me. In an interview on 06/12/2025 at 10:48 AM, the DON stated she has worked in the facility for 27years. The DON stated that care plan meetings were the responsibility of the MDS Coordinator. The DON stated Residents, their family members and employees would attend and rare times the ombudsman participate in the care plan meetings. The DON stated that the goals would be to ensure everyone was aware of all the information in the care plan, and an opportunity for Residents, family members to request changes. She stated that the whole point is to ensure highest quality of care. The DON stated possible negative outcome could be lower quality of care and wishes of Resident and family member would not be met. In an interview on 06/12/2025 at 11:08 AM, the MDS Coordinator stated she had worked at the facility for almost 10years and was responsible for care planning meetings. The MDS Coordinator stated care planning meetings were supposed to take place quarterly and as needed. She stated Residents and concerned parties were communicated through mails and emails with no evidence/records and the goal was to make sure Resident's concerns were addressed and their needs met. The MDS Coordinator stated mandatory attendees include family member, Resident and staff designate. Record review of the facility's policy labeled Care Plans, undated, revealed the following documentation, Procedures: Each resident, family, and/or responsible party member will be invited to meetings to review the care plan at least quarterly.

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 12 of 22 confidential residents. The facility failed to ensure confidential residents were provided access to the Grievance form and provided the procedure for how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: During Resident Council on, 06/11/2025 at 2:00pm, 12 of 22 confidential residents, stated they did not have access to the Grievance form, they did not know they could file a Grievance anonymously, they did not know where to submit an anonymous Grievance form, and the procedure for filing a grievance had not been discussed in Resident Council. The Residents attending Resident Council stated they can ask the AD for the grievance form; residents stated the grievance form was not available for them without asking the AD for the form. The residents stated the AD completed the grievance forms during Resident Council when complaints are voiced. The twelve Residents unaware of the grievance procedure had all been Residents of the facility for 6 plus months. Record Review of the facility Grievance policy on 6/12/2025 at 11:07am; according to the facilities' Grievance policy anonymous grievances can be submitted in a locked boxed on hall 3. Surveyor observed the locked box on hall 3, the label on the box indicated the locked box was for payments, the box did not have a label indicating its' use for anonymous grievances. Observation completed each of the hallways of the facility on 6/12/2025 at 11:45am, grievance forms were not available for the residents. Interview with the DON on 6/12/2025 at 12:05pm; the DON stated she was the Grievance Officer for the facility. The DON stated she was responsible for the review of Grievances and assigned them to department heads. The DON stated she had Grievance forms in her office and the AD had Grievance forms. The DON stated staff completed Grievance forms for Residents, Residents do not ask for forms and complete them on their own. The DON stated residents trusted her to complete the form on their behalf. The DON stated there was no procedure for Residents to submit Grievances anonymously. The DON stated the facility addressed Grievances immediately, the DON stated her desire was to have all Grievances resolved within 48 hours. The DON stated she assigned the Grievance to the appropriate department, that department addressed the grievance with the complainant, resolved the grievance, and explained the resolution to the complainant. The resolution was documented on the Grievance form and the completed form was submitted to the ADM for review. The DON stated completed Grievance forms were kept in a notebook. The DON stated she monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance, the DON stated the ADM will meet with the complainant to ensure they were satisfied with the resolution. The DON stated she was responsible for ensuring staff were trained on the Grievance process. The DON stated she was not aware the Grievance procedure was not being discussed in Resident Council. The DON stated the potential negative outcome for the Grievance policy not being followed was Resident issues will not be resolved. Grievance Policy Record Review of the Grievance Policy last updated in 2025. Policy Statement: Residents has the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances without discrimination or reprisal and without fear of discrimination or reprisal. Grievances can be completed orally or in writing, grievances can also be submitted anonymously. If the grievance is anonymous, it can be submitted in the locked box outside of the business on hall 3.

Based on interviews and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 2 of 22 residents (Residents #59 and #62) reviewed for PASRR screening, in that: Residents #59 and #62 did not have an accurate PASRR Level 1 assessments when they had a diagnosis of mental illness. These failures could place residents with an inaccurate PASRR Level 1 and no PASRR Level 2 Evaluation at risk for not receiving care and services to meet their needs. The findings were: Resident #59 Record review of Resident #59's electronic face sheet undated revealed a [AGE] year-old female initially admitted to the facility on [DATE]. Resident #59 had a medical diagnosis of major depressive disorder (a mental disorder characterized by persistent sadness), post-traumatic stress disorder (mental health condition that can develop after a person experiences or witnesses a traumatic event), cerebral infarction (occurs when the blood supply to the brain is interrupted, leading to brain tissue death) and dementia (a general term for the loss of cognitive function, including memory, language, problem-solving, and reasoning, that can interfere with daily life). The document did not indicate Resident #59 had a primary diagnosis of dementia. Record review of Resident #59's annual MDS dated [DATE], revealed under section I, Resident #59 had an active diagnosis of depression and post-traumatic stress disorder (PTSD). Additionally, under Section C Cognitive Patterns, Resident #59's MDS revealed a BIMS of 10, indicating the resident was moderately, cognitively impaired. Record review of Resident #59's care plan, last revised on 4/12/2025, revealed The resident has a mood problem r/t DEPRESSION, DEMENTIA, PTSD. Initiated on 12/10/2024. Additionally, the document revealed interventions to Monitor/record/report to MD prn acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills. The resident needs time to talk. Encourage the resident to express feelings. Monitor/record/report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behavior monitoring protocols. Educate the resident/family/caregivers regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, maintenance. Record review of Resident #59's physician's Order Summary as of 06/12/2025 revealed Resident #59 had been prescribed Sertraline 100mg tablet for Depression with a start date of 2/23/2025. Record review of Resident #7's Preadmission Screening and Resident Review (PASRR) Level One (PL1) form dated 11/11/2022 revealed under section C0100 Mental Illness an answer of NO, indicating the resident does not have a mental illness. Resident #62 Record review of Resident #62's electronic face sheet undated revealed a [AGE] year-old female initially admitted to the facility on [DATE]. Resident #62 had a medical diagnosis of major depressive disorder (a mental disorder characterized by persistent sadness) and post-traumatic stress disorder (mental health condition that can develop after a person experiences or witnesses a traumatic event). Resident #62 does not have a diagnosis of dementia. Record review of Resident #62's annual MDS dated [DATE], revealed under section I, Resident #62 had an active diagnosis of depression and post-traumatic stress disorder (PTSD). Additionally, under Section C Cognitive Patterns, Resident #62's MDS revealed a BIMS of 15, indicating the resident was cognitively intact. Record review of Resident #62's most recent care plan, dated 06/14/2025, revealed a diagnosis of Major Depressive Disorder and PSTD. Interventions included referring to mental authorities as needed, referring to psychiatrist, and referring to therapy. Record review of Physician orders for Resident #62's dated 06/18/2024 revealed under Diagnoses, Resident #62 has a diagnosis of Major Depressive Disorder and PTSD. Resident #62 is prescribed Buspirone 15mg, to be administered by mouth .5 tablet three times a day for anxiety. Record review of Resident #62's Preadmission Screening and Resident Review Level One (PL1) form dated 05/27/2025 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. During an interview conducted on 06/12/25 at 11:15AM with the MDS Nurse, she verified Residents #59 and #62 had a diagnosis of mental illness. The MDS Nurse verified Residents #59 and #62 did not have PASRR 2 Evaluations as their PASRR 1s were negative. The MDS Nurse stated the purpose of the PASRR 1 was to identify if Residents require additional services. She said if the PASRR 1 was positive then it gets put into an online system and they reach out to the necessary people to ensure a PASRR 2 Evaluation was done. She said she was responsible for entering the PASRR 1 into the system, the MDS nurse was also responsible for ensuring PASRR 1s were accurate by comparing them to medical records. The MDS Nurse stated the potential harm if a resident with a diagnosis of a mental illness had a negative PASRR 1, and no subsequent level PASRR 2 evaluation was the residents could potentially go without services. During an interview with the DON on 06/12/25 at 12:15PM, she verified Residents #59, and #62 had diagnosis of mental illnesses. The DON confirmed Residents #59, and #62 did not have PASRR 2 Evaluation as their PASRR 1s were negative. The DON stated it was the MDS nurses' responsibility to ensure every resident admitted to the facility had an accurate PASRR 1. The DON also stated it was the MDS nurses' responsibility to ensure PASRR 1s are completed accurately by comparing them to the residents' medical records. The DON stated residents with a positive PASRR 1 should be referred to the local mental health authority for completion of a PASRR 2 Evaluation. The DON stated the potential harm to a resident without an accurate PASRR 1 and a subsequent PASRR 2 Evaluation was the resident will not receive the services they need. ADM stated via email, on 6/18/2025 at 4:05pm, the facility does not have a PASRR policy.

Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days for 1 of 1 resident (Resident #61) reviewed for PRN psychotropic medications, in that: Resident #61 continued to have a PRN order for Lorazepam 2 MG/ML after 14 days without a duration. This failure could result in residents receiving antipsychotic medications when contraindicated and could result in residents experiencing adverse drug reactions. The findings include: Record review of Resident #61's face sheet, dated 06/12/25, reflected a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses to include Alzheimer's (cognitive loss), diabetes (high blood sugar), anxiety (felling of fear and worry) and major depressive disorder (mental illness). Record review of Resident #61's significant change in status, dated 04/12/25, reflected Resident #61's BIMS was a 00 which indicated Resident #61 had severely impaired cognitive impairment. The MDS further reflected Resident #61 had a diagnosis of anxiety disorder. Record review of Resident #61's physician order summary dated 03/19/24 reflected the following orders: *Order start date 04/03/25 with an indefinite end date for Lorazepam Oral Concentrate 2 mg/ml, give 0.25 ml by mouth every 2 hours as needed for anxiety. *Order start date 04/03/25 with an indefinite end date for Lorazepam Oral Concentrate 2 mg/ml, give 0.50 ml by mouth every 2 hours as needed for anxiety. *Order start date 04/03/25 with an indefinite end date for Lorazepam Oral Concentrate 2 mg/ml, give 0.75 ml by mouth every 2 hours as needed for anxiety. *Order start date 04/03/25 with an indefinite end date for Lorazepam Oral Concentrate 2 mg/ml, give 1 ml by mouth every 2 hours as needed for anxiety. Record review of Resident #61's PRN MAR reflected the following: *Lorazepam Intensol Oral Concentrate 2 mg/ml give 0.25 ml by mouth every 2 hours as needed for anxiety. Start Date 04/03/25 - DC Date 6/12/25. No medication was administered for the month of June. *Lorazepam Intensol Oral Concentrate 2 mg/ml give 0.50 ml by mouth every 2 hours as needed for anxiety. Start Date 04/03/25 - DC Date 6/12/25. No medication was administered for the month of June. *Lorazepam Intensol Oral Concentrate 2 mg/ml give 0.75 ml by mouth every 2 hours as needed for anxiety. Start Date 04/03/25 - DC Date 6/12/25. No medication was administered for the month of June. *Lorazepam Intensol Oral Concentrate 2 mg/ml give 1 ml by mouth every 2 hours as needed for anxiety. Start Date 04/03/25 - DC Date 6/12/25. No medication was administered for the month of June. During an interview on 06/12/25 at 09:20 AM with the DON, she stated she was not aware that Resident #61 had an order for Lorazepam PRN with no duration. She stated PRN psychotropic medications must have a stop dated and can only be given for 14 days. She stated lorazepam was a psychotropic medication. She stated the QA Nurse was responsible for checking all new doctor orders and all new medications. She stated all staff had been trained on PRN psychotropic medications. She stated the potential negative outcome could be resident declining and interfering with cognition. During an interview on 06/12/25 at 10:20 AM with the QA Nurse, she stated Resident #61 has an order for Lorazepam PRN because she was admitted to hospice services. She stated PRN psychotropic medications must have a stop dated and can only be given for 14 days even if on hospice. She stated she was responsible for competing medication audits. She stated she would be discontinuing the medication because resident has not used it. She stated the medication was not discontinued because she was waiting for pharmacy physician letter to come back from the physician. She stated all staff have been trained on PRN psychotropic medications. She stated the potential negative outcome could be giving the PRN psychotropic to the resident that really does not need it. Record review of the facility policy titled Psychoactive Medications revised date 11/05 reflected the following: Policy: Resident's will only receive psychoactive medications when medically necessary. Every effort will be made to ensure that residents who use these medication receive the intended benefit of the medications and to minimize the unwanted effects of the medications. Procedure: . The continued need for and the effectiveness of this type of medication will be reassessed monthly by the attending physician .

Based on interviews and record review, the facility failed to ensure residents were free of any significant medication errors for 1 (Resident #185) of 4 residents reviewed for medication administration. The facility failed to ensure metoclopramide (used to increase muscle contraction in the upper digestive tract) administered to Resident #185 as ordered. This failure could place residents at risk for not receiving medications as ordered by their physician. The findings include: Record review of Resident #185's face sheet dated 06/11/25 revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #185 had a medical history of gastroparesis (stomach muscles don't move food well), acute kidney failure, depression (feelings of sadness, loss or anger), anxiety (feeling of fear and worry) and hypertension (high blood pressure). Record review of Resident #185's physician orders revealed the following: Metoclopramide HCL Oral Tablet 10 MG give 1 tablet by mouth before meals for gastroparesis with a start date 06/07/25. Record review of Resident #185's medication administration record revealed Resident #185 received the following: Metoclopramide HCL 10MG on 06/11/25 at 07:30 AM. During an observation on 06/11/25 at 08:30 AM MA exited Resident #185 room and stated to CNA Resident #185 was done with her breakfast but would like more coffee. During an observation on 06/11/25 at 08:40 AM MA prepared the medication for Resident #185: Metoclopramide 10 MG along with five additional medications (Amlodipine 2.5mg, KCL 10meq, Coreg 6.25mg, Cefdinir 300mg, Amiodarone 200mg) and 30cc liquid (lactulose). Record review blister pack on 06/11/25 at 08:40 AM revealed a pharmacy label Metoclopramide 10 MG 1 tablet give before meals. During an observation on 06/11/25 at 08:45 AM Resident #185 at bedroom door in wheelchair. MA gave Resident #185 her medications. During an interview with DON on 06/12/25 at 09:20 AM, she stated Metoclopramide needs to be given before breakfast. She stated the charge nurses would be responsible for making sure MA give medications timely. She stated all nursing staff had been trained on medication times. She stated the pharmacy consultant does medication pass audits monthly. She stated her expectation was for the medications to be passed timely. She stated medications can be given an hour before or hour after the scheduled time. She stated Metoclopramide was scheduled before meals at 0730 AM. She stated the medication would be late if given at 08:40 AM. She stated the purpose of the medication was to help the stomach digest food. She stated if medication was not given timely the MD would need to be contacted. She stated the potential negative outcome could be the resident experiencing nausea, vomiting or stomach cramps. During an interview with MA on 06/12/25 at 10:32 AM, she stated the medication Metoclopramide for Resident #185 was scheduled for 07:30 AM. She stated the medication should be given before meals. She stated she was aware this medication needs to be given before meals, but she never can get to her before meals. She stated her hall medications start at 09:00 AM. She stated medications can be given one hour before or one hour after the scheduled time. She stated the medication was late because she gave it after 08:30 AM. She stated she has had training on giving medication timely. She stated she was not sure what the potential negative outcome could be. Record review of facility policy titled Medication Administration undated revealed: Purpose: To assure that residents receive their medication as ordered by the physician. Procedure: . 9. Medications are to be given within one hour prior to or after time ordered.

Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 meal (lunch meal 06/11/25) reviewed for dietary services, in that: The facility failed to ensure hot foods were maintained at 135 degrees F and above. These failures could place residents at risk of food borne illnesses. The findings included: Observation on 06/11/2025 at 11:15 AM staff brought in hamburgers and tater tots from an outside source into the kitchen and place them on the steam table and covered with lid. Observation of temperatures taken on 06/11/2025 at 11:25 AM revealed tater tots from outside source temped 129 degrees F. During an interview on 06/11/2025 at 11:35 AM with the dietary manager, she stated they would refry the tater tots to get them up to temp above 140. During an observation on 06/11/2025 at 11:40 AM the dietary manager turned on the fryer and placed the tater tots from the kitchen steam table in fry baskets. Observation on 06/11/2025 at 11:45 AM staff served residents in dining room from dining room steam table. During an interview on 06/11/2025 at 11:50 AM with the dietary manager, she stated the tater tots from outside source being served to residents in the dining room were served off the dining room steam table. She stated the food on the dining room steam table had not been temped. She stated the cook had not temped the dining room steam table, as she was waiting to temp the steam table in the kitchen. She stated the tater tots needed to be served at temp above 140 to prevent bacteria. She stated all staff had been trained to temp food and only serve if at the correct temp. She stated the potential negative outcome could be bacteria growth in food making the residents sick. During an interview on 06/11/2025 at 11:53 AM with [NAME] B, she stated tater tots needed to be at a temperature of 140 to be able to serve. She stated she did not take the temperature of the food on dining room steam table today. She stated she forgot to get the temperature of the food on the dining room. She stated she did not temp the tater tots that were being served to the residents in the dining room. She stated food on steam table in dining room served the dining room and steam table in kitchen served resident hall trays. She stated she was trained on food temperatures when serving. She stated the temperature should be 140 degrees or above. She stated the potential negative outcome was food being served cold and bacteria growing in food. During an interview on 06/12/2025 at 09:20 AM with the DON, she stated food should be served at the proper temperatures to prevent spoilage and increase palatability. She stated the dietary manager was responsible for making sure staff properly served food. She stated all staff have had training on proper temperatures to serve food. She stated the potential negative outcome could be bacteria growth and food poisoning. Record review of the facility policy and procedure titled, Food Preparation and Service, undated reflected the following: Procedure: . 4. Food will be served at acceptable temperatures, each type of food having an appropriate service temperature. 14. Food will be placed on the steam table to maintain acceptable temperatures during meal service. Record review of the facility police titled Temperatures Important Form Care of Food undated reflected the following: Holding food on hot food serving table 140 degrees to 165 degrees.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Residents #17) reviewed for infection control. CNA A failed to change gloves and utilize hand hygiene during incontinence care with Resident #17. This failure could place residents at risk for cross contamination and infection. The findings include: Record review of Resident #17's undated face sheet revealed a [AGE] year-old-female originally admitted to the facility on [DATE]. Resident #17 had a medical history of chronic respiratory failure with hypoxia (a condition where the lungs struggle to adequately oxygenate the blood, leading to low blood oxygen levels), end stage renal disease, and type 2 diabetes. Record review of Resident #17's annual MDS dated [DATE], Section C- Cognitive Patterns revealed a BIMS of 15, which indicated Resident #17 was cognitively intact. Section H- Bladder and bowel revealed resident was frequently incontinent of bowel and bladder. Record review of Resident #17's care plan last revised on 1/17/2025 revealed an intervention to Provide peri-care after each incontinent episode as needed. During an incontinence care observation on 6/11/2025 at 2:24pm, CNA A turned Resident #17 onto her right side and cleaned her bottom. CNA A grabbed clean linen and placed it underneath Resident #17 without changing her contaminated gloves or performing hand hygiene. During an interview with CNA A on 6/11/2025 at 2:47pm, she stated she was trained on infection control and her infection preventionist was the DON. She stated she was trained to change her gloves when going from dirty to clean during incontinence care. She stated the potential negative outcome of not changing gloves during incontinence care could be spreading infection. She stated she knew to change her gloves after turning the resident onto their right side but did not think to change them again before placing the clean linen. During an interview with the DON on 06/12/25 10:08 AM, she stated she was the infection preventionist and staff was trained monthly on infection control. She stated training on changing gloves during incontinence care was included in the infection control training. She stated they have annual competencies as well. She stated the potential negative outcome of staff not changing gloves when going from clean to dirty during incontinence care could be spreading infection. She stated they monitor compliance with infection control by monitoring monthly infection trends. She stated they also have hall monitors that make rounds and observations for noncompliance. Record review of facility undated policy titled Hand-washing Guideline revealed; Purpose: The purpose of this guideline is to provide guidance to employees for proper and appropriate hand-washing techniques that will aid in the prevention of the transmission of infections. To prevent the spread of infectious disease .When to wash hands guidelines: 10) After contact with blood, body fluids, secretions, excretions, mucous membranes, or broken skin .11) After handling items potentially contaminated with a resident's blood, body fluids, excretions, secretions.

Based on observation, interviews and record review, the facility failed to develop and implement abuse policies and procedures to prohibit, prevent and investigate allegations of abuse for 1 of 6 residents (Resident #1) reviewed for abuse. The Facility failed to establish abuse policies and procedures that mandate reporting of all allegations of abuse to the State Agency when Resident #1 made an outcry of abuse. The Facility failed to establish abuse policies and procedures that ensure reporting of all findings of allegations of abuse to the State Agency within five days of knowledge of the alleged abuse. These failures could place residents as risk for abuse and neglect. Findings included: Resident #1 A record Review of Resident #1's face sheet, dated 12/12/24, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of dementia with (memory loss) and the presence of a pacemaker. A record review of Resident #1's comprehensive MDS assessment dated [DATE] revealed diagnoses of Adjustment Disorder, Hallucinations, Dementia with Behavioral Disturbance, and Anxiety. Section B, Hearing/Speech and Vision revealed Resident #1 had moderate difficulty as it relates to hearing [B0200]. Resident #1 had a hearing aid [B0300]. Resident #1 usually could make herself understood [B0700] and had the ability to understand others [B0800]. Section C, Cognitive Patterns, a BIMS score of 1, indicating the resident was severely cognitively impaired. Section E revealed Resident #1 did not exhibit physical behavior (hitting, kicking, pushing, scratching, grabbing, and abusing) during the review [E0200]. A record review of Resident #1's care plan, dated 12/12/24, revealed a focused area, initiated on 11/29/24, Resident #1 had a communication problem r/t hearing deficit (had a left hearing aid). A focused area, initiated on 11/29/24, revealed Resident #1 had a pacemaker/defibrillator. Record review of Resident #1's care plan, dated 12/12/24, did not reveal any behaviors. Record review of Resident #1's progress notes dated from 09/11/24- 12/12/24 did not reveal any progress notes related to the incident on 11/27/24 between Resident #1 and LVN C. A record review of the facility incident report, dated 01/03/25, did not reveal any incidents involving Resident #1 on 11/27/24. There were no provider investigation reports available for review that involved Resident #1 prior to 12/12/24. Record Review of the provider investigation report, dated 12/12/24, revealed the finding of abuse was unconfirmed. The Report stated review of the video footage revealed Resident #1 was not pushed into the table by LVN C, and that LVN C spoke in a loud voice so Resident #1 could hear her. During an interview on 12/12/24 at 9:50 AM, the ADM stated she was the abuse coordinator for the facility. She said if her staff witnessed or suspected abuse, they should remove the resident, and then they should immediately report the allegation of abuse to the charge nurse. She said the staff then can go to her or the DON. She said if someone accidentally bumped a resident, it would not be an incident that the facility would have to report. She said if there was intent, an incident would be required to be reported. She said, Things happen accidentally all the time. She said if there were an injury, she would proceed as usual, but if there were no injury, then there would be no need for additional monitoring. The ADM said she was unaware of incidents involving a staff member accidentally running into a resident. During an interview on 12/12/24 at 11:50 AM, the ADM stated on 11/27/24, CNA A texted her, and she called CNA A back. She said she was told by CNA A that LVN C yelled at Resident #1. The ADM said she watched the cameras and observed LVN C roll a wheelchair between two residents (one being Resident #1). In the video, she saw Resident #1 standing up fast. She said that maybe the wheelchair that LVN C was pushing may have hit Resident #1's chair, but she could not tell. The ADM denied seeing evidence of abuse. During an interview on 12/12/24 at 12:40 PM, LVN D stated on 11/27/24 Resident #1 was crying and holding her chest. She said Resident #1 had her speak into her left ear because she could not hear very well. LVN D said Resident #1 told her, The woman taking care of me hurt me and stated LVN C hit her. LVN D said Resident #1 did not share specifics of the incident, nor did Resident #1 name LVN C specifically, but did describe how she looked and what she had on. LVN D said she assessed Resident #1 and took her vitals. She said Resident #1's vitals were normal and not concerning, but she did observe two lumps near Resident #1's pacemaker and felt it was swollen. LVN D said Resident #1 was in a lot of pain. She said the area around the pacemaker was tender to touch. She said CNA A observed the small lumps near Resident #1's pacemaker. LVN D said she was unfamiliar with Resident #1 and did not know her baseline. LVN D said she reached out to Physician E and obtained an order for pain medication (Tylenol 325 mg) because Resident had no existing orders for pain. LVN D said she reached out to the ADM via text message. LVN D said she told the ADM that Resident #1 was crying and that the area around the pacemaker was swollen and tender to touch. LVN D said she told the ADM that Resident #1 was nauseated. LVN D said she reported her assessment findings to the ADM. CNA A told her she had reported the incident between Resident #1 and LVN C to the ADM. She said CNA A told LVN D that CNA A told the ADM that she and CNA B saw LVN C hit Resident #1 against the table multiple times. A record review of LVN D's written statement, dated 12/14/24, revealed the following: On 11/27/24 at 6:31 PM, the ADM texted LVN D, stating, There was an incident with Resident #1 and LVN C, and she (Resident #1) was upset with LVN C but says her (Resident #1) chest is hurting. Could you (LVN D) go and assess her (Resident #1)? 6:32 PM: LVN D replied to the ADM text message, Yes. 6:35 PM: LVN D texted the ADM that Resident #1 claimed that LVN C hit her (Resident #1). 6:37 PM: LVN D texted the ADM that Resident #1 was showing her left upper chest and crying. 6:38 PM: LVN D texted the ADM that Resident #1 was hurting, and the area (around the pacemaker) was swollen and tender. 6:41 PM: LVN D texted the ADM that Resident #1 had two bumps near her pacemaker. 6:42 PM: LVN D texted the ADM that Resident #1 was nauseated from how emotional she (Resident #1) was. LVN D said she would get Resident #1 two Tylenol and that Resident #1 might need x-rays. 6:43 PM: LVN D texted the ADM that the pain medication was needed because Resident #1 was tender to touch and the bumps she was feeling with the swelling. 6:45 PM: LVN D texted the ADM, asking what she (the ADM) wanted her (LVN D) to do. LVN D wrote the ADM never responded to any of her text messages. 6:54 PM: LVN D texted the ADM that she received an order from Physician E for Tylenol because Resident #1 did not have any orders for pain medication. 6:44 PM: LVN D attempted to contact the ADM. LVN D indicated the ADM did not answer. 6:50 PM: LVN D texted Physician E asking if it was okay for Resident #1 to have Tylenol (650 mg) because Resident #1 was complaining of pain. 6:54 PM: LVN D indicated that Physician E responded to give Resident #1 tramadol 50 mg, and LVN D responded okay. 7:44 PM: LVN D texted the ADM, indicating Resident #1 complained of pain under her pacemaker and that LVN D felt two lumps. 7:51 PM ADM called LVN D, and the ADM acknowledged her text messages and LVN D said she reported to the ADM that CNA A had said another staff told her to report the incident that had occurred between Resident #1 and LVN C. LVN D indicated during the phone conversation she reported to the ADM that CNA A reported to her that LVN C always mistreats the residents on the memory care unit. She said she reported the findings of her assessment to the ADM and the ADM asked if the two lumps had been there and LVN D stated she did not know. LVN D indicated that she was asked by the ADM if the bumps could have been caused by Resident being bumped on the table and LVN D indicated she responded that it depended on how she was sitting. LVN D's written statement additionally stated, On 12/1/24 or 12/2/24, the DON asked her what happened on 11/27/24. LVN D reported to the DON that the ADM told her to assess Resident #1. LVN D indicated she told the DON that Resident #1 alleged that LVN C hit her, and that CNA A witnessed the incident. LVN D indicated that she was unfamiliar with Resident #1 and did not have the facts of the incident to document. LVN D indicated that the ADM instructed her that the ADM would investigate and that she would not write anything down until she investigated by watching the video. A record review of Resident #1's detailed order report dated, 11/27/24, revealed that LVN D had entered a medication ordered by Physician E for Tylenol 325 mg x2 PRN every 4 hours for general discomfort. A record review of Resident #1's order administration note dated, 11/27/24, revealed LVN D entered a note for Tylenol 325 mg x2 PRN every 4 hours for general discomfort. The note indicated Resident #1 complained of pain in her chest on the left side. A record review of Resident #1's MAR/TAR dated November 1-30th, revealed on 11/27/24 at 6:50PM, Resident #1 had a pain level of 5 and was administered acetaminophen tablet 325 mg (2 tablets by mouth). No further indication of pain was noted in the MAR/TAR, and no additional pain medication was given. During an observation and interview on 12/12/24 at 3:55 PM, observation of Resident #1's pacemaker site revealed no lumps, bruising, or redness. Resident #1 did flinch when MA P touched the pacemaker site and stated the site was tender. Resident #1 said she had it (pacemaker) for a long time. Resident #1 did not disclose any information regarding LVN C or the incident from 11/27/24. During an interview on 12/12/24 at 4:00 PM, the ADM stated CNA A said Resident #1 was crying and that LVN C had hollered at her. She said CNA A reported to her that LVN C was trying to push another resident through two residents (one resident being Resident #1). The ADM said Resident #1 was hard of hearing. She said she did interview LVN C, and she denied hollering at Resident #1. LVN C stated she elevated her voice as she came behind her. The ADM said Resident #1 did complain of chest pain. The ADM said she was told by CNA A that she took Resident #1 to her room and noticed Resident #1 had a pacemaker. The ADM said CNA A told her that when she went to touch Resident #1, Resident #1 was guarded. The ADM said Resident #1 had a history of exaggerating things. The ADM said she was told by CNA A that Resident #1 was upset. The ADM said that since Resident #1 was upset with LVN C, it was best that LVN C does not assess her. The ADM sent LVN D to assess Resident #1. The ADM said LVN D reported that Resident #1 complained of pain during the assessment. The ADM said she observed the cameras, and LVN C was moving the wheelchair through two residents (one resident being Resident #1). The ADM said she never observed Resident #1 hit her chest. The ADM said she did not observe Resident #1 crying in the video. The ADM said she did have information to support that she investigated the incident, and LVN C did not intentionally bump Resident #1. She said she did not interview LVN D. The ADM said no one reported to her that LVN C was agitated. The ADM said she started looking into the incident on 11/27/24 and finished on 11/28/24 after she watched the cameras. She said there was no allegation of abuse, so she did not report the incident to HHSC. She said it was normal for Resident #1 to cry. She said if nothing was wrong, then it does not have to be documented. She said that she did not believe there was an allegation of abuse, but the reason she did not have LVN C work with Resident #1 was because Resident #1 was upset with LVN C. The ADM said Family Member G was not notified because there was no allegation of abuse. She said no protection or preventative measures were put in place because there was no allegation of abuse, but maybe the tables needed to be spaced out correctly. The ADM would not allow the State surveyors to view the camera footage until authorized by her attorney. Record review of video of the alleged abuse, dated 11/27/24, was provided by facility via email on 1/5/25 at 9:30PM revealed no indication of abuse. The video revealed LVN C pushed a Resident in a wheelchair between two residents. LVN C pushed an unknown Resident closer to table and then attempted to pass through and bumped Resident #1 chair in the process. LVN C moved Resident #1's chair closer to the table. Resident #1 was not moved forcefully. Resident #1 immediately moved chair away from table and looked behind her. LVN C talked to Resident #1 and motioned for her to move her chair forward. Resident #1 stood up, looked at LVN C and moved the chair toward the table. LVN C left the dining room with an unknown resident in wheelchair, and Resident #1 sat back down in chair. NA walked up to Resident #1 and rubbed her left shoulder and walked away. CNA A walked to Resident #1, and Resident #1 pulled at Resident #1's shirt and rubbed her upper left chest. CNA A bent over and looked at Resident #1 chest, and then walked back to food tray cart. During an interview on 12/12/24 at 4:38 PM, the DON stated she was off when the incident between Resident #1 and LVN C occurred. She said she was notified on Monday (12/2/24) when she returned from work via email from the ADM. The DON said the email from the ADM said she had investigated the incident between Resident #1 and LVN C. She said the email said that Resident #1 reported her chest hurt and that Resident #1 hit her chest on the table, but the ADM found that Resident #1 did not hit her chest on the table. The DON said that she spoke with Resident #1, and Resident #1 reported that everything was fine. Resident #1 never mentioned the incident involving LVN C. The DON said that on 12/02/24, she observed Resident #1 at the dining table and observed an ample space between Resident #1 and the table. The DON said the dining room chairs cannot fit under the tables. She said the arms of the chairs were level with the table, hindering Resident#1 from being able to be bumped against the table. The DON said where Resident #1's pacemaker was located, she could not have hit it against the table. The DON said she observed the video surveillance. She said that Resident #1 was very quick with her movements. She said she observed Resident #1 seated at the dining room table. She said she saw LVN C pushing the geriatric chair. She said Resident #1 was hard of hearing. The DON said she observed an unidentified resident motioning to Resident #1 to move. The DON said Resident #1 attempted to move, but it was only a tiny fraction. The DON said she observed LVN C take her right hand and motion in front of Resident # 1 to move. She said that Resident #1 then got out of her chair. She said she did not observe Resident #1 crying during the video surveillance. The DON said she spoke with LVN C about her tone, and LVN C said Resident #1 scared her when she jumped up so fast from the dining room table. The DON said that the incident between Resident #1 and LVN C was not reported to HHSC because no allegation of abuse was made. The DON said she spoke with LVN D after 11/27/24 but that LVN D did not report any additional information about the incident, only that she felt awkward having to conduct the assessment on Resident #1. The DON said Resident #1 had a history of accusatory behavior. During an interview on 12/13/24 at 7:20 PM, the ADM stated the potential negative outcome for not following the abuse policy and reporting abuse to HHSC could become withdrawn, isolated, or depressed. The ADM said she did not report the incident to HHSC because it was not reported to her that there was ever an allegation of abuse. The ADM expected all allegations of abuse to be reported to the charge nurse and then to herself and the DON. The ADM said she expected the family to be notified if there was an allegation of abuse. During an interview on 12/18/24 at 1:23 PM, LVN C stated on 11/27/24, during dinner, she was pushing a resident in the dining room. As she passed Resident #1, she bent down and asked her to scoot her chair up. LVN C said she tapped Resident #1, and Resident #1 jumped up, causing her chair to slam against the wheelchair she was pushing. She said Resident #1 was visibly upset but not crying. She said Resident #1 was speaking Spanish and appeared to be cussing. She said she was unaware that Resident #1 was in pain. She said she was unaware that Resident #1 was upset with her because Resident #1 spoke Spanish, and she did not. LVN C said she told Resident #1 that she was sorry and provided care for another resident. She said she never had any contact with the ADM or LVN D after the incident on 11/27/24. She worked the remainder of her shift and provided no care to Resident #1. She said she had contact with Resident #1 after the incident because she returned to the memory care unit, and Resident #1 said hi to her. She said Resident #1 did not appear to be upset. She said she was never instructed not to have any contact with Resident #1 or questioned about the incident involving Resident #1. She said she was unaware that there was an allegation of abuse made. She said there was no documentation to reflect the incident on 11/27/24 because it was not an incident to report. She said Resident #1 acts this way (becoming upset) regularly. She said they had not been trained to document or report the incident but to give Resident #1 space to calm down. She said she did not assess the resident, nor was she aware that any assessment had been done. She said she was unaware if CNA A had taken Resident #1 to her room. She said the only staff in the dining room during the incident was CNA A. During an interview on 01/03/25 at 03:41 PM with NA, she stated she was in the dining room during the incident. She stated Resident #1 told her she (Resident #1) hit her chest on the table. She stated Resident #1 was in pain and crying but she never looked at Resident #1 chest. She stated she never reported the incident to the ADM. During an interview on 01/06/25 at 02:15 PM with CNA A, she stated she witnessed the incident between LVN C and Resident #1. She stated Resident #1's wheelchair was bumped by LVN C and LVN C raised her voice and asked Resident #1 to scoot up. She stated Resident #1 was hard of hearing and wore a hearing aide in the left ear and barely hears out of the right ear. She stated Resident #1 complained of chest pain. She stated she looked at Resident #1 upper chest where her pacemaker was and did not see any knots, bruising or redness. She stated she reported the incident to the ADM because the resident was upset with the LVN C (the charge nurse). She stated LVN C was naturally a loud person, and she did not feel LVN C was yelling at her. She stated she monitored the resident though out the rest of her shift (2p-10P) and Resident #1 had no mental or emotional distress. Record review of a progress note dated 12/17/24 revealed the following from the SW - Spoke with [Resident #1's family member] this date. Asked [family member] to come in and speak with SW and resident at a time that is convenient for him. Spoke to him about how she will sometimes state that she is being mistreated. SW told [family member] that I spoke with [Resident #1] today and she said that she was good, was not afraid and did not have any problems with anyone. [family member] stated that [Resident #1] has vacillated back and forth from stating that she is ok, to not being ok and that people are mistreating her for the last five years. SW reassured [family member] that we would make sure that [Resident #1] was taken care of. [family member] stated that he will make an appointment to come see us and he appreciated the information. [Sic] During an interview on 01/06/25 at 3:11 PM, the ADM stated at this point she was not sure what she should be reporting or not or what was considered abuse and that she had spent countless nights reading the Provider Letter from HHSC. She stated the incident with Resident #1 was not abuse and that was why she did not report to HHSC. Record review Long-Term Care Regulatory Provider Letter dated 7/10/19 revealed the following: 1.0 Subject and Purpose - This letter provides guidance for reporting incidents to HHSC and . 3.0 Background/History - State and federal law requires an owner or employee of a NF who has cause to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation. NFs must report all suspected or alleged incidents involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property. A NF must report these incidents to the HHSC CII section [Emphasis added] A record review of the facility policy, Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures, undated, revealed the following: Policy Statement The administrator assumes the responsibility for the overall coordination and implementation of our facility's prevention program policies and procedures. Policy Interpretation and Implementation The administrator has the overall responsibility for the coordination and implementation of our facility's abuse prevention program policies and procedures. A record review of the facility policy, Reporting Abuse to State Agencies and Other Entities/Individuals, undated, revealed the following: Policy Statement All substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law. Should a substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) occur, the facility administrator, or his/her designee, will promptly notify the following persons or agencies of such incident: [Emphasis added]. a. The State licensing/certification agency responsible for surveying/licensing the facility. b. The Resident's Representative (Sponsor) of Record. Notices to the above agencies will be made after knowledge of the occurrence of such incident in compliance with local and State requirements. Notices will include, at a minimum: c. The name of the resident. d. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.). e. The date and time the alleged incident occurred. f. The name(s) of all persons involved in the alleged incident; and g. What immediate action was taken by the facility The administrator or his/her designee will provide the appropriate agencies with a written report of the findings of the investigation within 5 days of having knowledge of the incident. A record review of the facility policy, Protection of Residents During Abuse Investigation, undated, revealed the following: Policy Statement Our facility will protect residents from harm during investigations of abuse allegations. Policy Interpretation and Implementation During abuse investigation, residents will be protected from harm by the following measures: Employees accused of participating in the alleged abuse could be reassigned to duties that do not involve resident contact or could be suspended without pay until the findings of the investigation have been reviewed by the administrator. This will be at the discretion of the Administrator or his/her designee. [Emphasis added].

Based on observation, interviews and record review, the facility failed to ensure all allegations of abuse were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to other officials, including the State Survey Agency for 1 of 6 residents (Resident #1) reviewed for abuse. The Administrator failed to report allegations of abuse to HHSC when Resident #1's alleged abuse against LVN C. This failure could place residents as risk for abuse and neglect. Findings included: Resident #1 A record Review of Resident #1's face sheet, dated 12/12/24, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of dementia with (memory loss) and the presence of a pacemaker. A record review of Resident #1's comprehensive MDS assessment dated [DATE] revealed diagnoses of Adjustment Disorder, Hallucinations, Dementia with Behavioral Disturbance, and Anxiety. Section B, Hearing/Speech and Vision revealed Resident #1 had moderate difficulty as it relates to hearing [B0200]. Resident #1 had a hearing aid [B0300]. Resident #1 usually could make herself understood [B0700] and had the ability to understand others [B0800]. Section C, Cognitive Patterns, a BIMS score of 1, indicating the resident was severely cognitively impaired. Section E revealed Resident #1 did not exhibit physical behavior (hitting, kicking, pushing, scratching, grabbing, and abusing) during the review [E0200]. A record review of Resident #1's care plan, dated 12/12/24, revealed a focused area, initiated on 11/29/24, Resident #1 had a communication problem r/t hearing deficit (had a left hearing aid). A focused area, initiated on 11/29/24, revealed Resident #1 had a pacemaker/defibrillator. Resident #1's care plan, dated 12/12/24, did not reveal any behaviors. Record review of Resident #1's progress notes dated from 09/11/24- 12/12/24 did not reveal any progress notes related to the incident on 11/27/24 between Resident #1 and LVN C. A record review of the facility incident report, dated 01/03/25, did not reveal any incidents involving Resident #1 on 11/27/24. There were no provider investigation reports available for review that involved Resident #1 prior to 12/12/24. Record Review of the provider investigation report, dated 12/12/24, revealed the finding of abuse was unconfirmed. The Report stated review of the video footage revealed Resident #1 was not pushed into the table by LVN C, and that LVN C spoke in a loud voice so Resident #1 could hear her. During an interview on 12/12/24 at 9:50 AM, the ADM stated she was the abuse coordinator for the facility. She said if her staff witnessed or suspected abuse, they should remove the resident, and then they should immediately report the allegation of abuse to the charge nurse. She said the staff then can go to her or the DON. She said if someone accidentally bumped a resident, it would not be an incident that the facility would have to report. She said if there was intent, an incident would be required to be reported. She said, Things happen accidentally all the time. She said if there were an injury, she would proceed as usual, but if there were no injury, then there would be no need for additional monitoring. The ADM said she was unaware of incidents involving a staff member accidentally running into a resident. During an interview on 12/12/24 at 11:50 AM, the ADM stated on 11/27/24, CNA A texted her, and she called CNA A back. She said she was told by CNA A that LVN C yelled at Resident #1. The ADM said she watched the cameras and observed LVN C roll a wheelchair between two residents (one being Resident #1). In the video, she saw Resident #1 standing up fast. She said that maybe the wheelchair that LVN C was pushing may have hit Resident #1's chair, but she could not tell. The ADM denied seeing evidence of abuse. During an interview on 12/12/24 at 12:40 PM, LVN D stated on 11/27/24, LVN D said Resident #1 was crying and holding her chest. She said Resident #1 had her speak into her left ear because she could not hear very well. LVN D said Resident #1 told her, The woman taking care of me hurt me and stated LVN C hit her. LVN D said Resident #1 did not share specifics of the incident, nor did Resident #1 name LVN C specifically, but did describe how she looked and what she had on. LVN D said she assessed Resident #1 and took her vitals. She said Resident #1's vitals were normal and not concerning, but she did observe two lumps near Resident #1's pacemaker and felt it was swollen. LVN D said Resident #1 was in a lot of pain. She said the area around the pacemaker was tender to touch. She said CNA A observed the small lumps near Resident #1's pacemaker. LVN D said she was unfamiliar with Resident #1 and did not know her baseline. LVN D said she reached out to Physician E and obtained an order for pain medication (Tylenol 325 mg) because Resident had no existing orders for pain. LVN D said she reached out to the ADM via text message. LVN D said she told the ADM that Resident #1 was crying and that the area around the pacemaker was swollen and tender to touch. LVN D said she told the ADM that Resident #1 was nauseated. LVN D said she reported her assessment findings to the ADM. CNA A told her she had reported the incident between Resident #1 and LVN C to the ADM. She said CNA A told LVN D that CNA A told the ADM that she and CNA B saw LVN C hit Resident #1 against the table multiple times. A record review of LVN D's written statement, dated 12/14/24, revealed the following: On 11/27/24 at 6:31 PM, the ADM texted LVN D, stating, There was an incident with Resident #1 and LVN C, and she (Resident #1) was upset with LVN C but says her (Resident #1) chest is hurting. Could you (LVN D) go and assess her (Resident #1)? 6:32 PM: LVN D replied to the ADM text message, Yes. 6:35 PM: LVN D texted the ADM that Resident #1 claimed that LVN C hit her (Resident #1). 6:37 PM: LVN D texted the ADM that Resident #1 was showing her left upper chest and crying. 6:38 PM: LVN D texted the ADM that Resident #1 was hurting, and the area (around the pacemaker) was swollen and tender. 6:41 PM: LVN D texted the ADM that Resident #1 had two bumps near her pacemaker. 6:42 PM: LVN D texted the ADM that Resident #1 was nauseated from how emotional she (Resident #1) was. LVN D said she would get Resident #1 two Tylenol and that Resident #1 might need x-rays. 6:43 PM: LVN D texted the ADM that the pain medication was needed because Resident #1 was tender to touch and the bumps she was feeling with the swelling. 6:45 PM: LVN D texted the ADM, asking what she (the ADM) wanted her (LVN D) to do. LVN D wrote the ADM never responded to any of her text messages. 6:54 PM: LVN D texted the ADM that she received an order from Physician E for Tylenol because Resident #1 did not have any orders for pain medication. 6:44 PM: LVN D attempted to contact the ADM. LVN D indicated the ADM did not answer. 6:50 PM: LVN texted Physician E asking if it was okay for Resident #1 to have Tylenol (650 mg) because Resident #1 was complaining of pain. 6:54 PM: LVN D indicated that Physician E responded to give Resident #1 tramadol 50 mg, and LVN D responded okay. 7:44 PM: LVN D texted the ADM, indicating Resident #1 complained of pain under her pacemaker and that LVN D felt two lumps. 7:51 PM ADM called LVN D and the ADM acknowledged her text messages and LVN D said she reported to the ADM that CNA A had said another staff told her to report the incident that had occurred between Resident #1 and LVN C. LVN D indicated during the phone conversation she reported to the ADM that CNA A reported to her that LVN C always mistreats the residents on the memory care unit. She said she reported the findings of her assessment to the ADM and the ADM asked if the two lumps had been there and LVN D stated she did not know. LVN D indicated that she was asked by the ADM if the bumps could have been caused by Resident being bumped on the table and LVN D indicated she responded that it depended on how she was sitting. LVN D's written statement stated, On 12/1/24 or 12/2/24, the DON asked her what happened on 11/27/24. LVN D reported to the DON that the ADM told her to assess Resident #1. LVN D indicated she told the DON that Resident #1 alleged that LVN C hit her, and that CNA A witnessed the incident. LVN D indicated that she was unfamiliar with Resident #1 and did not have the facts of the incident to document. LVN D indicated that the ADM instructed her that the ADM would investigate and that she would not write anything down until she investigated by watching the video. A record review of Resident #1's detailed order report, 11/27/24, revealed that LVN D had entered a medication ordered by Physician E for Tylenol 325 mg x2 PRN every 4 hours for general discomfort. A record review of Resident #1's order administration note, 11/27/24, revealed LVN D entered a note for Tylenol 325 mg x2 PRN every 4 hours for general discomfort. The note indicated Resident #1 complained of pain in her chest on the left side. A record review of Resident #1's MAR/TAR dated November 1-30th, revealed on 11/27/24 at 6:50PM, Resident #1 had a pain level of 5 and was administered acetaminophen tablet 325 mg (2 tablets by mouth). No further indication of pain was noted in the MAR/TAR, and no additional pain medication was given. During an observation and interview on 12/12/24 at 3:55 PM, observation of Resident #1's pacemaker site revealed no lumps, bruising, or redness. Resident #1 did flinch when MA P touched the pacemaker site and stated the site was tender. Resident #1 said she had it (pacemaker) for a long time. Resident #1 did not disclose any information regarding LVN C or the incident from 11/27/24. During an interview on 12/12/24 at 4:00 PM, the ADM stated CNA A said Resident #1 was crying and that LVN C had hollered at her. She said CNA A reported to her that LVN C was trying to push another resident through two residents (one resident being Resident #1). The ADM said Resident #1 was hard of hearing. She said she did interview LVN C, and she denied hollering at Resident #1. LVN C stated she elevated her voice as she came behind her. The ADM said Resident #1 did complain of chest pain. The ADM said she was told by CNA A that she took Resident #1 to her room and noticed Resident #1 had a pacemaker. The ADM said CNA A told her that when she went to touch Resident #1, Resident #1 was guarded. The ADM said Resident #1 had a history of exaggerating things. The ADM said she was told by CNA A that Resident #1 was upset. The ADM said that since Resident #1 was upset with LVN C, it was best that LVN C does not assess her. The ADM sent LVN D to assess Resident #1. The ADM said LVN D reported that Resident #1 complained of pain during the assessment. The ADM said she observed the cameras, and LVN C was moving the wheelchair through two residents (one resident being Resident #1). The ADM said she never observed Resident #1 hit her chest. The ADM said she did not observe Resident #1 crying in the video. The ADM said she did have information to support that she investigated the incident, and LVN C did not intentionally bump Resident #1. She said she did not interview LVN D. The ADM said no one reported to her that LVN C was agitated. The ADM said she started looking into the incident on 11/27/24 and finished on 11/28/24 after she watched the cameras. She said there was no allegation of abuse, so she did not report the incident to HHSC. She said it was normal for Resident #1 to cry. She said if nothing was wrong, then it does not have to be documented. She said that she did not believe there was an allegation of abuse, but the reason she did not have LVN C work with Resident #1 was because Resident #1 was upset with LVN C. The ADM said Family Member G was not notified because there was no allegation of abuse. She said no protection or preventative measures were put in place because there was no allegation of abuse, but maybe the tables needed to be spaced out correctly. The ADM would not allow the State surveyors to view the camera footage until authorized by her attorney. Record review of video of the alleged abuse, dated 11/27/24, was provided by facility via email on 1/5/25 at 9:30PM revealed no indication of abuse. The video revealed LVN C pushing a Resident in a wheelchair between two residents. LVN C pushed an unknown Resident closer to table and then attempts to pass through bumping the Resident #1 chair in the process. LVN C moved Resident #1''s chair closer to table. Resident #1 was not moved forcefully. Resident #1 immediately moves chair away from table and looks behind her. LVN C talked to Resident #1 and motioned for her to move her chair forward. Resident #1 stands up, looks at LVN C and moves chair towards table. LVN C proceeds to leave dining room with an unknown resident in wheelchair, and Resident #1 sits back down in chair. NA walked up to Resident #1 and rubbed her left shoulder and walks away. CNA A walks to Resident #1, and Resident #1 pulls at Resident #1's shirt and rubs her upper left chest. CNA A bends over and looks at Resident #1 chest, and then walks back to food tray cart. During an interview on 12/12/24 at 4:38 PM, the DON stated she was off when the incident between Resident #1 and LVN C occurred. She said she was notified on Monday (12/2/24) when she returned from work via email from the ADM. The DON said the email from the ADM said she had investigated the incident between Resident #1 and LVN C. She said the email said that Resident #1 reported her chest hurt and that Resident #1 hit her chest on the table, but the ADM found that Resident #1 did not hit her chest on the table. The DON said that she spoke with Resident #1, and Resident #1 reported that everything was fine. Resident #1 never mentioned the incident involving LVN C. The DON said that on 12/02/24, she observed Resident #1 at the dining table and observed an ample space between Resident #1 and the table. The DON said the dining room chairs cannot fit under the tables. She said the arms of the chairs were level with the table, hindering Resident#1 from being able to be bumped against the table. The DON said where Resident #1's pacemaker was located, she could not have hit it against the table. The DON said she observed the video surveillance. She said that Resident #1 was very quick with her movements. She said she observed Resident #1 seated at the dining room table. She said she saw LVN C pushing the geriatric chair. She said Resident #1 was hard of hearing. The DON said she observed an unidentified resident motioning to Resident #1 to move. The DON said Resident #1 attempted to move, but it was only a tiny fraction. The DON said she observed LVN C take her right hand and motion in front of Resident # 1 to move. She said that Resident #1 then got out of her chair. She said she did not observe Resident #1 crying during the video surveillance. The DON said she spoke with LVN C about her tone, and LVN C said Resident #1 scared her when she jumped up so fast from the dining room table. The DON said that the incident between Resident #1 and LVN C was not reported to HHSC because no allegation of abuse was made. The DON said she spoke with LVN D after 11/27/24 but that LVN D did not report any additional information about the incident, only that she felt awkward having to conduct the assessment on Resident #1. The DON said Resident #1 had a history of accusatory behavior. During an interview on 12/13/24 at 7:20 PM, the ADM stated the potential negative outcome for not following the abuse policy and reporting abuse to HHSC could become withdrawn, isolated, or depressed. The ADM said she did not report the incident to HHSC because it was not reported to her that there was ever an allegation of abuse. The ADM expected all allegations of abuse to be reported to the charge nurse and then to herself and the DON. The ADM said she expected the family to be notified if there was an allegation of abuse. During an interview on 12/18/24 at 1:23 PM, LVN C stated on 11/27/24, during dinner, she was pushing a resident in the dining room. As she passed Resident #1, she bent down and asked her to scoot her chair up. LVN C said she tapped Resident #1, and Resident #1 jumped up, causing her chair to slam against the wheelchair she was pushing. She said Resident #1 was visibly upset but not crying. She said Resident #1 was speaking Spanish and appeared to be cussing. She said she was unaware that Resident #1 was in pain. She said she was unaware that Resident #1 was upset with her because Resident #1 spoke Spanish, and she did not. LVN C said she told Resident #1 that she was sorry and provided care for another resident. She said she never had any contact with the ADM or LVN D after the incident on 11/27/24. She worked the remainder of her shift and provided no care to Resident #1. She said she had contact with Resident #1 after the incident because she returned to the memory care unit, and Resident #1 said hi to her. She said Resident #1 did not appear to be upset. She said she was never instructed not to have any contact with Resident #1 or questioned about the incident involving Resident #1. She said she was unaware that there was an allegation of abuse made. She said there was no documentation to reflect the incident on 11/27/24 because it was not an incident to report. She said Resident #1 acts this way (becoming upset) regularly. She said they had not been trained to document or report the incident but to give Resident #1 space to calm down. She said she did not assess the resident, nor was she aware that any assessment had been done. She said she was unaware if CNA A had taken Resident #1 to her room. She said the only staff in the dining room during the incident was CNA A. During an interview on 01/03/25 at 03:41 PM with NA, she stated she was in the dining room during the incident. She stated Resident #1 told her she (Resident #1) hit her chest on the table. She stated Resident #1 was in pain and crying but she never looked at Resident #1 chest. She stated she never reported the incident to the ADM. During an interview on 01/06/25 at 02:15 PM with CNA A, she stated she witnessed the incident between LVN C and Resident #1. She stated Resident #1 wheelchair was bumped by LVN C and LVN C raised her voice and asked Resident #1 to scoot up. She stated Resident #1 is hard of hearing and wears a hearing aide in the left ear and barely hears out of the right ear. She stated Resident #1 complained of chest pain. She stated she looked at Resident #1 upper chest where her pacemaker is and did not see any knots, bruising or redness. She stated she reported the incident to the ADM because the resident was upset with the LVN C (the charge nurse). She stated LVN C was naturally a loud person, and she did not feel LVN C was yelling at her. She stated she monitored the resident though out the rest of her shift (2p-10P) and Resident #1 had no mental or emotional distress. Record review progress note dated 12/17/24 revealed the following from the SW - Spoke with [Resident #1's family member] this date. Asked [Residents' family member] to come in and speak with SW and resident at a time that is convenient for him. Spoke to him about how she will sometimes state that she is being mistreated. SW told [Resident #'1s family member] that I spoke with [Resident #1's family member] today and she said that she was good, was not afraid and did not have any problems with anyone. [Resident #1's family member] stated that [Resident #1] has vacillated back and forth from stating that she is ok, to not being ok and that people are mistreating her for the last five years. SW reassured [Resident #1's family member] that we would make sure that [Resident #1] was taken care of. [Resident #1's family member] stated that he will make an appointment to come see us and he appreciated the information. [Sic] During an interview on 01/06/25 at 3:11 PM, the ADM stated at this point she is not sure what she should be reporting or not or what is considered abuse and that she had spent countless nights reading the Provider Letter from HHSC. She stated the incident with Resident #1 was not abuse and that is why she did not report to HHSC. Record review Long-Term Care Regulatory Provider Letter dated 7/10/19 revealed the following: 1.0 Subject and Purpose - This letter provides guidance for reporting incidents to HHSC and . 3.0 Background/History - State and federal law requires an owner or employee of a NF who has cause to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation. NFs must report all suspected or alleged incidents involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property. A NF must report these incidents to the HHSC CII section [Emphasis added] A record review of the facility policy, Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures, undated, revealed the following: Policy Statement The administrator assumes the responsibility for the overall coordination and implementation of our facility's prevention program policies and procedures. Policy Interpretation and Implementation The administrator has the overall responsibility for the coordination and implementation of our facility's abuse prevention program policies and procedures. A record review of the facility policy, Reporting Abuse to State Agencies and Other Entities/Individuals, undated, revealed the following: Policy Statement All substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law. Should a substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) occur, the facility administrator, or his/her designee, will promptly notify the following persons or agencies of such incident: [Emphasis added]. h. The State licensing/certification agency responsible for surveying/licensing the facility. i. The Resident's Representative (Sponsor) of Record. Notices to the above agencies will be made after knowledge of the occurrence of such incident in compliance with local and State requirements. Notices will include, at a minimum: j. The name of the resident. k. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.). l. The date and time the alleged incident occurred. m. The name(s) of all persons involved in the alleged incident; and n. What immediate action was taken by the facility The administrator or his/her designee will provide the appropriate agencies with a written report of the findings of the investigation within 5 days of having knowledge of the incident. A record review of the facility policy, Protection of Residents During Abuse Investigation, undated, revealed the following: Policy Statement Our facility will protect residents from harm during investigations of abuse allegations. Policy Interpretation and Implementation During abuse investigation, residents will be protected from harm by the following measures: Employees accused of participating in the alleged abuse could be reassigned to duties that do not involve resident contact or could be suspended without pay until the findings of the investigation have been reviewed by the administrator. This will be at the discretion of the Administrator or his/her designee. [Emphasis added].

Based on interview and record review the facility failed to ensure the resident had the right to be free from abuse for one (Resident #1) of six residents reviewed for abuse. The facility failed to ensure a safe environment free from abuse for Resident #1, who was combative, when CNA A and NA B continued to provide her care before, during, and after her shower. This failure could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm. Findings include: Record review of Resident #1's Admission Record dated 10/09/24, indicated she was a [AGE] year-old female admitted to the facility 10/18/23 and readmitted [DATE]. Resident #1's diagnosis included psychotic disorder with delusion due to know physiological condition (characterized by hallucination or delusions that are cause by another medical condition), unspecified psychosis not due to a substance or known physiological condition (mental state characterized by a loss of touch with reality and may involve hallucinations, delusion, disordered thinking and behavioral changes), and Alzheimer's disease ( disease that destroys memory and other important mental functions). Record review of Resident #1's Annual Minimum Data Set (MDS) dated [DATE] indicated she had a BIMS score of 2, that revealed she had severe cognitive impairment. MDS's Section E-Behaviors indicated she displayed every 4 to 6 days physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually; every 1 to 3 days verbal behavioral symptoms directed towards other (threatening others, screaming at others, cursing at others), and every 4 to 6 days other behavioral symptoms directed toward others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). This MDS indicated the above behaviors put Resident #1 at significant risk for physical illness or injury; significantly interfere with the resident's care, and significantly interfere with the resident's participation in activities or social interactions. This MDS indicated Resident #1 rejected evaluation of care (activities of daily living) necessary to achieve the resident's goals for health and well-being. Record review of Resident #1's Care Plan that was undated (because facility was migrating care plans into new system) indicated Care Task-CNA with onset date of 10/18/23 indicated they should document behaviors exhibited during the shift and give the resident a shower and shampoo her hair. This plan included Resident #1 was a high risk for side effects/physical injury due to need for psychotropic medications. This would be addressed by monitoring and documenting behaviors, and giving positive reinforcement, and not use a judgmental tone of voice. This plan indicated problem onset was added on 02/05/24 due to resident observed yelling and cursing at staff and peers at and times she is easily redirected, other times she will not calm down as easily. Resident #1 has attempted to bite staff when staff remove her dentures and has been observed throwing condiments at peers during mealtimes. These behaviors would be addressed by notifying MD and RP if resident behaviors increase. Anticipate residents needs to help decrease behaviors and refer resident to psychiatric services if needed. Record review of Resident #1's Behavior Preassessment Form and Discharge Receiving Acknowledgement indicated FM F signed this report on 07/18/24 agreeing to transfer Resident #1 to this facility for evaluation. Record review of Resident #1's Progress Notes dated 07/18/24 indicated Resident #1 was picked up by Behavioral Center for transport to their facility. Record review of Resident #1's Behavior Hospital's Take Home Medication List dated 08/07/24 indicated Resident #1 was returning to the facility 08/09/24. Record review of Resident #1's Progress Note dated 07/15/24 at 2:15 pm and written by LVN C, indicated resident (Resident #1) requires assistance with ADLs due to confusion and unsteady gait. She was recently at a behavioral hospital due to aggression and combativeness with staff and other residents. Since returning she continues to exhibit aggression and agitation. Record review of Resident #1's Progress Note dated (late entry) 07/15/24 at 3:00 pm and written by LVN D, indicated resident (Resident #1) was in her wheelchair, was alert and her confusion was normal. The male CNA (CNA A) was wheeling resident (Resident #1), who was swinging at staff and refusing to go to the shower. Nurse Aide (NA B) assisted resident into the shower. After resident was showered, she continued to be agitated, and was screaming in the hallway. Staff reported resident slapped NA B twice. When resident was wheeled down to the nurses' station resident was noted to have a small skin tear to her right forearm which was treated with dressing dry/intact. Record review of Resident #1's Progress Note (late entry) dated 07/15/24 at 4:00 pm and written by LVN D, indicated resident's (Resident #1) complained of paint to her index finger, middle finger, and ring finger on her left hand. Old bruising was noted to both hands/forearms, and left index lower knuckles were swollen. Mobile X-ray unit was called to x-ray resident's left hand. Record review of Resident #1's Progress Note dated 07/15/24 at 8:47 pm and written by LVN D, indicated mobile x-ray arrived at the facility to x-ray resident's left hand, and swelling was noted to left pointer finger. Record review of Resident #1's Progress Note dated 07/15/24 at 11:11 pm and written by LVN D, indicated x-ray results acute osseous abnormalities, osteopenia can obscure subtle bone lesions, a subtle bony abnormality or fracture may not be readily apparent on x-ray, thus clinical correlation and further imaging including follow up to CT (computed tomography that helps detect diseases and injuries), MRI (magnetic resonance imaging used to form pictures of the anatomy and the physiological process inside the body), or x-ray are as advise as needed. Record review of Resident #1's Patient Report (X-ray) dated 07/15/24 included findings of left hand: bones had no fracture of subluxation, joints had no sclerotic or destructive changes, and soft tissues had articular surfaces that were unremarkable. Review of Resident #1's Incident report dated 07/15/24 and written by LVN D indicated resident was in her wheelchair and was alert with confusion as normal. Resident #1 was swinging and kicking at staff and was refusing her shower. NA B assisted Resident #1 with her shower. After her shower, Resident #1 continue to be agitated and was screaming in the hallway. Staff (NA B) reported that she was slapped twice by Resident #1 during her shower. Resident #1 was taken to the nurses' station and LVN D noted she had a small skin tear to her right forearm and treated it with a dressing. LVN D noted that Resident #1 complained of pain to her index, middle finger, and ring finger on her left hand, there was bruising to both hands/forearms, and left index's lower knuckle was swollen. Afterwards, mobile x-ray was called to x-ray left hand (3 view). Resident #1's level of pain was a 4. Record review of NA B's witness statement dated 07/15/24 indicated When CNA A was pushing Resident #1's wheelchair she was reaching and grabbing his body. Then when CNA A was getting her through the shower door she started to shout. So, I went in to help and she was still shouting. When we were taking all her clothing off, she was swinging her arms a lot to try to hit her and CNA A. She attempted to reach enough to graze my face and slap my face, while were showering her and trying to dress her. While we bathed her, I had to hold her arms against her body so CNA A and I could properly do our task. Record review of LVN D's Witness Statement dated 07/15/24 indicated at 3 pm Resident #1 was sitting in her wheelchair at the nurses' station, and was alert and her confusion was normal. CNA A wheeled her (Resident #1) in her wheelchair to go give her a shower, she started swinging at him and made attempts to hold the handrails. After her shower Resident #1 was yelling loudly in the hallway and saying call the police. Resident #1 was swinging and attempting to hit staff, and she did slap female's face (NA B). While bathing her female staff (NA B) had to hold her hands while the male staff (CNA A) wash her off. Resident #1 attempt to bite staff (CNA A and NA B) while removing her dirty clothes. Record review of CNA A's General In-services with hire dated of 08/28/13 included the courses he had completed on 08/30/24: Abuse Prevention in Person with Dementia, Abuse, Neglect & Exploitation Prevention, Challenging Behaviors: Care and Intervention Dementia, and Resident Rights. During an interview on 10/09/24 at 10:42 am with Family Member F (FM F) indicated she had informed facility's staff that if Resident #1 displayed behaviors, staff should call her, and she would go to the facility to help Resident #1. FM F said on 07/15/24 she received a call from LVN D, who informed her Resident #1 was being combative. Minutes later, FM F said she entered the facility and could hear and see Resident #1 kicking, swinging her arms, crying, and yelling that they were trying to get her into her room; however, there was nobody near her. FM F said Resident #1 has a history of hallucinating, and on 07/15/24 said she had been attacked in the shower, and her nails were broken, her fingers were swollen, and she could not bend her fingers. FM F said she did not suspect abuse but said the staff should not have forced Resident #1 to take a shower. FM F said in the room she discovered a skin tear on Resident #1's calf that had bled into her shoe, and this looked like it was caused by her wheelchair. FM F said Resident #1's bra was ripped, she had blood on her shirt, and a skin tear to her elbow, which looked like it was caused by the grab bar. FM F said staff should have called her if Resident #1 was combative, but they did not. I received a call after staff had completed her shower. FM F said on 07/15/24 she did not suspect abuse, but when Resident #1 continued to complain about CNA A, who was working on the same hall where Resident #1's room was located, she reported her concerns and added the 07/15/24 shower incident. Afterwards, facility's staff investigated this incident. FM F said she did not want anybody terminated she just wanted the staff to be better trained, and after she complained she did not see CNA A working in the hallway where Resident #1's room was located. FM F said she had in the past informed staff to call her if Resident #1 was combative but had not told them to call her to assist with the showers. Since this incident 07/15/24, she asked staff to call her and she would help with Resident #1's showers, and they have called her for her assistance. Interview on 10/10/24 at 10:56 am was attempted with Resident #1 over the phone, who did not talk over the phone. During an interview on 10/09/24 at 1:20 pm with LVN F indicated Resident #1 becomes combative when she must shower. If she becomes combative staff should stop with the care, inform the charge nurse, and return later to attempt the care. During an interview on 10/09/24 at 1:30 pm with CNA G indicated if a Resident #1 becomes combative during her care, she will offer her the baby doll, which she keeps with her most of the day, and that calms her down at times. If a resident who is showering and becomes combative, she will stop the care, pull the call light to prevent leaving the resident in the shower unattended, and wait for the nurse. During an interview on 10/09/24 at 1:30 pm with CNA H indicated if Resident #1 becomes combative she will offer her doll to her to calm her down, and that sometimes works. CNA H said if during a shower a resident becomes combative or refuse their shower, staff should stop the care, pull the call light so you don't leave resident in the shower unattended, and wait for the nurse. During an interview on 10/09/24 at 1:40 pm with CNA H indicated if a resident becomes combative during their shower, staff should stop the care, pull the call light to prevent leaving the resident in the shower unattended, and wait for the nurse. Interviews and messages were attempted with NA B on 10/09/24 at 3:04 pm, 10/09/24 at 3:08 pm, and 10/10/24 at 11:22 pm; however, NA B, who no longer was employed by the facility, did not return these messages. During an interview on 10/09/24 at 3:50 pm, Certified Nurse Aide (CNA A) indicated on 07/15/24 Resident #1 was combative at the nurses' station, but he could not recall how she was being combative. CNA A said at the nurses' station he tilted Resident #1's wheelchair back as she sat in the wheelchair, to prevent her from grabbing the rails or planting her feet on the floor. CNA A said he pushed Resident #1, who was angry, in her wheelchair to the shower room. In the shower area, Resident #1 attempted to bite him and nurse aide (NA B); however, he could not recall if she bit him or left bite marks on his body. CNA A said he and NA B tried taking off Resident #1's clothes as she scratched at him and NA B but could not recall where she scratched him. CNA A said NA B held down Resident #1's hand and could not recall if she was resisting. CNA A said he washed Resident #1's hair and body, dried her, and dressed her as Resident #1 resisted care, was combative, and yelled at him and NA B. After Resident #1 was showered, CNA A said he dressed her, then pushed her in her wheelchair into the hallway, where Resdent #1 was left screaming, but CNA A could not recall what she was saying. Shortly afterwards, CNA A said LVN D directed him not to care for Resident #1, instead the nurses would take care of her. A couple of days later, CNA A said LVN E informed him that Resident #1 in the future would be showered by a female staff only. CNA A said Resident #1 was already in the shower and that is why he continued showering. CNA A said he suspects Resident #1 sustained the injuries from grabbing the rails in the shower and from hitting and scratching him and NA B. CNA A said he knew that if a resident becomes combative you should stop and report to the charge nurse; however, Resident #1 had behaviors all the time and she needed to take her shower. CNA A said he did not have an answer as to why he did not stop and call the charge nurse when Resident #1 resisted being taken to the shower, during the shower, and after the shower. CNA A said he could not recall why he did not use the call light in the shower area to call for the nurse. CNA A said NA B assisted him with showering Resident #1, and she can confirm he did not mistreat her during Resident #1's shower. During an interview on 10/09/24 at 4:29 pm with LVN D indicated said she was at the nurses' station and could not recall witnessing Resident #1 being upset before her shower on 07/15/24. Then CNA A approached Resident #1, who was at the nurses' station, and told her he was going to give her a shower. Resident #1 responded by planting her feet onto the floor and saying she did not want to shower. CNA A tilted Resident #1's wheelchair back as she sat in her wheelchair and pushed her to the shower area. Resident #1 was swinging her arms backwards at CNA A and tried to grab the hall's rails. NA B followed them into the shower area to assist with Resident #1's shower. LVN D said she did not see anything wrong with CNA A taking Resident #1, who was upset, to the shower area because this is how she reacts when she is getting a shower. Minutes later, Resident #1 was in the hallway yelling police. LVN D said the staff reported to her that during Resident #1's shower, she was swinging and attempting to hit them, and did slap NA B on her face. That was when NA B said she had to hold her hands while CNA A washed her body. LVN D said NA B informed her that Resident #1 attempted to bite them when they were removing her clothes. LVN D said she did not recall hearing the shower's call light beeping during Resident #1's shower. LVN D said FM F informed her Resident #1's fingers were hurting, and she replied she would call for an order to get x-ray mobile unit to x-ray her fingers. LVN D said she assessed Resident #1's hand and noted one of the knuckles was swollen; however, there were no fingernails missing. Afterwards, LVN D directed CNA A not to care for Resident #1 until he was directed to do so. LVN D said she was not informed by anyone that Resident #1's bra was ripped nor that she was abused by anyone. LVN D said CNA A and NA B should have stopped Resident #1's shower, used the call light to request her assistance, and she would have called FM F to assist with the shower. LVN D said on 07/15/24 she called FM F after the shower because she was screaming in the hallway, and she arrived shortly afterwards. LVN D said Resident #1's family member (FM F) had requested she be called if they were having trouble with Resident 1's care. In the past she had called FM F, who would arrive at the facility within minutes to assist with Resident #1's care. During an interview on 10/10/24 at 10:05 am with a Non-staff N (NS N) indicated on 09/09/24 FM F complained that a male and female staff (CNA A and NA B) forced Resident #1 to take a shower on 07/15/24, even after she became combative. FM F informed her that she was informed that Resident #1 was displaying behaviors, which is when she went to the facility. Upon entering the facility, she discovered Resident #1 in the hallway with the CNA A and NA B, and that is when CNA and NA B threw their arms up in the air and walked off. FMA said she saw that Resident #1 was upset, and her fingernails were ripped off, her fingers were bruised, and she had blood going into her shoes. FM F said Resident #1 reported to her that CNA A forced her to shower, and her doll was thrown under the sink. NS N said FM F said CNA A was going to assist Resident #1 to the bathroom, but she refused. NS N said FM F said she wanted CNA A terminated. Resident #1 was sent to the behavioral unit on 07/18/24, 3 days after the shower on 07/15/24. NS N said FM F denied Resident #1 having any behaviors and informed her the facility had reported the 07/15/24 shower incident on 09/05/24, after she had alleged abused. NS N said on 09/09/24 she received a call from Admin M requesting to discharge Resident #1 because they could not meet her needs. In addition, Admin M informed her that she tried to moved Resident #1 to the facility's secure unit due to her behaviors (exit seeking and combativeness towards staff and other). NS N said she went to the facility and witnessed Resident #1, who has dementia, display these behaviors; however, FM F refused to move her to the facility's secure unit. During an interview on 10/10/24 at 10:58 am with MD J's LVN I indicated when Resident #1 was refusing her shower and became combative, staff should have stopped the shower process, and attempted the shower later in the day. During an interview on 10/10/24 at 4:15 am with Admin M indicated when FM F said she had concerns because Resident #1 asked why CNA A was not in jail, and she did not want him working at facility. Admin M said she reported this allegation to Health and Human Services and initiated an investigation against CNA A and NA B. Admin M said she identified in her investigation that CNA A and NA B on 07/15/24 should have stopped Resident #1's shower when she became combative. These staff should have called the charge nurse and let her take over and offer the shower later. Admin M she suspended CNA A, NA B did not return to work, she in-serviced the staff, and reassigned CNA A to the secure unit. Admin M said NA B stopped working at the facility after this incident. Admin M said she was not informed that Resident #1 was abused by anyone on 07/15/24. Afterwards, Admin M implemented and in-service indicating staff should stop care when a resident becomes combative, report to the charge nurse after ensuring resident is safe, including using a call light to alert the nurse, and attempt the care later. During an interview on 10/10/24 at 11:14 am with MD K indicated when Resident #1 was refusing her shower and became combative, staff should have stopped the shower process, and tired again later. During an interview on 10/14/24 at 10:15 am with Staff L indicated before 07/15/24 Resident #1 has been combative during her showers and when staff applied her AVAP machine (newer modality of non-invasive ventilation that integrates the characteristics of both volume and pressure-controlled non-invasive ventilation). Staff L said this Resident #1's Care Plan for triggered items, which was current as of 10/09/24, included notifying the physician and family member when Resident #1 had behaviors, but not notifying the family member to assist when Resident #1's combativeness. Staff L said she had not updated Resident #1's care plan to include her behaviors of being combative during showers, offering her a baby doll that staff said calms her down, and calling her family member to assist with her care when she becomes combative, per family members request. Staff L said if a resident is combative, they should stop care, notify a charge nurse, and attempt care later. Review of facility's Policy and Procedure for Preventing Abuse (undated) included facility would not condone any form of resident abuse and will continually monitor facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. Preventing resident abuse is a primary concern for this facility. It is our goal to achieve and maintain an abuse free environment. This abuse prevention/intervention program includes, but is not necessarily limited to the following: Rotating staff working with difficult abusive residents; Monitoring staff on all shifts to identify appropriate behaviors towards residents; Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect; Assessing resident with signs and symptoms of behavior problems and developing and implementing care plan that can assist in resolving, behavioral issues; and encouraging all personnel, residents, family members, visitors, etc., to report any signs and suspected incident of abuse to facility management immediately.

Based on observation, interview, and record review, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of six residents reviewed for dementia care. The facility failed to comprehensively assess the physical, mental, and psychosocial needs of Resident #1, who had dementia, and identify the risks and/or to determine underlying causes after she became combative before, during and after her shower. This facility's failure could place residents with dementia at risk for their medical, physical, and psychological needs not being met and resulting in a decline in health. Findings included: Record review of Resident #1's Admission Record dated 10/09/24, indicated she was a [AGE] year-old female admitted to the facility 10/18/23 and readmitted [DATE]. Resident #1's diagnosis included psychotic disorder with delusion due to know physiological condition (characterized by hallucination or delusions that are cause by another medical condition), unspecified psychosis not due to a substance or known physiological condition (mental state characterized by a loss of touch with reality and may involve hallucinations, delusion, disordered thinking and behavioral changes), and Alzheimer's disease ( disease that destroys memory and other important mental functions). Record review of Resident #1's Annual Minimum Data Set (MDS) dated [DATE] indicated she had a BIMS score of 2, that revealed she had severe cognitive impairment. MDS's Section E-Behaviors indicated she displayed every 4 to 6 days physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually; every 1 to 3 days verbal behavioral symptoms directed towards other (threatening others, screaming at others, cursing at others), and every 4 to 6 days other behavioral symptoms directed toward others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). This MDS indicated the above behaviors put Resident #1 at significant risk for physical illness or injury; significantly interfere with the resident's care, and significantly interfere with the resident's participation in activities or social interactions. This MDS indicated Resident #1 rejected evaluation of care (activities of daily living) necessary to achieve the resident's goals for health and well-being. Record review of Resident #1's Care Plan that was undated (because facility was migrating care plans into new system) indicated Care Task-CNA with onset date of 10/18/23 indicated they should document behaviors exhibited during the shift and give the resident a shower and shampoo her hair. This plan included Resident #1 was a high risk for side effects/physical injury due to need for psychotropic medications. This would be addressed by monitoring and documenting behaviors, and giving positive reinforcement, and not use a judgmental tone of voice. This plan indicated problem onset was added on 02/05/24 due to resident observed yelling and cursing at staff and peers at and times she is easily redirected, other times she will not calm down as easily. Resident #1 has attempted to bite staff when staff remove her dentures and has been observed throwing condiments at peers during mealtimes. These behaviors would be addressed by notifying MD and RP if resident behaviors increase. Anticipate residents needs to help decrease behaviors and refer resident to psychiatric services if needed. Record review of Resident #1's Behavior Preassessment Form and Discharge Receiving Acknowledgement indicated FM F signed this report on 07/18/24 agreeing to transfer Resident #1 to this facility for evaluation. Record review of Resident #1's Progress Notes dated 07/18/24 indicated Resident #1 was picked up by Behavioral Center for transport to their facility. Record review of Resident #1's Behavior Hospital's Take Home Medication List dated 08/07/24 indicated Resident #1 was returning to the facility 08/09/24. Record review of Resident #1's Progress Note dated 07/15/24 at 2:15 pm and written by LVN C, indicated resident (Resident #1) requires assistance with ADLs due to confusion and unsteady gait. She was recently at a behavioral hospital due to aggression and combativeness with staff and other residents. Since returning she continues to exhibit aggression and agitation. Record review of Resident #1's Progress Note dated (late entry) 07/15/24 at 3:00 pm and written by LVN D, indicated resident (Resident #1) was in her wheelchair, was alert and her confusion was normal. The male CNA (CNA A) was wheeling resident (Resident #1), who was swinging at staff and refusing to go to the shower. Nurse Aide (NA B) assisted resident into the shower. After resident was showered, she continued to be agitated, and was screaming in the hallway. Staff reported resident slapped NA B twice. When resident was wheeled down to the nurses' station resident was noted to have a small skin tear to her right forearm which was treated with dressing dry/intact. Record review of Resident #1's Progress Note (late entry) dated 07/15/24 at 4:00 pm and written by LVN D, indicated resident's (Resident #1) complained of paint to her index finger, middle finger, and ring finger on her left hand. Old bruising was noted to both hands/forearms, and left index lower knuckles were swollen. Mobile X-ray unit was called to x-ray resident's left hand. Record review of Resident #1's Progress Note dated 07/15/24 at 8:47 pm and written by LVN D, indicated mobile x-ray arrived at the facility to x-ray resident's left hand, and swelling was noted to left pointer finger. Record review of Resident #1's Progress Note dated 07/15/24 at 11:11 pm and written by LVN D, indicated x-ray results acute osseous abnormalities, osteopenia can obscure subtle bone lesions, a subtle bony abnormality or fracture may not be readily apparent on x-ray, thus clinical correlation and further imaging including follow up to CT (computed tomography that helps detect diseases and injuries), MRI (magnetic resonance imaging used to form pictures of the anatomy and the physiological process inside the body), or x-ray are as advise as needed. Record review of Resident #1's Patient Report (X-ray) dated 07/15/24 included findings of left hand: bones had no fracture of subluxation, joints had no sclerotic or destructive changes, and soft tissues had articular surfaces that were unremarkable. Review of Resident #1's Incident report dated 07/15/24 and written by LVN D indicated resident was in her wheelchair and was alert with confusion as normal. Resident #1 was swinging and kicking at staff and was refusing her shower. NA B assisted Resident #1 with her shower. After her shower, Resident #1 continue to be agitated and was screaming in the hallway. Staff (NA B) reported that she was slapped twice by Resident #1 during her shower. Resident #1 was taken to the nurses' station and LVN D noted she had a small skin tear to her right forearm and treated it with a dressing. LVN D noted that Resident #1 complained of pain to her index, middle finger, and ring finger on her left hand, there was bruising to both hands/forearms, and left index's lower knuckle was swollen. Afterwards, mobile x-ray was called to x-ray left hand (3 view). Resident #1's level of pain was a 4. Record review of NA B's witness statement dated 07/15/24 indicated When CNA A was pushing Resident #1's wheelchair she was reaching and grabbing his body. Then when CNA A was getting her through the shower door she started to shout. So, I went in to help and she was still shouting. When we were taking all her clothing off, she was swinging her arms a lot to try to hit her and CNA A. She attempted to reach enough to graze my face and slap my face, while were showering her and trying to dress her. While we bathed her, I had to hold her arms against her body so CNA A and I could properly do our task. Record review of LVN D's Witness Statement dated 07/15/24 indicated at 3 pm Resident #1 was sitting in her wheelchair at the nurses' station, and was alert and her confusion was normal. CNA A wheeled her (Resident #1) in her wheelchair to go give her a shower, she started swinging at him and made attempts to hold the handrails. After her shower Resident #1 was yelling loudly in the hallway and saying call the police. Resident #1 was swinging and attempting to hit staff, and she did slap female's face (NA B). While bathing her female staff (NA B) had to hold her hands while the male staff (CNA A) wash her off. Resident #1 attempt to bite staff (CNA A and NA B) while removing her dirty clothes. Record review of CNA A's General In-services with hire dated of 08/28/13 included the courses he had completed on 08/30/24: Abuse Prevention in Person with Dementia, Abuse, Neglect & Exploitation Prevention, Challenging Behaviors: Care and Intervention Dementia, and Resident Rights. During an interview on 10/09/24 at 10:42 am with Family Member F (FM F) indicated she had informed facility's staff that if Resident #1 displayed behaviors, staff should call her, and she would go to the facility to help Resident #1. FM F said on 07/15/24 she received a call from LVN D, who informed her Resident #1 was being combative. Minutes later, FM F said she entered the facility and could hear and see Resident #1 kicking, swinging her arms, crying, and yelling that they were trying to get her into her room; however, there was nobody near her. FM F said Resident #1 has a history of hallucinating, and on 07/15/24 said she had been attacked in the shower, and her nails were broken, her fingers were swollen, and she could not bend her fingers. FM F said she did not suspect abuse but said the staff should not have forced Resident #1 to take a shower. FM F said in the room she discovered a skin tear on Resident #1's calf that had bled into her shoe, and this looked like it was caused by her wheelchair. FM F said Resident #1's bra was ripped, she had blood on her shirt, and a skin tear to her elbow, which looked like it was caused by the grab bar. FM F said staff should have called her if Resident #1 was combative, but they did not. I received a call after staff had completed her shower. FM F said on 07/15/24 she did not suspect abuse, but when Resident #1 continued to complain about CNA A, who was working on the same hall where Resident #1's room was located, she reported her concerns and added the 07/15/24 shower incident. Afterwards, facility's staff investigated this incident. FM F said she did not want anybody terminated she just wanted the staff to be better trained, and after she complained she did not see CNA A working in the hallway where Resident #1's room was located. FM F said she had in the past informed staff to call her if Resident #1 was combative but had not told them to call her to assist with the showers. Since this incident 07/15/24, she asked staff to call her and she would help with Resident #1's showers, and they have called her for her assistance. Interview on 10/10/24 at 10:56 am was attempted with Resident #1 over the phone, who did not talk over the phone. During an interview on 10/09/24 at 1:20 pm with LVN F indicated Resident #1 becomes combative when she must shower. If she becomes combative staff should stop with the care, inform the charge nurse, and return later to attempt the care. During an interview on 10/09/24 at 1:30 pm with CNA G indicated if a Resident #1 becomes combative during her care, she will offer her the baby doll, which she keeps with her most of the day, and that calms her down at times. If a resident who is showering and becomes combative, she will stop the care, pull the call light to prevent leaving the resident in the shower unattended, and wait for the nurse. During an interview on 10/09/24 at 1:30 pm with CNA H indicated if Resident #1 becomes combative she will offer her doll to her to calm her down, and that sometimes works. CNA H said if during a shower a resident becomes combative or refuse their shower, staff should stop the care, pull the call light so you don't leave resident in the shower unattended, and wait for the nurse. During an interview on 10/09/24 at 1:40 pm with CNA H indicated if a resident becomes combative during their shower, staff should stop the care, pull the call light to prevent leaving the resident in the shower unattended, and wait for the nurse. Interviews and messages were attempted with NA B on 10/09/24 at 3:04 pm, 10/09/24 at 3:08 pm, and 10/10/24 at 11:22 pm; however, NA B, who no longer was employed by the facility, did not return these messages. During an interview on 10/09/24 at 3:50 pm, Certified Nurse Aide (CNA A) indicated on 07/15/24 Resident #1 was combative at the nurses' station, but he could not recall how she was being combative. CNA A said at the nurses' station he tilted Resident #1's wheelchair back as she sat in the wheelchair, to prevent her from grabbing the rails or planting her feet on the floor. CNA A said he pushed Resident #1, who was angry, in her wheelchair to the shower room. In the shower area, Resident #1 attempted to bite him and nurse aide (NA B); however, he could not recall if she bit him or left bite marks on his body. CNA A said he and NA B tried taking off Resident #1's clothes as she scratched at him and NA B but could not recall where she scratched him. CNA A said NA B held down Resident #1's hand and could not recall if she was resisting. CNA A said he washed Resident #1's hair and body, dried her, and dressed her as Resident #1 resisted care, was combative, and yelled at him and NA B. After Resident #1 was showered, CNA A said he dressed her, then pushed her in her wheelchair into the hallway, where Resdent #1 was left screaming, but CNA A could not recall what she was saying. Shortly afterwards, CNA A said LVN D directed him not to care for Resident #1, instead the nurses would take care of her. A couple of days later, CNA A said LVN E informed him that Resident #1 in the future would be showered by a female staff only. CNA A said Resident #1 was already in the shower and that is why he continued showering. CNA A said he suspects Resident #1 sustained the injuries from grabbing the rails in the shower and from hitting and scratching him and NA B. CNA A said he knew that if a resident becomes combative you should stop and report to the charge nurse; however, Resident #1 had behaviors all the time and she needed to take her shower. CNA A said he did not have an answer as to why he did not stop and call the charge nurse when Resident #1 resisted being taken to the shower, during the shower, and after the shower. CNA A said he could not recall why he did not use the call light in the shower area to call for the nurse. CNA A said NA B assisted him with showering Resident #1, and she can confirm he did not mistreat her during Resident #1's shower. During an interview on 10/09/24 at 4:29 pm with LVN D indicated said she was at the nurses' station and could not recall witnessing Resident #1 being upset before her shower on 07/15/24. Then CNA A approached Resident #1, who was at the nurses' station, and told her he was going to give her a shower. Resident #1 responded by planting her feet onto the floor and saying she did not want to shower. CNA A tilted Resident #1's wheelchair back as she sat in her wheelchair and pushed her to the shower area. Resident #1 was swinging her arms backwards at CNA A and tried to grab the hall's rails. NA B followed them into the shower area to assist with Resident #1's shower. LVN D said she did not see anything wrong with CNA A taking Resident #1, who was upset, to the shower area because this is how she reacts when she is getting a shower. Minutes later, Resident #1 was in the hallway yelling police. LVN D said the staff reported to her that during Resident #1's shower, she was swinging and attempting to hit them, and did slap NA B on her face. That was when NA B said she had to hold her hands while CNA A washed her body. LVN D said NA B informed her that Resident #1 attempted to bite them when they were removing her clothes. LVN D said she did not recall hearing the shower's call light beeping during Resident #1's shower. LVN D said FM F informed her Resident #1's fingers were hurting, and she replied she would call for an order to get x-ray mobile unit to x-ray her fingers. LVN D said she assessed Resident #1's hand and noted one of the knuckles was swollen; however, there were no fingernails missing. Afterwards, LVN D directed CNA A not to care for Resident #1 until he was directed to do so. LVN D said she was not informed by anyone that Resident #1's bra was ripped nor that she was abused by anyone. LVN D said CNA A and NA B should have stopped Resident #1's shower, used the call light to request her assistance, and she would have called FM F to assist with the shower. LVN D said on 07/15/24 she called FM F after the shower because she was screaming in the hallway, and she arrived shortly afterwards. LVN D said Resident #1's family member (FM F) had requested she be called if they were having trouble with Resident 1's care. In the past she had called FM F, who would arrive at the facility within minutes to assist with Resident #1's care. During an interview on 10/10/24 at 10:05 am with a Non-staff N (NS N) indicated on 09/09/24 FM F complained that a male and female staff (CNA A and NA B) forced Resident #1 to take a shower on 07/15/24, even after she became combative. FM F informed her that she was informed that Resident #1 was displaying behaviors, which is when she went to the facility. Upon entering the facility, she discovered Resident #1 in the hallway with the CNA A and NA B, and that is when CNA and NA B threw their arms up in the air and walked off. FMA said she saw that Resident #1 was upset, and her fingernails were ripped off, her fingers were bruised, and she had blood going into her shoes. FM F said Resident #1 reported to her that CNA A forced her to shower, and her doll was thrown under the sink. NS N said FM F said CNA A was going to assist Resident #1 to the bathroom, but she refused. NS N said FM F said she wanted CNA A terminated. Resident #1 was sent to the behavioral unit on 07/18/24, 3 days after the shower on 07/15/24. NS N said FM F denied Resident #1 having any behaviors and informed her the facility had reported the 07/15/24 shower incident on 09/05/24, after she had alleged abused. NS N said on 09/09/24 she received a call from Admin M requesting to discharge Resident #1 because they could not meet her needs. In addition, Admin M informed her that she tried to moved Resident #1 to the facility's secure unit due to her behaviors (exit seeking and combativeness towards staff and other). NS N said she went to the facility and witnessed Resident #1, who has dementia, display these behaviors; however, FM F refused to move her to the facility's secure unit. During an interview on 10/10/24 at 10:58 am with MD J's LVN I indicated when Resident #1 was refusing her shower and became combative, staff should have stopped the shower process, and attempted the shower later in the day. During an interview on 10/10/24 at 4:15 am with Admin M indicated when FM F said she had concerns because Resident #1 asked why CNA A was not in jail, and she did not want him working at facility. Admin M said she reported this allegation to Health and Human Services and initiated an investigation against CNA A and NA B. Admin M said she identified in her investigation that CNA A and NA B on 07/15/24 should have stopped Resident #1's shower when she became combative. These staff should have called the charge nurse and let her take over and offer the shower later. Admin M she suspended CNA A, NA B did not return to work, she in-serviced the staff, and reassigned CNA A to the secure unit. Admin M said NA B stopped working at the facility after this incident. Admin M said she was not informed that Resident #1 was abused by anyone on 07/15/24. Afterwards, Admin M implemented and in-service indicating staff should stop care when a resident becomes combative, report to the charge nurse after ensuring resident is safe, including using a call light to alert the nurse, and attempt the care later. During an interview on 10/10/24 at 11:14 am with MD K indicated when Resident #1 was refusing her shower and became combative, staff should have stopped the shower process, and tired again later. During an interview on 10/14/24 at 10:15 am with Staff L indicated before 07/15/24 Resident #1 has been combative during her showers and when staff applied her AVAP machine (newer modality of non-invasive ventilation that integrates the characteristics of both volume and pressure-controlled non-invasive ventilation). Staff L said this Resident #1's Care Plan for triggered items, which was current as of 10/09/24, included notifying the physician and family member when Resident #1 had behaviors, but not notifying the family member to assist when Resident #1's combativeness. Staff L said she had not updated Resident #1's care plan to include her behaviors of being combative during showers, offering her a baby doll that staff said calms her down, and calling her family member to assist with her care when she becomes combative, per family members request. Staff L said if a resident is combative, they should stop care, notify a charge nurse, and attempt care later. Review of facility's Policy and Procedure for Care Plans that was undated included guidelines to assure any problems identified are addressed in the care plan. And procedures to ensure all goals are measurable and interventions are in place to help achieve the goals, update the plan on a quarterly basis and as needed, use the CCA's as a reference to determine problem or focus area, and any changes in the resident's status will be put on the care plan. Review of facility's Policy and Procedure for Behaviors - Care of the Resident (undated) included purpose to decrease the resident's inappropriate behavior and/or maintain safety during the behavior. The Procedures/Guidelines included If appropriate, stop giving care when the resident is exhibiting inappropriate behavior if resident wound not be put in any risk or danger. Review of the facility's Policy and Procedure for Tub or Shower Bath with Shampooing the Hair that was undated included to explain procedure to resident and encourage resident to participate as much as they can and assist resident to undress as needed.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1) The facility failed to ensure foods were stored under sanitary conditions. 2) The facility failed to ensure food and nonfood contact surfaces were clean. 3) The facility failed to ensure foods were in sound condition 4) The facility failed to ensure food storage areas were clean and good condition 5) The facility failed to ensure food contact items were stored in a sanitary manner 6) The facility failed to ensure hair restraints were worn in food areas 7) The facility failed to ensure manufacturers guidelines were followed regarding food retention These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made during a kitchen tour on 5/07/24 that began at 10:50 AM and concluded at 12:30 PM: *The fryer had gummy buildup on the sides. *In the walk-in refrigerator there was a zip lock bag of cooked breakfast food, which contained eggs and sausage, stored on top of a box of raw bacon. The bag was marked 5/7/24. The exterior of the box was stained. *The underside of the steamtable top shelf was rusted and soiled. *There were drinking glasses stacked wet on a cart on the clean side of the dishwasher and not stored in a manner to effectively air dry. *Containers of juice (Styrofoam cup with lid) and shakes were stored in a bin that was in undrained iced on the service line. The following observations were made during a kitchen tour on 5/07/24 that began at 12:43 PM and concluded at 1:00 PM: *There were 2- #10 (large) cans of unsweetened applesauce that was badly dented on the rim and There was one #10 (large) can of pears that was badly dented on the rim. These cans were stored in the can rack with other cans of in use foods. *There was a container of cottage cheese in the walk-in refrigerator that was labeled by the manufacturer Best by 4/29/24. *The walk-in refrigerator had rusted racks. The following observations were made during a kitchen tour on 5/07/24 that began at 4:09 PM and concluded at 4:39 PM: *The upright dicer had dried food on the blades. It was stored on a rear kitchen table. *A rear kitchen table lower shelf had a rusty surface. The table was located next to the convection oven and food equipment was stored on this shelf. *In the walk-in there was still a container of cottage cheese that was labeled Best by 4/29/24 The following observations were made during a kitchen tour on 5/07/24 that began at 5:02 PM and concluded at 6:00 PM: There were health shakes stored in a bin of undrained ice on the service line. *Facility staff were entering the kitchen without hair restraints, dispensing drinks from the drink dispenser, retrieving cups and other containers. In this area was a large tea urn that was uncovered/lid removed. Housekeeper B wore no hair restraint and was filling cups with juice from the drink dispenser and the tea dispenser urn was uncovered. CNA A entered the kitchen and retrieved dispensed drinks and retrieved cups as the tea urn was uncovered in the area. She wore no hair restraint. *Dietary staff A was observed caring bags of potato chips up against her chest and shirt and then placed them in a bin at the service line. -The following observations and interviews were made during a kitchen tour on 5/08/24 that began at 11:23 AM and concluded at 12:24 PM: * Cartons of shakes were stored in a bin of undrained ice at the service line. *The walk-in floor underneath the racks had a buildup of food and debris. *There was a zip lock bag of cooked breakfast food stored on top of a box of raw bacon in the walk-in refrigerator. The box was stained/soiled. This bag was labeled 5/8/24. *There was a box of cooked sliced beef stored on top of a box of raw ground beef in the walk-in refrigerator. *There was still the same container of cottage cheese present that was labeled Best by 4/29/24 by the manufacturer. *There were clean glasses stacked wet on the clean side of the dishwasher. During an interview with the Dietary Manager on 5/8/24 at 11:39 AM, she stated the bag that was on top of the box of raw bacon was cooked breakfast foods. She stated These are the foods from breakfast. We use it the next day for purees. During an interview and observations on 5/9/24 at 10:47 AM with the Dietary Manager. She stated since her employment, staff had stored cooked food on top of boxes of raw foods. She further stated the dietary department had been short staffed and she tried to do rounds daily. She stated she removed the dented cans and she and the staff go through and check the cans. She stated, everyone had to wear a hair restraint when they entered the main kitchen from the rear wall to the front wall (excluding front and rear entry corridors). She added staff thought they could be in the front corridor area where the drinks were because nothing was uncovered. She stated she had not reviewed anything with staff regarding the storage of foods in undrained ice. She added she had told staff not to stack glasses wet. Observation at that time revealed the dicer still had dried food on the blades and the shelves were rusted in the walk-in and on a rear kitchen table. In the walk-in there was an approximately 6 x 6 area of the floor that had a missing metal section, which caused a depression in the floor and was not easily cleanable. The floor was soiled with food debris under the racks. The Dietary Manager stated, Yes the dicer needed cleaning. She added the dietary department was getting a new floor for the walk-in but had no timeframe for the installation. Regarding the staff member caring bags of chips against her chest, she stated, the Dietitian had mentioned carrying tablecloth against the body, but there was no mention of foods. She stated the dietary issues occurred due to staff not knowing or not being aware. She said that her dietary monitoring system was making rounds. She added the person responsible for ensuring dietary policies and procedures were followed was the Dietary Manager. She stated that she conducted in-services and had done one yesterday (5/08/24); the in-service discussed not propping the door open. She stated, during initial dietary staff training, they wait until staff were comfortable, then they let them go on their own and were monitored. She added the dietary issues observed could place residents at risk for foodborne illness. She further stated staff did not know about not holding things against their shirts and what was on the shirt could get on the food. She also stated she had reviewed hair restraints with staff. During an interview on 5/9/24 at 4:07 PM, the Administrator stated she was not aware of the issue with containers of cooked foods stored directly on top of containers of raw foods. Regarding the hair restraints, she stated she thought staff could go by the wall (entrance corridor). She stated the Dietary Manager and Administrator was responsible for ensuring that correct procedures were followed in the dietary department. She stated these issues could place residents at risk for foodborne illness. She added that the facility was getting an estimate for the walk-in floor repair and that staff had been storing drinks in undrained ice for years. Record review of the in-service training report dated 4/11/24 revealed that the subject of the in-service was Dietary and conducted by the Dietary Manager and Administrator. Items covered were listed as: 1. Make sure you are wearing a hairnet at all times. 2. Sign cleaning schedule and actually do the cleaning. 3. Make sure you are labeling and dating everything you put in the walk-in and freezer 4. Clean up after yourself - if you drop or spill something make sure you clean it right away not later . Record review of the facility undated current policy titled, Sanitation, and Food Handling, revealed the following documentation, Procedures. 1. The Food Service Director will provide work schedules and cleaning assignments to be carried out .

Based on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible in 2 of 4 common resident baths (200 and 400), and 1 of 4 halls (400) in that: The facility failed to ensure chemicals were not accessible to residents and were not stored with resident toiletries and personal items in 2 of 4 common resident baths (200 and 400), and 1 of 4 halls (400). These failures could lead to chemical associated resident injuries. The findings include: On 5/8/24 at 2:32 PM an observation was made of the Hall 200 bath. The door was locked but there were cleaners stored on the lower shelf of the unlocked cabinet among resident use items. These cleaners were stored next to toilet tissue, hair conditioner, and body wash. The specific cleaners/chemicals were as follows: -Fabulosa (two bottles) labeled, Caution: May irritate eyes. If swallowed. Contact poison control center or doctor immediately. -Mean Green Super Strength Cleaner and Degreaser labeled, Warning: eye irritant. Ingest: . Contact poison control center, physician or emergency room immediately. -Diversity Crew Clean Toilet Bowl Cleaner labeled, . Danger: Corrosive . -Aerosol can of [NAME] Duz all Dust and Shine labeled, . Danger: Harmful or fatal if swallowed. Danger: Extremely flammable. On 5/8/24 at 2:49 PM an observation was made of a housekeeping cart unattended in hall 400 outside room [ROOM NUMBER]. There was a male resident walking in the corridor near room [ROOM NUMBER] at the time. Housekeeper A was inside room [ROOM NUMBER] and not observing the cart. There was a spray bottle of cleaner hooked on the exterior of the cart and there was a container of Clorox Hydrogen Peroxide Cleaner Wipes on top of the cart and both items were accessible to residents. The wipes were labeled Caution: Causes moderate eye irritation . The spray bottle contained Ecolab Rapid Multi Surface Disinfectant Cleaner. The bottle was labeled, Do not drink. Causes moderate eye irritation . On 5/08/24 at 2:52 PM Housekeeper A exited room [ROOM NUMBER] stated, Sorry I should have put it (chemicals) away. Housekeeper A she added, I was not intending to stop (at the room). She stated residents would need to get checked out or taken to the emergency room if they came in contact with the assessable chemicals. On 5/8/24 at 2:57 PM an observation was made of hall 400 bath. The door to the bath was a jar. The cabinet inside was unlocked. The lower cabinet top shelf had a spray bottle of Ecolab Peroxide Multi-Surface Cleaner and Disinfectant on the shelf next to mouthwash, an unlabeled spray bottle of clear liquid, spray deodorant, lotion, and a hairbrush. Below the top shelf (on the lower shelf) was an open plastic cabinet drawer containing hair conditioner. The lower shelf also contained fabric freshener, Mean Green Cleaner, body wash, and hair conditioner stored next to each other. On 5/8/24 at 3:04 PM CNA B was interviewed regarding the chemicals in the 400 bath cabinet. At that time, she was observed, spraying the shower chair with the peroxide multi-surface cleaner and then placing the spray bottle back on the lower shelf with toiletries. She stated the unlabeled spray bottle with clear liquid contained water. She added, staff usually kept cleaners on the bottom shelf of the cabinet. She said that she had been working in the facility approximately a year. She stated someone could mistakenly grab it (chemical) and spray it on a resident as a result of the chemicals being stored among resident items. On 5/9/24 at 9:24 AM an interview was conducted with LVN A in the hall 200 bath. Observation with LVN A revealed that the same chemicals were stored as they were the day before, with chemicals stored on the same cabinet shelf with toilet tissue and hair conditioner. All the same cleaners were present which included Fabulosa cleaner, Mean Green Cleaner, and toilet bowl cleaner. She stated the chemicals could leak and harm residents. She added, We need to be educated on this (chemical storage in baths). On 5/9/24 at 11:43 AM an interview was conducted with the Housekeeping Supervisor. She stated staff should have kept the chemicals in the cart and locked them in the cart. She added, staff should have stayed in sight of the cart while they were in the room. She stated, at the time of the incident, Housekeeper A had just stopped for a moment and was heading to disinfect her cart when she left the cart unattended in hall 400. She stated the housekeeping supervisor was responsible for ensuring that chemicals were not accessible to residents. She stated she made rounds to ensure chemicals were stored safely and not accessible to residents. She stated, residents could sustain skin injury, death, chemical burns, and respiratory problems as a result of chemicals being accessible to residents. On 5/9/24 at 12:03 PM an interview was conducted with the DON regarding chemical storage in baths. She stated nursing staff were taught that housekeeping chemicals should be stored separate from resident items and not accessible to residents. She stated staff possibly stored the chemicals, as observed, for convenience. She stated, nursing staff conducted compliance rounds and the Quality Assurance nurses had worksheets that were used. She added, the worksheets needed to be more specific and include the bath storage cabinets. She stated there was a potential that residents could come in contact with the chemicals as a result of chemicals stored with resident toiletries and items. On 5/9/24 at 4:07 PM, an interview was conducted with the Administrator. She stated staff carelessness was the reason for the chemical accessibility and storage issues. She stated the Housekeeping Supervisor, Administrator, and DON were responsible for ensuring that chemicals were stored in a safe manner in the facility. She stated, chemicals could spill on residents and dementia residents could get into the chemicals if they were not stored in a safe manner and inaccessible. Record review of the Safety Data Sheet for Ecolab Peroxide Multi Surface Cleaner and Disinfectant dated 9/13/21 revealed the following documentation, . Section 2. Hazards identification. Product at use dilution. Eye irritation. Product at use dilution. Signal word: Warning. Hazard Statements: Causes eye irritation. Precautionary Statements: Prevention: Wash skin thoroughly after handling. Response: IF IN EYES: Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing. If eye irritation persists: get medical advice/attention . Section 11. Toxicological information. Product at use dilution. Eyes: Causes eye irritation . Record review of the Census List dated 5/9/24 submitted by Administrative Nurse A revealed that 65 residents were independently ambulatory either by walking or wheelchair. Of those 65 residents, 10 were documented as confused. Two of the 10 confused and independently ambulatory residents resided on Hall 400. Record review of the current undated facility policy, titled Storage Areas, Environmental Services, revealed the following documentation, Housekeeping, and laundry department storage areas shall be maintained in a clean and safe manner. Interpretation and Implementation. 3. Cleaning supplies, etc., shall be stored in area separate from food storage and shall be stored as instructed on the labels of such products.

Based on observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 3 residents (Residents #50 and #76) reviewed for infection control. 1. CNA C failed to utilize proper hand hygiene during incontinence care for Resident #50. 2. CNA D failed to utilize proper hand hygiene during incontinence care for Resident # 76. These failures could place residents at risk for infection and cross contamination. Findings included: Resident # 50 Record review of Resident #50's undated face sheet revealed a [AGE] year-old female originally admitted on [DATE]. Resident #50 had the following medical history: retention of urine, contracture of the right and left hand, muscle weakness, and hypertension (high blood pressure). Record review of Resident #50's care plan dated 10/09/2023, revealed a problem of urinary and bowel incontinence with increased risk for skin breakdown/UTI's. Resident #50 had a goal of Resident will not develop any UTI's for 90 days. Resident #50's approaches revealed, Provide proper peri care after each incontinent episode. Record review of Resident #50's MDS dated [DATE] revealed a BIMS score of 7 which indicated Resident #50 had severe cognitive impairment. During incontinence care observation on 5/08/2024 at 09:54 AM, CNA C removed Resident #50's dirty brief, cleaned resident's peri area and doffed dirty gloves. CNA C did not wash her hands or utilize alcohol-based hand sanitizer prior to donning clean gloves. CNA C placed a new brief on Resident #50 and doffed dirty gloves. CNA C did not wash her hands or utilize alcohol-based hand sanitizer before donning clean gloves. CNA C readjusted Resident #50 doffed dirty gloves and washed her hands with soap and water. CNA C not available for interview on 5/8/2024 and 5/9/2024. Resident #76 Record review of Resident #76's undated face sheet revealed a [AGE] year-old male originally admitted on [DATE]. Resident #76 had the following medical history: acute kidney failure, hydronephrosis (condition where one or both kidneys become stretched and swollen), urinary tract infection and benign prostatic hyperplasia (enlarged prostate). Record review of Resident #76's care plan dated 2/14/2024 revealed problem onset, bowel incontinence, increased risk for skin breakdown/UTI's. Resident #76 had a goal stating .will not develop any UTI's over the next 90 days. Resident #76 approaches revealed, provide proper peri- care after each incontinent episode. Resident #76's care plan revealed increased risk for UTI due to indwelling catheter (catheter that remains in the bladder to drain urine). Resident #76's approach revealed catheter care every day and as needed. Record review of Resident #76's MDS dated [DATE] revealed a BIMS score of 7 which indicated Resident #76 had severe cognitive impairment. Record review of physician orders dated 2/14/2024 revealed an order for Foley catheter care every shift. During incontinence care observation on 5/08/2024 at 10:32 AM, CNA D was observed removing Resident #76's dirty brief, cleaned around resident's peri area and doffed dirty gloves. CNA D did not utilize alcohol-based hand sanitizer or wash her hands prior to donning clean gloves. CNA D turned resident onto his side, cleaned his buttocks and doffed dirty gloves. CNA D did not wash her hands or utilize alcohol-based hand sanitizer. During an interview with CNA D on 5/8/2024 at 1045 AM, she stated she was trained to wash her hands before and after resident care, after grabbing soiled items, bodily fluids, and between distributing meal trays in between residents. She stated she should have washed her hands between glove changes. She stated the risk of not utilizing proper handwashing technique was spreading bacteria from one resident to another, or to staff. She stated her infection preventions was the ADM. She stated her last training was 1/2024. During an interview with the ADM on 5/8/2024 at 12:45pm she stated staff is trained on handwashing upon hire, and annually with in services in between as needed. She stated the risk of improper handwashing could be spreading infection. She stated the DON is the infection preventionist. The ADM stated they monitor compliance with annual competencies and as needed. The ADM stated she was not aware of CNA C and CNA D not washing their hands between glove changes. During an interview with the DON on 5/8/2024 at 1:10pm, she stated staff are trained to wash their hands between glove changes. She stated staff are trained during in-services, skills checkoff, as needed and annually. The DON she stated the last training was 5/6/2024. She stated the risk of staff not washing their hands between glove changes would be contamination of the hands when removing their gloves. She stated the DON is the infection preventionist. The DON stated they monitor staff for handwashing compliance through any opportunity for observation with resident direct care. She stated RN A is the QA nurse and she monitors the halls primarily for handwashing. She stated she was not aware of staff not washing their hands between glove changes. Record review of the facility's policy titled Infection Prevention and Control Guideline dated 2/2023 revealed: .A. Hand Hygiene: The single most important component to infection prevention in all circumstances and should always be practiced in addition to other measures outlined in this policy. 1. Includes the use of alcohol-based hand rub and the use of soap and water. Record review of facility's undated policy titled Hand-washing Guideline revealed: When to was hands Guidelines: .7) After handling items potentially contaminated with residents' blood, body fluids, excretions, secretions. .Alcohol based sanitizer may be used in place of soap and water. Record review of Internet CDC Handwashing Guidelines titled Hand Hygiene in the Healthcare Setting last revised January 8, 2021, revealed: The CDC Guideline for Hand Hygiene in Healthcare Settings recommends: During Routine Patient Care .Use an Alcohol-Based Hand Sanitizer .Immediately after glove removal.