Every finding on record at Prestonwood Rehabilitation & Nursing Center

Based on observation, interview, and record review, the facility failed to ensure that residents receive adequate supervision and assistance devices to prevent accidents for one of five residents (Resident #1) reviewed for accident hazards. The facility failed to use a two-person transfer, as determined necessary by the comprehensive care plan, during a transfer from the resident's bed to wheelchair, resulting in the resident sustaining a left kneecap fracture. The noncompliance was identified as PNC. The noncompliance began on 07/30/26 and ended on 08/05/26. The facility had corrected the noncompliance before the survey began. This failure placed Resident #1 at risk of avoidable accidents.Findings included: Record review of Resident #1's Face Sheet, dated 08/13/26, reflected she was an [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including dementia in other diseases classified elsewhere (dementia is a general term for a decline in mental ability severe enough to interfere with daily life, encompassing memory loss, thinking, and behavioral changes), Osteoporosis (medical condition where bones become weak, thin, and fragile), and muscle weakness (a condition where muscles are unable to contract or move as easily as they used to, potentially due to various underlying causes). Record review of Resident #1's MDS Assessment, dated 06/03/26, reflected she had severe cognitive impairment. Resident #1 was identified as dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity for Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). Record review of Resident #1's Care Plan, dated 05/14/26, reflected she was in hospice care and required the use of a mechanical lift for transfers, with two staff members to assist in the transfer. Record review of the facility's Provider Investigation Report, dated 08/05/25, reflected on 07/30/26 at around 2PM, CNA A independently transferred Resident #1 from her bed to wheelchair without a mechanical lift. Resident #1 sustained a skin tear of 6cm x 0.4cm and bruised her left knee. RN A [BR3.1]was called to the room and RN A assessed Resident #1. Initial X-ray (a fast, painless medical test that sends a tiny bit of invisible radiation through your body. It takes a picture of your bones and organs on a computer or film) was done and the result was negative for a knee fracture. Three days later Resident #1's swelling and pain in her knee had no improvement, and she was sent to hospital. An X-ray in the hospital [BR4.1]indicated a closed displaced (a broken bone that has moved out of its normal line or position, leaving a gap between the pieces) [BR5.1]fracture of left patella (Kneecap). CNA A was suspended pending the outcome of the facility investigation. CNA A admitted ly knew that Resident #1 needed two staff members for transfer via mechanical lift. Facility staff were in-serviced on mechanical lift transfer protocols; staff completed mechanical lift competency checks. CNA A was terminated due to the incident.Record review of Resident #1 hospital discharge records and x-ray dated 08/03/2026 stated closed displaced fracture of left patella, unspecified. Hospital discharge records showed no surgery, cast or knee brace were recommended for the knee. Record review of in-service records, dated 4/24/26, reflected direct care staff were in-serviced on mechanical transfer protocols.Record review of in-service records, dated 8/04/26, reflected staff were in-serviced on Following Transfer Plan. Record review of the Manual Lift Competency Assessments, dated from 08/4/26 to 08/5/26, reflected facility staff were screened for competency in using mechanical lifts. Facility staff were documented to have demonstrated competency in this area via return demonstration. Review of CNA A's employee folder reflected CNA A was terminated on 08/04/26. During an observation and interview on 08/13/2026 at 10:00 AM with Resident #1, she stated that her left knee hurt when she touched it. Resident #1 stated she received pain medications from her nurse as needed and that the medications are effective in controlling her pain. Resident #1 stated she was non ambulatory and self-propel with wheelchair before the incident. She stated she was dependent on staff for bed mobility and transfer and other ADLs like bathing and dressing. Resident #1 stated she could not remember how and when her left knee and right hand were injured. It was observed that Resident #1 had a faded discoloration bruise of 18cm x 20cm on her left knee. The left knee had no swelling, open skin, bandage or cast. Resident #1 had a 6cm x 0.4cm healing skin tear on her right arm covered with a bandage dated 8/13/26. Observation on 08/13/26 at 11:30AM of a mechanical lift transfer for Resident #2, conducted by CNA B and CNA C revealed the mechanical lift transfer was completed without incident. Facility staff were observed to follow the facility's policies and procedures related to mechanical lift transfers. During an interview with RN A on 8/13/2026 at 10:32AM, she stated she was on duty on the day of the incident (7/30/2026). She stated she was called to the room by CNA A and notified that Resident #1 had skin tear to right arm. RN A stated she did first aid on the arm. She said that Resident #1 started screaming her knee hurt. RN A stated Resident #1 was transferred back to bed with a mechanical lift and assessed. RN A stated she noted swelling and discoloration to residents left knee and notified DON, MD and Hospice. RN A stated Xray was done and result showed no acute fracture or dislocation. RN A stated that Resident #1's pain was managed with Tramadol and Morphine which she had been getting as a hospice patient.RN A stated that in about 3 days the pain and swelling was not reduced and Resident #1 was sent to hospital. RN A stated that Resident #1 returned same day, and hospital discharge record stated closed displaced fracture of left patella unspecified. RN A stated that Resident #1 was non-ambulatory and dependent on ADLs prior to the incident and that the incident did not change Resident #1's level of daily functioning. During an interview with CNA A on 08/13/256 at 11:37 PM, she stated on the day of the incident (07/30/25), she transferred Resident #1 from her bed and into her wheelchair without assistance. CNA A stated Resident #1 always complained when she was transferred with the mechanical lift, and she decided to transfer Resident #1 by herself without mechanical lift.CNA A stated she did not ask any other staff members to assist her, because she thought the other staff members were busy providing care for other residents. CNA A stated during the transfer, her knee had an impact with Resident #1's left knee. CNA A stated that Resident #1 had bruise to her left knee and a skin tear to her right arm. CNA A stated she was suspended and terminated due to the incident. CNA A stated the risk of transferring a resident without the recommended/required number of staff was that residents could be injured. During interviews with Resident #2, Resident #3, Resident #4, and Resident #5 on 8/13/26 from 9:30AM to 2:00PM, they each reported they required transfers via mechanical lift. Each of the residents reported two staff members assisted during the mechanical lift transfers. The residents denied any incidents and/or injuries had occurred because of the mechanical lift transfers. During interviews with CNA B, RN A, CNA C, CNA D, CNA E, and LVN [BR7.1]A on 08/13/26 from 11:40AM to 2:00 PM, they all worked day shift and each reported being in-serviced on the facility's mechanical lift transfer protocol. The staff members were able to explain, in detail, how to complete a mechanical lift transfer (including the requirement of having at least two staff members present) per the facility's written policies and procedures. The staff members reported they had completed return demonstration competency checks for understanding. During an interview with DON on 8/13/2026 at 4:20 PM, she stated she was working as the administrator and oversaw the facility as DON until a new DON was hired. The administrator stated that she was notified by RN A of Resident # 1's swollen knee on 7/30/2026. She stated Resident #1 was asked what happened and she responded, I don't know why my knee hurts. The administrator/DON stated she was informed by RN A that CNA A independently transferred Resident #1 from her bed to wheelchair without a mechanical lift. The Administrator stated that the police, MD, Hospice company and Resident #1's daughter were notified. An X-ray was ordered and Resident #1's daughter opted to not send resident to hospital but to wait for the results of the x-ray. The administrator stated the x-ray result showed no acute fracture or dislocation. The Administrator stated that the police (case# 26-150941) interviewed Resident #1 and reported that she made no allegation of someone hurting her. The Administrator stated that on 8/03/2026 resident #1's left knee appeared to have faded in color, but pain persisted. Resident #1 was sent to hospital and returned with finding of left knee acute fracture of the patella (kneecap). The Administrator stated that no surgery, cast or knee brace were recommended for the knee and that Resident #1's daily functioning did not change. The administrator stated that CNA A was suspended pending the outcome of the facility investigation and later fired. Facility staff were in-serviced on mechanical lift transfer protocols; staff completed mechanical lift competency checks, return demonstration of Hoyer lift and transfer technique was done and staff were in-serviced on Abuse and Neglect. Review of the facility's Safe Resident Handling and Movement Standards of Practice policy, undated, reflected, .Mechanical Lift -2 persons to be utilized when transferring residents who are non-weight bearing and unable/unsafe to be transferred by alternate methods .

Based on observation, interview, and record review, the facility failed to ensure the right to file grievances anonymously for 9 of 9 residents (confidential group members) reviewed for grievances.1. The facility failed to ensure that the 66 residents at the facility had access to file a grievance anonymously.The facility's failure could place the residents at risk of their concerns not being reported and addressed.Findings included:In a confidential group meeting at an undisclosed date and time, the residents stated that the facility's Grievance Forms were located on the wall at both Nurses Stations. The residents stated that they have completed grievances at the facility on several occasions but did not like completing the Grievance Forms and submitting them to staff. The residents stated that their concerns on their previous filed Grievance Forms had been addressed, but they did not feel comfortable completing and filing their grievance concerns. The residents stated that after completing and filing a grievance, they would give it to staff and were uncertain if any staff were able to read and review their grievances and share with other staff members their grievance concerns after they have been filed. The residents stated that the staff at the facility were not only coworkers, but also friends outside of work and they have not filed any grievances regarding their concerns because they feared being retaliated against by their caregivers and staff at the facility. The residents stated that they would like the option to file a grievance anonymously in a designated location that was in a discrete location.An observation on 06/01/26 at 11:38 AM revealed there were blank Grievance Forms located inside of a clear bin located on a wall adjacent to the front Nurses' Station.An observation on 06/01/26 at 11:42 AM revealed there were blank Grievance Forms located inside of a clear bin located on a wall adjacent to the rear Nurses' Station.An observation on 06/03/26 at 10:49 AM revealed there were blank Grievance Forms in a wooden file box located behind the Receptionist Desk in the Lobby of the facility.An observation on 06/03/26 at 10:52 AM revealed there was a black lock box on the wall at the Business Office with a white piece of paper labeled, Payments, Mulligans and Communication with Office Staff. The black lock box was in the Front Lobby of the facility near the Receptionist's Desk.During an interview with the SW on 06/02/26 at 1:20 PM revealed, she had been employed at the facility for 3 months. The SW stated that the facility's Grievance Forms were called, [NAME] Forms. The SW stated she would assist residents with completing the [NAME] Forms, if needed. The SW stated that she hand delivered the completed [NAME] Forms to the Administrator. The SW stated that the [NAME] Forms were located at both Nurses' Stations and behind the Receptionist's Desk in the front lobby of the facility. The SW stated she was not the Grievance Officer at the facility and was unsure who the Grievance Officer was at the facility. The SW stated she was unaware that the facility needed to have an area for Grievance Forms that could be completed and submitted anonymously. The SW stated she was unsure if there was any risk to residents, family members, or visitors if there was not an anonymous designated area for a [NAME] Form to be completed and submitted.During an interview on 06/03/26 at 11:48 AM with LVN E revealed, she had been employed at the facility for 1 year. LVN E stated that she was unaware that the facility needed to have an area for Grievance Forms that could be completed and submitted anonymously. LVN E stated that the facility's Grievance Forms, which were called [NAME] Forms were located on the walls besides the front and back area Nurses' Stations. LVN E stated if a resident completed a [NAME] Form, they were to give the completed forms to staff and staff were to drop the document into the black box located on the Business Office door. LVN E stated that when a resident or someone such as a family member or visitor completed the [NAME] Form, she would fold it closed and tape the ends and then place the completed [NAME] Form in the black lock box located outside the Business Office. LVN E stated that if the residents, their family members, friends and/or visitors wanted or needed to voice their concerns about something at the facility there should be an area designated for them to voice their concerns anonymously to ensure privacy for all parties. LVN E stated that harm could be caused to a resident if a [NAME] Form was completed by a staff member. LVN E stated that there was no potential for harm such as retaliation against the resident or psychosociological harm if there was not an anonymous designated area for a [NAME] Form to be completed and submitted.During an interview on 06/03/26 at 1:16 PM with the DON, she revealed she had been employed at the facility for 1 year. The DON stated that the Administrator was the Grievance Officer at the facility. The DON stated the Administrator was currently on Leave and did not have a return date and did not have access to her work equipment. The DON stated she was the Grievance Officer while the Administrator was on Leave. The DON stated that she was unaware that the facility needed to have an area for Grievance Forms that could be completed and submitted anonymously. The DON stated that the facility's Grievance Forms were called [NAME] Forms and they were located at both Nurses' Station and at the Receptionist Desk. The DON stated residents who were bed bound would have to get a [NAME] Form from a staff member. The Administrator stated that the facility was in the process of posting grievance forms on the wall so that the [NAME] Forms could be obtained and filed anonymously. The Administrator stated that the facility purchased a lock box for the [NAME] Forms to be submitted anonymously. The Administrator stated that there will be a designated area for [NAME] Forms to be obtained, completed, and filed anonymously. The Administrator stated that the staff will be In-Serviced on the location of the newly purchased lock box. He stated that he would be the only person in the facility to have a key to the lock box to retrieve the [NAME] Forms. The Administrator stated that residents, family members, or visitors who could not file anonymous grievances were at risk for not being able to safely express their concerns. The Administrator stated that the potential harm to residents, family members, or visitors who could not file anonymous grievances was that there could be some retaliation against the person filing the Grievance Form by staff, and/or other residents. The DON stated she did not feel that there was any risk or harm to residents due to not having the opportunity to file a grievance anonymously.The Administrator was unavailable for an interview due to being on Leave for an undetermined timeframe.Record review revealed an email from the DON on 06/03/26 at 8:08 AM. The email included a receipt for a black lock box purchased on 06/02/26.Record review of the facility's policy, Grievance Policy and Procedures, updated 03/21/2024, reflected: Policy Statement:All grievances and complaints filed with the facility will be investigated and corrective actions if needed will be implemented to resolve the grievance.Policy Interpretation and Implementation:1. Whenever a resident or responsible party/legal representative has a concern, they should contact the resident's charge nurse to seek immediate resolution to the concern or meet with the Director of Nursing (DON) or Administrator (ADMIN) to discuss the concern.2. Residents, staff, family and resident representatives have the right to voice or file grievances without fear of discrimination or reprisal.3. The ADMIN is the Grievance Officer and can be contacted in person by phone or via email.4. If neither the DON or ADMIN are available residents, staff or responsible party/legal representative are encouraged to complete a Resident Grievance/Complaint Form ([NAME] Form). Located on the wall at both the front [NAME] and back Pebble Beach nurses' stations and returned under the door of the ADMIN's office or placed in the black box to the left of the receptionist desk.5. Upon admission, residents are also provided with written information on how to file a grievance or complaint these submissions can be filed anonymously per the filer's preference.6. Should a staff member overhear or be the recipient of a complaint voiced by a resident or a resident's representative the staff member is to inform the resident or the person acting on the resident's behalf as to where to obtain a Resident Grievance/Complaint Form ([NAME] Form) and where to locate the procedures for filing a grievance or complaint (e.g., posted on the residents' bulletin board).7. If the Recipient is unable to write the complaint down the staff member should offer to write it with their permission.8. All complaints that involve alleged abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, must be reported to the administrator immediately. The ADMIN and/or designee will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations.9. Upon receiving grievance, the Grievance Officer/ADMIN and or designee will take responsibility of investigating the grievance he or she will record, log and begin an investigation into the concerns.10. The department director(s) of any named employee(s) will be notified of the investigation underway and the nature of the complaint.11. The Administrator and/or designee will review the findings to determine what corrective actions, if any are needed.12. If the person filing the grievance is known, the ADMIN and/or designee will follow up to determine if it has been corrected and receive acknowledgement from the residents that they have been followed up with. If needed note will be made in matrix, printed and attached to Grievance/[NAME]. If the grievance was filed anonymously, the ADMIN and/or designee will investigate based upon the facts that are available. 13. Once the grievance has been resolved it is then recorded in the Resident Grievance Complaint Log located in the ADMIN office.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety.1. The facility failed to ensure food in the facility's dry storage and freezer areas were labeled and dated according to guidelines.2. The facility failed to seal open items in plastic bags in the dry storage pantry and freezer areas.3. The facility failed to ensure that expired items in the dry storage pantry area were removed.4. The facility failed to ensure that dented cans were removed in the dry pantry area and were separated from the other canned food.These deficient practices could affect residents who received meals and/or snacks from the main kitchen and placed them at risk for cross contamination and other food-borne illnesses. Findings Included:An Observation of the facility's kitchen during the brief initial tour of the kitchen on 06/01/26 at 8:58 AM, revealed the following:Dry Pantry area:*1 can of 7 lb. Butterscotch Pudding was dented.*1 bag of 8 lb. vanilla pudding & pie filling mix was unsealed and exposed to air.* 3 bottles of 16 fl. oz. imitation coconut extract had an expiration date of 05/08/2025.* 1 bottle of designer dessert cinnamon sauce had an expiration date of March 2025.* 1 can of 14 oz. sweetened condensed milk had an expiration date of 04/16/2026.* 1 16 fl. oz. bottle of green food color had an expiration date of 01/15/2026.* 1 bottle of 16 fl. oz. of imitation almond extract did not have an expiration date.* 1 bottle of 16 fl. oz. of pure lemon extract did not have an expiration date.* 1 box of dijon mustard included 80 individualized packages had an expiration date of 05/10/2026.* 1 box of 1 oz. cocktail sauce included 33 individualized packages had an expiration date of 04/20/2026.* 1 package of 16 oz. mini marshmallows was unsealed and exposed to air.* 1 package of breadcrumbs did not have an expiration date and was unsealed and exposed to air.* 1 package of 16 oz. imitation bacon bits did not have an expiration date and was unsealed and exposed to air.* 1 unsealed box of [NAME] couscous was in a plastic bag that was unsealed and exposed to air.* 1 unsealed box of enriched macaroni product as in a plastic bag that was unsealed and exposed to air.* 2 packages of 10 oz. elbow noodles were unsealed and exposed to air.* 1 bag of 16 oz. tricolor rotini noodles had a hole and was unsealed and exposed to air.* 1 bag of 10 lb. enriched macaroni angel hair pasta was unsealed in an open zip loc bag and was exposed to air.* 1 box of 25 lb. thick & easy instant food & beverage thickening powder was unsealed and exposed to air.Freezer area:* 1 clear container with a green lid labeled hot dogs was unsealed and exposed to air.* 1 ziploc bag labeled sliced cheese was unsealed and exposed to air.* 1 box of baking soda was unsealed and exposed to air.* 1 container of 25 lb. chicken flavor base was unsealed and exposed to air.* 1 carton of 12 lb. liquid whole eggs was unsealed and exposed to air.* 1 box of white dinner roll dough was unsealed and exposed to air.* 1 box of biscuit dough was unsealed and exposed to air.* 1 box of carrots was unsealed and exposed to air.* 1 box of imitation snow crab cakes was unsealed and exposed to air.* 1 bag of fish sticks was undated, unsealed and exposed to air.* 1 box of chicken strips was unsealed and exposed to air.* 1 box of beef patties was unsealed and exposed to air.* 1 box of potato wedges was unsealed and exposed to air.* 1 box of sugar free cookie dough was unsealed and exposed to air.Kitchen Shelves:* 1 clear container labeled sugar was unsealed and exposed to air.* 1 clear container labeled thickener was unsealed and exposed to air.* 1 clear container labeled rice was unsealed and exposed to air.* 1 container of 5 lb. seasoned salt was unsealed and exposed to air.* 1 container of 6 lb. garlic powder was unsealed and exposed to air.* 1 container of 4.5 oz accent seasoning was unsealed and exposed to air.During an interview with the Interim Dietary Manager on 06/02/26 at 1:34 PM, he stated he had been employed with the company for 7 years. He stated he was assisting the facility's kitchen staff with their assignment duties and responsibilities until the Dietary Manager returned to work from her scheduled Leave. He was informed about the findings during the initial brief tour of the facility's kitchen, which included dented cans, labeling, expired and unsealed items in the dry storage, refrigerator, and freezer areas. The Interim Dietary Manager stated he would inform all kitchen staff of the findings of the initial brief tour of the kitchen and provide In-Service Trainings on food storage, labeling and ensuring that dented cans were removed from the shelf and placed in the designated area for dented cans. The Interim Dietary Manager stated all staff were responsible for ensuring that there were not any food items in the facility's kitchen that were unlabeled, undated, expired, unsealed, and dented cans on the shelves in the facility's dry pantry, refrigerator, and freezer areas. He stated at his facility he had a Checklist that he utilized daily to ensure the food items in the facility's kitchen were labeled, dated, not expired, sealed, and no dented cans on the shelves in the facility's dry pantry, refrigerator, and freezer areas. The Interim Dietary Manager stated he was unsure if the Dietary Manager had a Daily Checklist Sheet, but he would meet with her upon her return and ask her if she had one and if she stated she did not have a Daily Checklist Sheet, he would provide her with a copy of his Daily Checklist Sheet. The Interim Dietary Manager stated all kitchen staff received on-going In-Service Trainings on Food Preparation and Food Storage, which included ensuring that the food items in the facility's kitchen were labeled, dated, not expired, sealed, and no dented cans on the shelves in the facility's dry pantry, refrigerator, and freezer areas. The Interim Dietary Manager stated that the In-Service Trainings included reeducation on removing expired items from the shelf and utilizing the FIFO method (an asset management and valuation method where the oldest inventory, stock, or data items are processed, sold, or used first). He stated if staff were to find any food items such as expired items and unsealed items in the facility kitchen's dry pantry, refrigerator, and freezer areas, his expectation was for the staff to immediately throw away the food item (s) and inform him about the food item (s) that were thrown away. The Interim Dietary Manager stated that the kitchen staff would then receive In-Service Training relating to the issue that was found. He stated that the food items that were expired and unsealed in the facility's dry pantry, refrigerator, and freezer areas during the brief initial tour of the kitchen on 06/01/26 would immediately be thrown away. He stated the dented can found during the brief initial tour of the kitchen on 06/01/26 would immediately be removed from the shelf with the other cans in the facility's dry storage area. The Interim Dietary Manager stated there was a designated area in the Dietary Manager's Office for the dented cans to be stored. The Interim Dietary Manager stated he would provide In-Service Training to all kitchen staff on 06/01/26 on Food Storage and reeducate the staff on the facility's Food Storage Policy. He stated if anyone ingested any food from the facility's kitchen that was expired, unsealed and dented cans there was a risk of the person contracting food botulism (caused by eating foods contaminated with the toxin) and salmonella poisoning (a common bacterial infection that affects the intestinal tract contracted by ingesting Salmonella bacteria-typically through contaminated food). He stated if anyone ingested any food from the facility's kitchen that was expired, unsealed and dented cans there was a potential for harm which included diarrhea, stomach aches and c.diff (a bacterium that infects the large intestine).During an interview with Dietary [NAME] D on 06/02/26 at 11:33 AM, he stated that she had been employed at the facility for 1 year. He stated he was unaware there were expired and unsealed items in the facility kitchen's dry storage, and refrigerator areas on 06/01/26. Dietary [NAME] D stated she was unaware that dented cans were observed in the facility's dry storage area on 06/01/26. Dietary [NAME] D stated the Interim Dietary Manager informed the kitchen staff about the findings during the initial brief tour of the kitchen on 06/01/26. He stated all the staff were responsible for labeling and storing the items on the shelf and checking the expiration dates on everything in the dry storage, refrigerator, and freezer areas in the facility's kitchen. Dietary [NAME] D stated dented cans, if found were to be immediately removed from the shelves in the dry pantry area. Dietary [NAME] D stated the dented cans, if found were to be placed with the other dented cans in the designated area marked Dented Cans, which was in the Dietary Managers Office. Dietary [NAME] D stated that all kitchen staff received previous education and trainings via In-Service Trainings on food storage, and utilizing the FIFO method for restocking items on the shelves. Dietary [NAME] D stated if he observed any food items that were expired and/or unsealed, and not labeled in the facility's dry pantry, refrigerator, and/or freezer areas, he would immediately trash the item(s), then immediately notify the Dietary Manager of her findings. Dietary [NAME] D stated that prior to 06/01/26, the Dietary Manager provided several In-Service training courses for all kitchen staff on food storage, handling, and preparation. He stated all kitchen staff were responsible for labeling and storing the items on the shelf and checking the expiration dates on everything in the facility kitchen's dry storage, refrigerator, and freezer areas. Dietary [NAME] D stated if he observed any food item (s) that were expired and/or unsealed, and not labeled in the facility's dry pantry, refrigerator, and/or freezer areas, he would immediately trash the item (s), then immediately notify the Dietary Manager of her findings. Dietary [NAME] D stated if someone ingested food from the facility kitchen's dry pantry, refrigerator and freezer areas that were unsealed or expired, or from dented cans they were at risk of food-borne illness from cross-contamination and could become sick. He stated that any ingestion of food that had been unsealed or expired, or from dented cans can cause a person to have stomach issues including stomach aches, diarrhea, vomiting, and/or salmonella poisoning.During a telephone interview with the Dietary Manager on 06/03/2026 at 1:24 PM, she stated that she had been employed at the facility for 1 1/2 years. The Dietary Manager stated that she had a total of 6 staff members in the kitchen, which included 2 staff members per shift. The Dietary Manager stated she was currently on Leave and would return to work on Friday, 06/05/26. She was informed about the findings during the initial brief tour of the facility's kitchen, which included dented cans, not labeling, expired and unsealed items in the dry storage, refrigerator, and freezer areas. The Dietary Manager stated she had a checklist she used to perform daily checks in the facility's kitchen to ensure that the food items in the kitchen were labeled, dated, not expired and the dented cans were removed from the shelves throughout the kitchen and in the dry storage, refrigerator, and freezer areas. The Dietary Manager stated the items that were found in the facility's kitchen on 06/01/26 were overlooked by mistake by herself and all kitchen staff. She stated that the items that were found on 6/1/26 were not found by her staff and herself during their daily inspections. She stated that all staff in the facility's kitchen were responsible for ensuring that the items in the dry storage, refrigerator, and freezer areas in the kitchen were labeled, which included writing the name and the date the item was stored and the items use by date. She stated that all items in the dry storage, refrigerator, and freezer areas in the kitchen should always be sealed and closed and expired items, if found should immediately be discarded, thrown away into a trashcan. The Dietary Manager stated all staff are to ensure items in the kitchen's dry pantry, refrigerator, and freezer areas are not expired, sealed and not exposed to air. She stated if any items are found unsealed, they are to be thrown away immediately. She stated her expectation was for staff to throw away any items that are expired or opened in the kitchen's dry pantry, refrigerator and freezer areas and notify her of what they found. She stated that if staff found dented cans, the dented cans were to be immediately removed from the shelf and placed in the designated area for Dented Cans, which was in her Office. She stated staff have received several in-services relating to food preparation, storage, and labeling and to immediately remove any expired items and the removal of dented cans. The Dietary Manager stated all kitchen staff have been reeducated and retrained on Food Storage, Food Safety and Food Preparation via in-service trainings, which are ongoing. She stated that the staff also have been reeducated on using the First In, First Out procedures to ensure there were not any expired food items throughout the dry pantry, refrigerator, and freezer areas facility's kitchen. She stated upon her return to work, she would perform an audit of everything in the facility's kitchen to ensure there were not any opened and expired items in the dry pantry, refrigerator and freezer areas and the dented cans were removed from the shelves with the other cans. She stated if any item (s) were not labeled and/or dated, her expectation was for her staff to inform him of their findings, therefore she would reeducate and retrain all kitchen staff through in-service training. She stated all kitchen staff were to ensure items in the kitchen's dry pantry, refrigerator, and freezer areas were not expired, unsealed, labeled, dated, and dented cans should be removed. She stated the kitchen staff were reeducated and retrained through in-service training regularly, which was monthly or as needed. She stated that she could not recall when the kitchen staff received their previous in-service training on Food Storage was taken. The Dietary Manager stated if anyone ingested food from the kitchen that was expired, dented cans and unsealed containers or bags, there were no risks or harm.Record review of the In-Service Training on from the Dietary Department revealed the 6 dietary staff members received an In-Service Training on 06/01/26 on Labeling and Dating Food Items and the facility's policy, Food and Receiving Storage.Record review of facility's policy, Food Receiving and Storage Policy, dated 2001 and revised 2008 reflected, Policy Statement:Foods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation:2. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted.6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in - first out system.7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).9. Refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers.10. The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing.12. Uncooked and raw animal products and fish will be stored separately in drip-proof containers.Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301- 3-306.

Based on interview and record review, the facility failed to complete a Quarterly MDS Assessment for 1 (Resident #12) of 5 residents reviewed for Resident Assessments. 1. The facility failed to ensure Resident #12's Quarterly MDS Assessment was completed within 90 days (01/27/2026 - 04/26/2026) and included an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions to ensure that care.This failure could place residents at risk of not having their individual care needs met, which could cause a decline in physical health, psychosocial health, and quality of care. Findings included: Record review of Resident #12's admission face sheet, dated 06/03/26, reflected a [AGE] year-old female, admitted to the facility on [DATE], with diagnoses that included: dementia (a progressive decline in mental ability-including memory, reasoning, and behavior-severe enough to interfere with daily life), anxiety (the body's natural response to stress, manifesting as a feeling of fear, dread, or unease about upcoming events or uncertain outcomes), GERD (Gastroesophageal Reflux Disease is a chronic digestive condition where stomach acid or bile repeatedly flows back into the tube connecting your mouth and stomach), and glaucoma (a group of eye diseases that damage the optic nerve).Record review of Resident #12's Quarterly MDS Assessment, dated 10/27/25, reflected a BIMS score of 3 indicating severe cognitive impairment.Record review of Resident #12's Quarterly MDS Assessment, dated 04/27/26, reflected a BIMS score of 3 indicating severe cognitive impairment. Resident #12's Quarterly MDS Assessment was completed by the Interim MDS Coordinator on 05/25/26.Record review of Resident #12's EHR (an Electronic Health Record is a digital, patient-centered version of a medical chart) reflected a Quarterly MDS Assessment completed from 10/27/25 - 05/25/26, which was more than 120 days past due.During a telephone interview with the Interim MDS Coordinator on 06/03/26 at 11:14 AM, she stated that she had been employed part-time at the facility for 1 month. She stated that the previous full-time MDS Coordinator's last day of employment was in May 2026. The Interim MDS Coordinator stated she was unaware that the Quarterly MDS Assessment for Resident #12 was last completed on 10/27/25 and needed to be updated. The Interim MDS Coordinator stated that Quarterly MDS Assessments should be completed for every resident every 90 days per the RAI Manual issued by CMS. The Interim MDS Coordinator stated the MDS Coordinators role included opening and closing the Quarterly MDS Assessment for each resident. The Interim MDS Coordinator stated it was her responsibility to open the Quarterly MDS Assessment and inform the rest of the IDT it was open. The Interim MDS Coordinator was asked to verify in the facility's EHR, the previous dates for Resident #12's most recent Quarterly MDS Assessments, she stated she was in training and did not have access to the EHR records for the facility. The Interim MDS Coordinator stated she covered 2 facilities and Resident #12's name did not sound familiar to her. She stated that she would reach out to staff at the facility to audit the MDS Assessments for the residents in the facility. The Interim MDS Coordinator stated there were risks to residents if their Quarterly MDS Assessments were not completed included proper resident care with special instructions would not be followed for each resident's needs. The Interim MDS Coordinator stated if a resident's Quarterly MDS Assessment was not completed with the designated timeframe and past the 90 days, the facility was not in compliance with CMS and the residents' plan of care which was a personalized, written roadmap that outlines how staff will manage a resident's daily, medical, and personal needs. The Interim MDS Coordinator stated she was unsure if there was any harm associated with a resident's Quarterly MDS Assessment not being completed by the RAI Manuals guidelines.During an interview on 06/03/26 at 1:16 PM with the DON, she revealed she had been employed at the facility for 1 year. The DON stated the facility currently did not have a Full Time MDS Coordinator/Nurse and the position was vacant. The DON stated that the previous MDS Coordinator's last day of employment was 05/07/26. The DON stated the facility is currently utilizing an MDS Coordinator [Interim MDS Coordinator] from another facility, who was assisting the facility with their MDS Assessments on a part-time basis. The DON stated she was not familiar with the MDS Assessment RAI timeframes but was aware that MDS Assessments needed to be completed Quarterly for each resident every 90 days. The DON stated her staff (CNA's and Nurses) utilized the Care Plan for each resident regarding the level of care required for each resident. The DON stated each resident's MDS Assessment was a blueprint for the residents, and the staff used the Care Plan for directives for ADL care, diagnoses, and BIMS Scores. The DON stated every Friday and audit was done on the MDS Assessments for the residents and Resident #12's MDS Assessment being over 120 days was not caught during the weekly audits. The DON stated there was not at any risk or harm to Resident #12 due to the Quarterly MDS Assessment not being completed within the mandated 90 days, the deadline required by the Centers for Medicare & Medicaid Services (CMS).Record review of the facility policy Resident Assessments, dated 2001 and revised March 2002 reflected, Policy Statement: A comprehensive assessment of every resident's needs is made at Intervals designated by OBRA and PPS requirements.Policy Interpretation and Implementation:Definitions:OBRA-Required Assessments - are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes.PPS Assessments - provide information about the clinical condition of beneficiaries receiving Part A SNF-level care in order to be reimbursed under the SNF PPS for both SNFs and Swing Bed providers.1. The resident assessment coordinator is responsible for ensuring that the Interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements:a. OBRA required assessments- conducted for all residents in the facility: (1) admission Assessment (Comprehensive); (2) Quarterly Assessment; (3) Annual Assessment (Comprehensive); (4) Significant Change in Status Assessment (SCSA) (Comprehensive); (5) Significant Correction to Prior Comprehensive Assessment (SCPA) (Comprehensive); (6) Significant Correction to Prior Quarterly Assessment (SCQA); and (7) Discharge Assessment (return anticipated and return not anticipated).b. PPS required assessments - conducted (In addition to the OBRA required assessments) for residents for whom the facility receives Medicare Part A SNF benefits: (1) 5-day Assessment; (2) Interim Payment Assessment; and (3) Part A PPS Discharge Assessment.2. The RAI User's Manual (Chapter 2) provides detailed Information on timing and submission of assessments.3. A comprehensive assessment includes: a. completion of the Minimum Data Set (MDS); b. completion of the care area assessment (CAA) process; and c. development of the comprehensive care plan.4. OBRA and PPS assessments may be combined when all requirements for each type can be met. The RAI User's Manual (Chapter 2) provides further Information on combining assessments.5. The Interdisciplinary team uses the MDS form currently mandated by federal and state regulations to conduct the resident assessment.6. Residents and/or their representatives (sponsors) are- encouraged to participate in the- assessment process. The resident assessment coordinator or designee is responsible for notifying the resident and/or sponsor in advance of the scheduled assessment or review.7. All members of the care team, including licensed and unlicensed staff members, are asked to participate in the resident assessment process.8. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such Information.9. All resident assessments completed within the previous 15 months are maintained in the resident's active clinical record. The results of the assessments are used to develop, review and revise the resident's comprehensive care plan.Record review of the Centers for Medicare & Medicaid Services RAI Manual for MDS Quarterly Assessment, dated September 24, 2025, reflected, ARD of Quarterly Assessment must be set within 92 days of the ARD of the previous OBRA Assessment. Federal requirements dictate that a minimum, three quarterly assessments be completed in each 12-month period (if no SCSA or discharge occurs.

Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 6 (Resident #2) residents reviewed for comprehensive assessment accuracy. The facility failed to ensure Resident #2's MDS assessment accurately reflected their mental health diagnoses. This deficient practice could place residents at risk of inaccurate assessment and not having their needs met.Findings included: Record review of Resident #2's, face sheet dated 06/02/2026, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included bipolar disorder (mood swings between high (manic) and low (depressive) moods). Record review of Resident # 2's admission MDS, dated [DATE] reflected her BIMs score was coded as 15 out of 15, which indicated she was cognitively intact. Section I - Active Diagnoses of the MDS revealed a diagnosis of Schizophrenia only. Record review of Resident #2's care plan, dated 04/21/2026, reflected Resident #2 was taking Psychotropic Medication(s) for Schizophrenia. Record review of Resident #2's hospital discharge records dated 04/19/2026, reflected Resident #2 had a history of schizophrenia, bipolar, and depression. The medical record reflected she should continue the medications: Risperidone, Divalproex, and Carbamazepine. Record review of Resident #2's summary of active medication, dated 06/02/2026, reflected she was taking carbamazepine 200 mg tablet, twice a day, for bipolar disorder, divalproex 500 mg tablet at bedtime for bipolar disorder, and risperidone 1 mg at bedtime for bipolar disorder. Record review of Resident #2's progress note entered on 5/30/2026 by Medical Doctor, reflected that Resident #2 had a history of bipolar disorder and to continue Risperidone, Divalproex, and Carbamazepine. The note reflected Resident #2's mood and behavior should be monitored due to bipolar disorder. Record review of Resident #2's psychological diagnostic assessment dated [DATE], reflected the resident was referred by the facility to be assessed. The psychologist evaluator noted Resident #2's chart review revealed a mental health diagnosis that included schizophrenia. The Resident reported she had a private psychiatrist evaluation who diagnosed her with bipolar predominately depressive type. The assessment reflected Resident #2's primary diagnosis as bipolar disorder; current episode depressed, mild. Observation and interview on 06/02/2026 at 10:00AM with Resident #2, revealed she was wheeling herself into her room. She reported she had a current diagnosis of bipolar. She reported years ago her primary care physician (PCP) put in her medical record that she had schizophrenia, which was incorrect. She reported she had an evaluation completed by a psychiatrist who diagnosed her with bipolar. She reported she knew the facility had her diagnosis as schizophrenia, and it was supposed to be corrected. She stated she and her brother had spoken to someone at the facility about fixing the diagnosis to reflect just bipolar. During an interview on 06/03/2026 at 11:20 AM with the Interim MDS Nurse, she reported she was working part time as the Interim MDS Nurse for the facility until they hire someone fulltime. She reported she had been working there for a month. She reported she was not working at the facility during survey so could not recall specific information regarding Resident #2. She reported she received a directive from CMS that stated in order to claim schizophrenia on an MDS assessment for a resident, they would have had significant signs/symptoms documented in their record of schizophrenia and have a psychiatrist evaluation stating that was the diagnosis. She stated if a resident had a history documented of schizophrenia but not an active diagnosis, the facility would sit down as a team to discuss any symptoms and signs the resident may have had to determine if the diagnosis should be kept in their profile, if not, the diagnosis would remain as history. The MDS was not aware of any meetings that had occurred regarding Resident #2's schizophrenia history. She reported she could not answer as to why bipolar was not added to the MDS assessment but should have been if it was documented by a physician in the last 60 days. The MDS Nurse reported the risk to residents who had an inaccurate MDS assessment could result in inaccurate data submitted to CMS. She stated the Interim MDS assessment should be accurate and paint a picture of the residents' status. During an interview with DON on 06/03/2026 at 1:15 PM, she reported Resident #2 did not have an active diagnosis of schizophrenia. She reported Resident #2 had an active diagnosis of bipolar and not on any medications for schizophrenia. She reported Resident #2 was a previous resident at the facility but could not access her previous records to see prior diagnoses. She reported when a new resident is admitted from a hospital, their medical doctor reviews the hospital records and will see the resident in person at the facility. She reported she was not sure why schizophrenia was added to the MDS Assessment and not bipolar. The DON reported the risk to residents who do not have an accurate MDS assessment could result in the residents not receiving appropriate treatments. Record review of facility policy titled 'Resident Assessments,' dated March 2022, did not address accuracy of assessments.

Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #2) reviewed for comprehensive care plans. The facility failed to ensure Resident #2's care plan identified accurate mental health diagnosis of bipolar disorder. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings included: Record review of Resident #2's, face sheet dated 06/02/2026, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included bipolar disorder (mood swings between high (manic) and low (depressive) moods). Record review of Resident # 2's admission MDS, dated [DATE] reflected her BIMs score was coded as 15 out of 15, which indicated she was cognitively intact. Record review of Resident #2's comprehensive care plan, dated 04/21/2026, did not address the resident's mental health diagnosis of bipolar disorder. Record review of Resident #2's summary of active medication, dated 06/02/2026, reflected she was taking carbamazepine 200 mg tablet, twice a day, for bipolar disorder, divalproex 500 mg tablet at bedtime for bipolar disorder, and risperidone 1 mg at bedtime for bipolar disorder. Record review of Resident #2's psychological diagnostic assessment dated [DATE], reflected the resident was referred by the facility to be assessed. The psychologist evaluator noted Resident #2's chart review revealed a mental health diagnosis that included schizophrenia. The Resident reported she had a private psychiatrist evaluation who diagnosed her with bipolar predominately depressive type. The assessment reflected Resident #2's primary diagnosis as bipolar disorder; current episode depressed, mild. Observation and interview on 06/02/2026 at 10:00AM with Resident #2, revealed she was wheeling herself into her room. She reported she had a current diagnosis of bipolar. She reported she had an evaluation completed by a psychiatrist who diagnosed her with bipolar. She reported she was prescribed medication to treat her bipolar symptoms. During an interview on 06/03/2026 at 12:03PM with the Medical Records Nurse, she reported she completed resident's care plans. She reported she used information from resident's hospital records, transfer orders, nurses' notes, and observations to complete resident care plans. She stated when she completed Resident #2's care plan, she only used the resident's admission orders that stated she only had schizophrenia. She stated she should have checked the other records to see she had a diagnosis of bipolar disorder which would have been included in the care plan. During an interview with DON on 06/03/2026 at 1:15 PM, she reported Resident #2 did not have an active diagnosis of schizophrenia. She reported Resident #2 had an active diagnosis of bipolar and was not on any medications for schizophrenia. She reported when a new resident is admitted from a hospital, their medical doctor reviews the hospital records and will see the resident in person at the facility. She reported that bipolar disorder should have been addressed in the residents' care plan. She reported care plans were the blueprint to care for resident. She further explained if the care plan was incorrect, a resident may not receive accurate services, or an order may not be followed or missed. A request for the facility care plan policy was requested on 06/02/2026 at 12:50 PM. The facility provided a policy titled 'Resident Assessments,' dated March 2022, which did not address accuracy of care plan assessments.

Based on observations, interviews, and record review, the facility failed to ensure residents who need respiratory care, including tracheostomy care and tracheal suctioning, are provided such care, consistent with professional standards of practice, for one of seven residents (Resident #73) reviewed for respiratory care. The facility failed to ensure that Resident #73's nebulizer mask and mouthpiece were bagged in a plastic bag. These failures could place residents receiving respiratory therapy at risk of health-associated infections.The findings included: Record review of Resident #73's's Face Sheet, dated 06/01/26, reflected she was a [AGE] year-old female, who was originally admitted to the facility on [DATE], with diagnoses including: acute respiratory failure with hypoxia (a sudden, life-threatening inability to maintain oxygen levels, while chronic respiratory failure develops gradually, causing persistent low oxygen in the blood), and pneumonia (an infection that inflames the air sacs in one or both lungs). Record review of Resident #73's Physician's Orders, dated 05/31/26, reflected an active order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) inhale orally every 6 hours for wheezing/shortness of breath [via nebulizer]. Record review of Resident #73's Care Plan, dated 05/30/26 (but active as of 06/01/26), reflected no evidence that Resident #73's order for treatment via nebulizer was included in the plan of care. Observation of Resident #73's nebulizer equipment on 06/01/26 at 9:15AM revealed her nebulizer mask and mouthpiece were not in use and were lying on her bedside table, unbagged. During an interview with the DON on 06/01/26 at 9:22AM, she confirmed observing Resident #73's nebulizer mask and mouthpiece, not in use and unbagged. She stated oxygen tubing/nasal cannulas, nebulizer masks, and nebulizer mouthpieces should all be bagged when not in use. She stated the risk of not bagging these items included the potential for infection. The DON stated it was the responsibility of every staff member to ensure respiratory equipment was appropriately bagged when not in use to prevent infection. During an interview with the DON and Administrator on 06/03/26 at 12:22PM, they stated they did not have a policy related to proper storage of respiratory equipment (such as oxygen tubing/nasal cannulas, nebulizer masks, and nebulizer mouthpieces).

Based on observation, interview and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of 1 medication on 1 of 3 medication carts, reviewed for pharmacy services.The facility failed to ensure proper storage and disposal of Resident#3's Cefuroxime 500mg tablet (antibiotics) medication that was discontinued.This failure could place residents at risk for compromised medication efficacy, administration error, and increased harm to residents. Findings included: Record review of Resident #3's Comprehensive MDS Assessment, dated [DATE], reflected Resident #3 was an [AGE] year-old male and admitted [DATE]. He had a BIMS score of 11, indicating his cognitive status was moderately impaired. The resident had diagnoses including Sepsis (The body's extreme, life- threatening response to infection), unspecified organism, Urinary tract infection (bacterial infection affecting part of kidney, bladder or urethra) and Pressure ulcer (localized wound to skin and underlying tissue) of sacral region unstageable. Record review of Resident #3's Comprehensive Care Plan, Date Initiated [DATE] reflected [Resident #3] has a pressure ulcer to coccyx with goal: Skin will remain clean, dry, and free of infection during course of treatment. Record review of Resident #3's active physician orders, dated [DATE], reflected the resident had no orders for Cefuroxime 500mg tablet (antibiotic) The order was discontinued [DATE]. An observation on [DATE] at 11:00 AM of the 600 Hall Nurses' Cart revealed Resident #3's discontinued Cefuroxime 500mg tablet (antibiotic) was in the cart. During an interview on [DATE] at 11:00 AM with RN C revealed nurses were responsible for ensuring the medication carts were clean, all medications were within date, and all medication that was discontinued was removed from the cart for proper disposal. RN C stated Resident #3's Cefuroxime 500mg tablet (antibiotic) was discontinued [DATE]. She stated discontinued medications should be removed from the cart immediately and given to the DON. RN C stated there may be risk of medication error when discontinued medications are left in the cart. In an interview on [DATE] at 09:30 AM, the DON stated if a medication was discontinued, the nurses were supposed to remove the medication from the cart and take it to her office to be secured properly until the pharmacist consultant disposed it. The DON stated all expired medication, discontinued medication, and medication of discharged residents should immediately be removed from the medication cart. She stated the risk to the residents was possible medication error. She stated the DON and the ADON audited the medication carts biweekly and as needed, but there was no set schedule. She stated that the pharmacist audited the medication carts monthly. Review of the facility's policy Medication Labelling and Storage dated 2001 reflected the following: Medications and biologicals are stored in the packaging containers or other dispensing systems they are received in. Only the issuing pharmacy is authorized to transfer medications between containers. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. If the facility has discontinued, outdated or deteriorated medications or biologicals the dispensing pharmacy is contacted for instructions regarding returning or destroying these items Medications are stored in an orderly manner in cabinets, drawers' carts, or automatic dispensing systems. Each resident's medication shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals used in the facility in locked compartments under proper temperature controls for 1 resident (Resident#25) on one of three medication carts reviewed for medication storage. The facility failed to ensure Resident #25's Systane Eye drop was stored in the medication cart. The eye drop was on the bedside table of the resident.This failure could place residents at risk for compromised unsafe administration and increased harm to residents. Findings included: Record review of Resident #25's Comprehensive MDS Assessment, dated [DATE], reflected she was a 98- year- old female and admitted [DATE]. She had a BIMS score of 10, which indicated moderate cognitive impairment. Resident #25 was identified as having adequate vision and no corrective lenses. Record review of Resident #25's Care Plan active as of [DATE] did not indicate any goals or interventions related to the medication that was at bedside or self-administration. Record review of Resident #25's active Physician's Orders, dated [DATE], reflected there were no orders for Systane Eye drop. Record review of Resident #25's Physician's Orders, dated [DATE], reflected there were no orders for Resident #25 to self-administer medications. An observation on [DATE] at 1:00 PM revealed Resident #25 was in her recliner chair, and a bottle of Systane Eye drop on her bedside table. During an interview on [DATE] at 1:05 PM with Resident #25, she revealed she administered her eye drops. During an interview on [DATE] at 1:10 PM with RN B, she stated she was not aware Resident #25 had eye drops in her room. She stated Resident #25 may be at risk of infection, drug overdose, and use of expired medication by unauthorized self-medication. During an interview on [DATE] at 9:30AM with the DON, revealed Resident #25 was unable to safely self-administer medications. The DON stated the bottle of eye drops on Resident #25's bedside table should have been appropriately secured and stored in the facility's medication cart. The DON stated the risk of unsecured medications included the potential for drug interactions and overdose. Review of the facility's policy Medication Labelling and Storage dated 2001 reflected the following: Medications and biologicals are stored in the packaging containers or other dispensing systems they are received in. Only the issuing pharmacy is authorized to transfer medications between containers. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. If the facility has discontinued, outdated or deteriorated medications or biologicals the dispensing pharmacy is contacted for instructions regarding returning or destroying these items Medications are stored in an orderly manner in cabinets, drawers' carts, or automatic dispensing systems. Each resident's medication shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observations, interviews, 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 (Resident #70) of 5 residents, reviewed for infection control. 1. RN A failed to don PPE prior to performing the high contact resident care activity on a resident who was on enhanced barrier precaution. This failure placed residents at risk for healthcare associated cross contamination and infections.Findings included: Record review of Resident #70's Comprehensive MDS Assessment, dated 05/29/26, reflected MDS assessment was in progress. Resident #70's Face sheet dated 05/29/2026 reflected the resident was a [AGE] year-old female and admitted [DATE]. The resident had diagnoses which included perforation of intestine (hole, puncture, or tear in the wall of the small or large intestine), peritoneal abscess (localized pocket of pus and infected fluid inside the abdominal cavity) and hypertension (condition where the blood pushing against your artery walls is consistently too high). Record review of Resident #70's Comprehensive Care Plan, initiated 06/01/26, reflected (Residents name) had JP drains ( a surgical device used to remove excess fluids, like blood or pus, from a wound site) to abdominal area post abdominal surgery with goal: To experience no complications during JP drain use, Resident was on antibiotics and at risk for infection and resident required enhanced barrier precaution(EBP) with goal; EBP will continue in 30 days- nursing staff will follow physician orders to discontinue enhanced barriers. An observation on 06/02/2026 at 8:04 AM revealed Resident #70's room had an Enhanced Barrier Precaution sign outside her room, and cart set up with PPE inside the room. RN A prepared Resident #70's incontinent care items and entered resident's bathroom, she did incontinent care without PPE (gown). An interview on 06/02/26 at 10:00 AM with RN A revealed RN A knew Residentt#70 was on enhanced barrier precaution, and she should have donned PPE before assisting Resident#70 with incontinent care. RN A stated she forgot to wear the gown and failure to use PPE could put the resident at risk for infection. She stated she had been in-serviced on enhanced barrier precautions. An interview on 06/03/2026 at 1:41 PM with the DON revealed her expectation was staff should use appropriate PPE while providing care to residents on enhanced barrier precautions. She stated the risk to the patient was infection. She stated staff had been in-serviced on infection control and enhance barrier precautions. The facility policy titled Enhanced Barrier Precautions revised August 2022: Policy Interpretation and Implementation stated1. Enhanced barrier precautions (EBP) are used as an infection prevention and control intervention to reduce the spread of multi drug resistant organisms (MDROs) to residents.2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.a. Gloves and gown are applied prior to performing the high contact resident care activities (as opposed to before entering the room)b. personal protective equipment (PPE) is changed before caring for another resident.c. face protection may be used if there is also a risk of splashes or spray.3. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that place them at increased risk.Examples of Enhanced-Based Precaution residents: Wounds - Includes chronic wounds, but are not limited to pressure ulcers, diabetic ulcers, unhealed surgical wounds and venous statis ulcers.Indwelling medical devices - Include central lines, urinary catheters, feeding tubes, and tracheostomies/vents.Examples of high contact resident care activities requiring the use of gowns and gloves for EBPs include: Dressing Bathing/showering Providing hygiene Changing linens Changing briefs or assisting with toileting Device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator etc) and Wound care (any skin opening requiring a dressing)

Based on interview and record review, the facility failed to protect the residents right to be free from sexual abuse for 2 residents (Resident #22 and Resident #52) of 24 residents reviewed for abuse and neglect. On 02/21/25, Resident # 1 inappropriately touched Resident # 22 and asked Resident #22 to kiss him. On 02/21/15, Resident # 1 grabbed the hand of Resident #52 and put Resident # 52's hand in his groin area. Resident # 1 then attempted to bend over and kiss Resident # 22. Resident # 1 asked Resident #52 to go to his room. A past noncompliance IJ was identified on 04/17/2025, and the IJ template was provided to the facility on [DATE] at 01:45 PM. The noncompliance began on 02/21/2025 and ended on 02/25/2025. The facility had corrected the noncompliance before the Incident investigation began on 03/31/2025. This failure placed the facility's residents at risk for abuse and neglect. Findings included: 1. Review of Resident #1's face sheet dated 03/31/2025 reflected Resident #1 was a [AGE] year-old male, with an admitted [DATE] and diagnoses of Dementia (memory loss), psychotic disturbance (a mental health condition characterized by a loss of touch with reality, leading to distorted perceptions, thoughts and behaviors), and was discharged on [DATE]. Review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 07 indicating severe cognitive impairment, was independent in transition from sitting to standing position and walking. Review of Resident #1's care plan dated 02/15/2025 reflected Resident #1 displays inappropriate behavior of a sexual manner towards females at times. He has also asked other female residents to go back to his room with him . Monitor resident in activities as needed . Remove other residents from harm and sexual advances as needed . Remove resident from public areas if behavior is demonstrated. 2. Review of Resident #22's face sheet dated 04/02/2025 reflected she was an [AGE] year-old female, with an admitted [DATE] and diagnoses of Dementia (memory loss), psychotic disturbance (a mental health condition characterized by a loss of touch with reality, leading to distorted perceptions, thoughts and behaviors). Review of Resident #22's MDS assessment dated [DATE] reflected Resident #22 had a BIMS score of 02 indicating severe cognitive impairment, was dependent in chair to bed transfers. Review of Resident #22's care plan dated 01/24/2022 reflected resident #22 had a diagnosis of Dementia, 09/19/2022 reflected resident #22 was unable to perform ADL functions independently. 3. Review of Resident #52's face sheet dated 04/02/2025 reflected she was a [AGE] year-old female, with an admitted [DATE] and diagnoses of encephalopathy (brain disfunction leading to symptoms such as altered mental status, memory loss), Cognitive communication deficit (impaired cognitive process). Review of Resident #52's MDS assessment dated [DATE] reflected Resident #52 had a BIMS score of 10 indicating moderate cognitive impairment and she required moderate assistance with chair to bed transfers. Review of Resident #52's care plan dated 01/28/2025 reflected she was taking psychotropic medications for depression and anxiety, had a diagnosis of dementia/Alzheimer's and was at risk for increased confusion. Review of Resident #22's progress note dated 02/21/2025 at 09:36 AM reflected LVN M heard Resident #22 yell No, do not touch me. LVN M observed Resident #1 inappropriately touching Resident #22 and asking her to kiss Resident #1. Review of Resident #52's progress note dated 02/21/2025 at 01:34 PM reflected LVN E observed Resident # 1 grab the hand of Resident #52 and said, come to my room, then attempted to bend over and kiss Resident #52. Record review of the provider investigation report reflected the Administrator completed the investigation on 03/04/2025, notified HHSC, ombudsman, medical director, police department, psych services, responsible parties of Residents #1, #22 and #52, Resident #1's medications were reviewed by the medical director, Resident #22 and Resident #52 were assessed and no emotional distress was noted, staff interviews were conducted, and Resident safe surveys were completed. Record review of the in-service training revealed 63 employees, including LVN E and LVN M, received in service on the topic Reporting abuse neglect and exploitation on 02/25/2025. Record review of the in-service training revealed 92 employees received in-service on the topic ANE reporting response on 03/31/2025. Review of Resident #1's progress note dated 03/04/2025 at 02:53 PM revealed social services had a care plan meeting with Resident #1's family member to address Resident #1's behavior issues and appropriate discharge plan, revealed a 30-day discharge notice was issued to Resident #1's family member . Review of the Q 15-minute check list revealed Resident #1 was checked every 15 minutes from 02/25/25 till 03/17/25. Record review of the physician order dated 02/26/2025 reflected Resident #1 received a new standing order for Prozac 20 mg, once a day, to address his behavior issues. Review of the Quality Assurance Committee sign in sheet revealed the facility had the committee meeting on 04/01/2025 to address the identified issue of staff did not report potential ANE to the administrator immediately. Record review of Resident #1's progress note revealed he had displayed inappropriate behaviors towards females prior to February 2025. An observation and interview with Resident #22 in the facility TV room on 03/31/2025 at 03:59 PM revealed she was sitting in her wheelchair and watching TV. Resident #22 did not remember the alleged incident which happened on 02/21/2025. Resident #22 felt safe at the facility, she was not afraid of any residents or employees. An observation and interview with Resident #52 in her room on 03/31/2025 at 04:15 PM revealed she was sitting in her wheelchair watching TV. Resident #52 stated on an unknown date Resident #1 approached her while she was sitting in her wheelchair in the 500 hallway and told her to go to Resident #1's room, Resident #1 grabbed Resident #52's hands and put her hand in Resident #1's private area. Resident #52 stated she told Resident #1 to stop, and an unknown nurse came and separated both. Resident # 52 stated this was the first such incident, she was not injured, she was not afraid of any residents, and she felt safe. Resident #52 stated Resident #1 did not stay at the same hall and he stayed in 600 hall, she did not have any similar experience from Resident #1 anymore. She stated later ADON H and the Administrator came and spoke to her and assured they were addressing the concern, and she would be safe. Interview with the Administrator on 03/31/2025 at 4:32 PM revealed she had worked at the facility for 3 years and she was the abuse coordinator. She stated she expected all the employees to report to her any suspicion of abuse immediately, all the employees had her contact information available, and all the employees were given in-service training on a regular basis on abuse/neglect. The Administrator stated two female residents, Residents #22 and #52 were inappropriately touched by Resident #1 on 02/21/2025. The Administrator said she first learned about the incident involving Resident # 52 from LVN E on 02/25/2025. As part of the investigation of that incident, she spoke with LVN M on the same day and learned about another incident involving Resident #1 inappropriately touching Resident #22. The Administrator stated both female residents were assessed and they found no injuries, discoloration, pain, or emotional distress. The Administrator stated she educated LVN M on the importance of timely notification of instances where ANE could potentially have taken place. The Administrator stated she instructed staff to complete a 15-minute check on Resident #1 until further notice, reported the alleged incident to the police, and an officer came and spoke with residents. The Administrator stated the incidents were reported to the medical director, responsible parties of each resident who were involved and to the Ombudsman. Resident #1 was referred for psych services and he received new order for medication Prozac. Safe surveys were conducted and ensured no other residents were affected and the residents felt safe and comfortable at the facility. In-service training on ANE and notification was provided to all the employees. The Administrator stated she had a care plan meeting with Resident #1's family and Resident #1 was discharged from the facility. The Administrator stated both incidents involving Residents #22 and #52 were considered as abuse, and abuse was supposed to be reported to the state within 2 hours. She stated she expected the employees to report to her the abuse incident immediately rather than waiting until 02/25/2025. She stated those were the only two incidents involving Resident #1 inappropriately behaving with residents. Interview with LVN E on 03/31/2025 at 05:10 PM revealed she observed the inappropriate behavior of Resident #1 towards Resident #52 on 02/21/2025 when Resident #52 told her about the incident. She stated she did not consider that incident as abuse since Resident #1was attempting to touch Resident #52. She stated she documented the incident in the nurses note on the same day. She stated she sent an email on 02/25/2025 to the Administrator/abuse coordinator notifying her of the alleged incident. She stated she was expected to report any suspected abuse immediately to the abuse coordinator. She stated she was not aware of any sexually inappropriate behavior by Resident #1. She stated she had received in-services on abuse regularly. She stated once she learned about the incident, she separated both residents, redirected Resident #1, and made sure Resident #52 was safe and comfortable. She stated there were several types of abuse such a physical, sexual, verbal, emotional. She stated she would also report abuse to the physician and family of the residents involved. Interview with LVN M on 04/01/2025 at 09:30 AM revealed she had worked at the facility for over two years, and she worked on the 600 hall. She stated abuse was hitting or speaking to a resident inappropriately, and there were several types of abuse such as physical, sexual, emotional. She stated she received in-service training on abuse and the most recent one was in February. She stated she would notify the DON and the Administrator/the abuse coordinator immediately of any suspected abuse/neglect. She stated not immediately reporting abuse can lead to continuation of the abusive behavior towards more residents. She stated if she observed a resident was abused, she would immediately intervene and separate them, redirect the aggressor, and make sure the victim was safe. She stated there would be interventions in place to make sure the aggressor was not repeating the behavior, he/she would be always monitored. She stated she would also report the incident to the physician and family. LVN M stated on 02/21/2025, she was working on the 600 hall nurses' station when she heard Resident #22, who was sitting in her wheelchair on the hallway, yelling don't touch me to Resident #1. She stated she saw Resident #1 touching the side of Resident #22's breast, holding, and pulling her arm, asking her to come to his room. LVN M stated she immediately separated both, took Resident #22 to her room and Resident #1 to his room, educated Resident #1 about inappropriate behaviors and boundaries. She stated she made sure Resident #1 stayed in his room, and monitored him frequently. She stated she did not report this incident to the Abuse Coordinator/the Administrator, but she reported this incident to ADON H, soon after the incident. She stated that was a suspected abuse incident and she was supposed to report it immediately to the abuse coordinator. She stated she had reported this incident she witnessed to the Administrator on 02/25/2025 when the Administrator approached her to ask about a similar incident. An interview with ADON H on 04/01/2025 at 01:34 PM revealed he had worked at the facility for [AGE] years and he was the supervisor for 400, 500 and 700 halls. He stated there were several types of abuse such as physical, mental, sexual, verbal, and the most recent in-service he received on abuse was yesterday. He stated Resident #1 was staying in 600 hall, and one of the nurses had made a complaint about Resident #1 inappropriately talking but they did not have any abuse incidents involving other residents. He stated he learned from the Administrator on 02/25/2025 about Resident #1 holding the hand of a female resident. He stated he was not told by any LVN about this incident. He said he received in-service on abuse and reporting abuse. He stated if an employee witnessed abuse/suspected abuse, his expectation was the employee should immediately separate the residents and made sure the residents were safe, right away call the abuse coordinator on her phone, and notify her, the physician, and family. He stated all the employees had the abuse coordinator's phone number and it was important to report the abuse to the state and have interventions in place to stop similar incidents from happening. He stated the incidents involving Resident #1 inappropriately touching Resident #22 and #52 were considered as suspected abuse and it had to be reported to the abuse coordinator immediately. Interview with CNA N on 04/02/2025 at 02:37 PM revealed she had worked at the facility for [AGE] years; she worked on 500 hall. She stated Resident #1 once inappropriately touched her and she reported this to the Administrator. She stated she was not aware of any other incidents where Resident #1 behaved inappropriately with female residents, other than to Resident #52 sometime in February 2025. She said she received in-service on abuse regarding this incident. She stated Resident #1 never went to other resident's rooms. She stated there were several types of abuse such as physical, sexual, verbal, financial, and she would immediately report any suspected abuse to the abuse coordinator and make sure the residents involved were safe. Observation and Interview with Resident #22 on 04/16/2025 at 11:36 AM revealed she was sitting in her wheelchair and watching TV in the common area. She appeared clean and stated she did not know Resident #1. She stated she never had any experience of inappropriate touch/behavior towards her by anybody at the facility. She stated she had no concerns about abuse. Observation and interview with Resident #52 in the dining room on 04/16/2025 at 11:49 AM revealed she was sitting in her wheelchair, ready to have her lunch. Resident #52 stated there was only one incident of an inappropriate behavior since she came to the facility, that was regarding Resident #1 touching her and asking her to come to his room. Resident #52 stated she was not aware of any similar incidents involving Resident #1, she was not afraid of any resident or employees at the facility, and she felt safe. She stated Resident #1 held her hand, asked to go to his room, then moved her hand towards his groin area, she suddenly realized his intention and moved her hand, raised her hand, and got the attention of a nurse. She stated the nurse suddenly separated Resident #1 and took her to her room. Interview with the Administrator on 04/16/2025 at 01:48 PM revealed once she learned about the sexually inappropriate behavior by Resident #1, she interviewed Resident #22 and #52, asked about the inappropriate behavior by Resident #1. The Administrator stated Resident #22 was confused and she did not remember anything about the incident. Resident #52 told the Administrator Resident #1 came to her, grabbed her hand and asked her to go to his room. Resident #52 said no, and the nurse intervened at this point and separated both residents, redirected Resident #1. The Administrator stated Resident #52 never told her about Resident #1 putting Resident #52's hand in Resident #1's groin area. The Administrator stated she was not aware of any previous sexually inappropriate incidents by Resident #1 towards other residents. She stated she had not put any interventions in place from 02/21/2025 till 02/25/2025 regarding Resident #1's behavior but LVN M monitored Resident #1 frequently. She stated once she learned about the incident on 02/25/2025, interventions were in put in place such as: notified medical director, family, 15-minute check on Resident #1, psychiatric services referral, investigated the incident and made sure there were no other similar incidents, provided in service on abuse reporting and reeducated LVN E and LVN M, discharged Resident #1 from the facility on 03/17/2025. She stated she had given verbal waning to LVN E and LVN M for not notifying the abuse coordinator immediately about the abuse incidents which happened on 02/21/2025. Interview with RN S on 04/17/2025 at 12:29 PM revealed there were several types of abuse such as physical, verbal, sexual. She stated inappropriate touch was an example of sexual abuse, and she would immediately report it to the abuse coordinator. She stated not reporting immediately would lead to more abuse incidents. She stated she received in service on abuse twice a month. She stated the only incident she knew was Resident #1 inappropriately touched staff and she did not know of any other incidents. Interview with LVN I on 04/17/2025 at 12:50 PM revealed she was working as a nurse at the facility for 2 years. She stated abuse was in different forms such as verbal, physical, emotional and it could happen between resident to resident or employee to resident. She stated an inappropriate touch was example for sexual abuse, she would immediately report to the Administrator of any abuse because delaying would lead to the abuse to continue. She stated she knew Resident #1 and heard from other staff that he inappropriately touched staff and residents. She stated she was not aware of any similar incidents; she received in service on abuse every two weeks. Interview with ADON H on 04/17/2025 at 2:17 PM revealed there were several types of abuse such as mental, physical, sexual and an example for sexual abuse was inappropriate touch. He stated if he knew about an abuse incident, he made sure the resident was safe, immediately reported to the abuse coordinator/the Administrator because it was a reportable incident to the state. He stated not notifying the abuse coordinator about abuse immediately would put resident at risk for repeated abuse incidents. He stated he received in service every two weeks, most recent one was last week, and there were no incidents of abuse at that time. He stated he learned about Resident #1's inappropriate behavior towards Resident #22 and #52 from the Administrator. Interview with CNA Q on 04/17/25 at 02:33 PM revealed she was working on the 300 hall and abuse was of several types such as sexual, emotional, physical, verbal. An example for sexual abuse was unnecessary touch of body parts, which she would let the Administrator know immediately. She stated not reporting the abuse would lead to repeat such incidents. She stated she received in services on abuse every two weeks. She stated she had one inappropriate touch incident from Resident #1, and she had reported that incident to the abuse coordinator. She stated she was not aware of any abuse incidents at that time. Interview with CNA P on 04/17/25 at 03:13 PM revealed she was working at the facility for a year. She stated abuse had several forms such as physical, verbal, sexual and inappropriate touch was sexual abuse. She stated she would immediately report to the Administrator about any abuse incident and not notifying abuse would put more residents at risk and it affected resident safety. She stated the most recent in-service on abuse was a week ago, she was not familiar with Resident #1, and she was not aware of any such abuse incidents in the facility. Interview with CNA O on 04/17/25 at 03:22 revealed she was working at the facility for [AGE] years. She stated abuse was of several types such as verbal, physical, sexual, neglect. She stated hitting, sexual touch were examples of abuse. She stated she received in service on abuse a week ago, she would immediately notify the Administrator of aby suspected abuse, not notifying would lead to more abuse. She stated she heard about Resident #1's sexually inappropriate behavior towards others but she had not experienced it, and she was not aware of any other such abuse incidents. Interview with RN K on 04/17/25 at 03:27 PM revealed abuse was of various types such as physical, verbal, sexual, mental. She stated inappropriate touch and comments were examples of sexual abuse. She stated she had received in-services on abuse every two weeks and she received the most recent one last week. She stated she would immediately notify the abuse coordinator whenever she learned about abuse, the risk for not notifying the Administrator about abuse would lead to continue the abuse towards more residents. She stated she was not aware of any abuse incidents at the facility. She stated she was not familiar with Resident #1; she learned from other staff about his inappropriate behavior towards females. Review of the facility's undated abuse policy titled Prohibition of abuse, neglect, and exploitation standards of practice. The Facility will ensure a safe environment for residents by prohibiting ANE. The Facility establishes and implements mechanisms for reporting, investigating, and protecting residents from actual or potential harm . SEXUAL ABUSE: Is non-consensual sexual contact of any type with a resident, including, but not limited to, sexual harassment, sexual coercion, or sexual assault PREVENTION 3. Residents identified as exhibiting abusive behaviors will be assessed and appropriate interventions included in the plan of care Definition: HHSC rules define abuse as: The negligent or willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under Penal Code S21.08 (indecent exposure) or Penal Code Chapter 22 (assaultive offenses), sexual harassment, sexual coercion, or sexual assault. Sexual abuse: Is non-consensual sexual contact of any type with a resident, including, but not limited to, sexual harassment, sexual coercion, or sexual assault .

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of 2 (Resident #22 and Resident #52) of 24 residents reviewed for abuse and neglect. 1) LVN E and LVN M failed to immediately report sexual abuse incidents involving Resident #1 against Residents #22 and #52 to the Abuse Coordinator/the Administrator. 2) The facility failed to follow their policy to immediately protect Resident #22 and #52 from harm. 3) LVN E failed to identify sexual abuse when Resident #1 attempted to inappropriately touch Resident #52. A past noncompliance IJ was identified on 04/17/2025, and the IJ template was provided to the facility on [DATE] at 01:45 PM. The noncompliance began on 02/21/2025 and ended on 02/25/2025. The facility had corrected the noncompliance before the Incident investigation began on 03/31/2025. This could place residents at risk for abuse, neglect and exploitation. Findings included: Review of the undated facility policy titled PROHIBITION OF ABUSE, NEGLECT, AND EXPLOITATION (ANE) STANDARDS OF Practice revealed . STANDARDS . This Facility's abuse prohibition program includes standards and practice guidelines that address the essential components of an ANE prohibition program to include screening, training, prevention, identification, investigation, protection, reporting and response. The Facility will ensure a safe environment for residents by prohibiting ANE.The Facility establishes and implements mechanisms for reporting, investigating, and protecting residents from actual or potential harm ABUSE: HHSC rules define abuse as: The negligent or willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under Penal Code S21.08 (indecent exposure) or Penal Code Chapter 22 (assaultive offenses), sexual harassment, sexual coercion, or sexual assault. SEXUAL ABUSE: Is non-consensual sexual contact of any type with a resident, including, but not limited to, sexual harassment, sexual coercion, or sexual assault . PREVENTION . 4. Facility staff will immediately report and protect the resident if an allegation or observation of abuse has occurred . IDENTIFICATION 1. Potential ANE is identified through, but not limited to: a. Allegations of abuse / neglect or misappropriation of resident property as immediately reported to the Administrator. PROTECTION 1. Residents will be immediately protected from harm. REPORTING 1. Any employee who becomes aware of an allegation of abuse, neglect or misappropriation of resident property, shall report the incident to the abuse coordinator, Administrator immediately. 1. Review of Resident #1's face sheet dated 03/31/2025 reflected Resident #1 was a [AGE] year-old male, with an admitted [DATE] and diagnoses of Dementia (memory loss), psychotic disturbance (a mental health condition characterized by a loss of touch with reality, leading to distorted perceptions, thoughts and behaviors), and was discharged on [DATE]. Review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 07 indicating severe cognitive impairment, was independent in transition from sitting to standing position and walking. Review of Resident #1's care plan dated 02/15/2025 reflected Resident #1 displays inappropriate behavior of a sexual manner towards females at times. He has also asked other female residents to go back to his room with him . Monitor resident in activities as needed . Remove other residents from harm and sexual advances as needed . Remove resident from public areas if behavior is demonstrated. 2. Review of Resident #22's face sheet dated 04/02/2025 reflected she was an [AGE] year-old female, with an admitted [DATE] and diagnoses of Dementia (memory loss), psychotic disturbance (a mental health condition characterized by a loss of touch with reality, leading to distorted perceptions, thoughts and behaviors). Review of Resident #22's MDS assessment dated [DATE] reflected Resident #22 had a BIMS score of 02 indicating severe cognitive impairment, was dependent in chair to bed transfers. Review of Resident #22's care plan dated 01/24/2022 reflected resident #22 had a diagnosis of Dementia, 09/19/2022 reflected resident #22 was unable to perform ADL functions independently. 3. Review of Resident #52's face sheet dated 04/02/2025 reflected she was a [AGE] year-old female, with an admitted [DATE] and diagnoses of encephalopathy (brain disfunction leading to symptoms such as altered mental status, memory loss), Cognitive communication deficit (impaired cognitive process). Review of Resident #52's MDS assessment dated [DATE] reflected Resident #52 had a BIMS score of 10 indicating moderate cognitive impairment and she required moderate assistance with chair to bed transfers. Review of Resident #52's care plan dated 01/28/2025 reflected she was taking psychotropic medications for depression and anxiety, had a diagnosis of dementia/Alzheimer's and was at risk for increased confusion. Review of Resident #22's progress note dated 02/21/2025 at 09:36 AM reflected LVN M heard Resident #22 yell No, do not touch me. LVN M observed Resident #1 inappropriately touching Resident #22 and asking her to kiss Resident #1. Review of Resident #52's progress note dated 02/21/2025 at 01:34 PM reflected LVN E observed Resident # 1 grab the hand of Resident #52 and said, come to my room, then attempted to bend over and kiss Resident #52. Record review of the provider investigation report reflected the Administrator completed the investigation on 03/04/2025, notified HHSC, ombudsman, medical director, police department, psych services, responsible parties of Residents #1, #22 and #52, Resident #1's medications were reviewed by the medical director, Resident #22 and Resident #52 were assessed and no emotional distress was noted, staff interviews were conducted, and Resident safe surveys were completed. Record review of the in-service training revealed 63 employees, including LVN E and LVN M, received in service on the topic Reporting abuse neglect and exploitation on 02/25/2025. Record review of the in-service training revealed 92 employees received in-service on the topic ANE reporting response on 03/31/2025. Review of Resident #1's progress note dated 03/04/2025 at 02:53 PM revealed social services had a care plan meeting with Resident #1's family member to address Resident #1's behavior issues and appropriate discharge plan, revealed a 30-day discharge notice was issued to Resident #1's family member. Review of the Q 15-minute check list revealed Resident #1 was checked every 15 minutes from 02/25/25 till 03/17/25. Record review of the physician order dated 02/26/2025 reflected Resident #1 received a new standing order for Prozac 20 mg, once a day, to address his behavior issues. Review of the Quality Assurance Committee sign in sheet revealed the facility had the committee meeting on 04/01/2025 to address the identified issue of staff did not report potential ANE to the administrator immediately. Record review of Resident #1's progress note revealed he had displayed inappropriate behaviors towards females prior to February 2025. An observation and interview with Resident #22 in the facility TV room on 03/31/2025 at 03:59 PM revealed she was sitting in her wheelchair and watching TV. Resident #22 did not remember the alleged incident which happened on 02/21/2025. Resident #22 felt safe at the facility, she was not afraid of any residents or employees. An observation and interview with Resident #52 in her room on 03/31/2025 at 04:15 PM revealed she was sitting in her wheelchair watching TV. Resident #52 stated on an unknown date Resident #1 approached her while she was sitting in her wheelchair in the 500 hallway and told her to go to Resident #1's room, Resident #1 grabbed Resident #52's hands and put her hand in Resident #1's private area. Resident #52 stated she told Resident #1 to stop, and an unknown nurse came and separated both. Resident # 52 stated this was the first such incident, she was not injured, she was not afraid of any residents, and she felt safe. Resident #52 stated Resident #1 did not stay at the same hall and he stayed in 600 hall, she did not have any similar experience from Resident #1 anymore. She stated later ADON H and the Administrator came and spoke to her and assured they were addressing the concern, and she would be safe. Interview with the Administrator on 03/31/2025 at 4:32 PM revealed she had worked at the facility for 3 years and she was the abuse coordinator. She stated she expected all the employees to report to her any suspicion of abuse immediately, all the employees had her contact information available, and all the employees were given in-service training on a regular basis on abuse/neglect. The Administrator stated two female residents, Residents #22 and #52 were inappropriately touched by Resident #1 on 02/21/2025. The Administrator said she first learned about the incident involving Resident # 52 from LVN E on 02/25/2025. As part of the investigation of that incident, she spoke with LVN M on the same day and learned about another incident involving Resident #1 inappropriately touching Resident #22. The Administrator stated both female residents were assessed and they found no injuries, discoloration, pain, or emotional distress. The Administrator stated she educated LVN M on the importance of timely notification of instances where ANE could potentially have taken place. The Administrator stated she instructed staff to complete a 15-minute check on Resident #1 until further notice, reported the alleged incident to the police, and an officer came and spoke with residents. The Administrator stated the incidents were reported to the medical director, responsible parties of each resident who were involved and to the Ombudsman. Resident #1 was referred for psych services and he received new order for medication Prozac. Safe surveys were conducted and ensured no other residents were affected and the residents felt safe and comfortable at the facility. In-service training on ANE and notification was provided to all the employees. The Administrator stated she had a care plan meeting with Resident #1's family and Resident #1 was discharged from the facility. The Administrator stated both incidents involving Residents #22 and #52 were considered as abuse, and abuse was supposed to be reported to the state within 2 hours. She stated she expected the employees to report to her the abuse incident immediately rather than waiting until 02/25/2025. She stated those were the only two incidents involving Resident #1 inappropriately behaving with residents. Interview with LVN E on 03/31/2025 at 05:10 PM revealed she observed the inappropriate behavior of Resident #1 towards Resident #52 on 02/21/2025 when Resident #52 told her about the incident. She stated she did not consider that incident as abuse since Resident #1was attempting to touch Resident #52. She stated she documented the incident in the nurses note on the same day. She stated she sent an email on 02/25/2025 to the Administrator/abuse coordinator notifying her of the alleged incident. She stated she was expected to report any suspected abuse immediately to the abuse coordinator. She stated she was not aware of any sexually inappropriate behavior by Resident #1. She stated she had received in-services on abuse regularly. She stated once she learned about the incident, she separated both residents, redirected Resident #1, and made sure Resident #52 was safe and comfortable. She stated there were several types of abuse such a physical, sexual, verbal, emotional. She stated she would also report abuse to the physician and family of the residents involved. Interview with LVN M on 04/01/2025 at 09:30 AM revealed she had worked at the facility for over two years, and she worked on the 600 hall. She stated abuse was hitting or speaking to a resident inappropriately, and there were several types of abuse such as physical, sexual, emotional. She stated she received in-service training on abuse and the most recent one was in February. She stated she would notify the DON and the Administrator/the abuse coordinator immediately of any suspected abuse/neglect. She stated not immediately reporting abuse can lead to continuation of the abusive behavior towards more residents. She stated if she observed a resident was abused, she would immediately intervene and separate them, redirect the aggressor, and make sure the victim was safe. She stated there would be interventions in place to make sure the aggressor was not repeating the behavior, he/she would be always monitored. She stated she would also report the incident to the physician and family. LVN M stated on 02/21/2025, she was working on the 600 hall nurses' station when she heard Resident #22, who was sitting in her wheelchair on the hallway, yelling don't touch me to Resident #1. She stated she saw Resident #1 touching the side of Resident #22's breast, holding, and pulling her arm, asking her to come to his room. LVN M stated she immediately separated both, took Resident #22 to her room and Resident #1 to his room, educated Resident #1 about inappropriate behaviors and boundaries. She stated she made sure Resident #1 stayed in his room, and monitored him frequently. She stated she did not report this incident to the Abuse Coordinator/the Administrator, but she reported this incident to ADON H, soon after the incident. She stated that was a suspected abuse incident and she was supposed to report it immediately to the abuse coordinator. She stated she had reported this incident she witnessed to the Administrator on 02/25/2025 when the Administrator approached her to ask about a similar incident. An interview with ADON H on 04/01/2025 at 01:34 PM revealed he had worked at the facility for [AGE] years and he was the supervisor for 400, 500 and 700 halls. He stated there were several types of abuse such as physical, mental, sexual, verbal, and the most recent in-service he received on abuse was yesterday. He stated Resident #1 was staying in 600 hall, and one of the nurses had made a complaint about Resident #1 inappropriately talking but they did not have any abuse incidents involving other residents. He stated he learned from the Administrator on 02/25/2025 about Resident #1 holding the hand of a female resident. He stated he was not told by any LVN about this incident. He said he received in-service on abuse and reporting abuse. He stated if an employee witnessed abuse/suspected abuse, his expectation was the employee should immediately separate the residents and made sure the residents were safe, right away call the abuse coordinator on her phone, and notify her, the physician, and family. He stated all the employees had the abuse coordinator's phone number and it was important to report the abuse to the state and have interventions in place to stop similar incidents from happening. He stated the incidents involving Resident #1 inappropriately touching Resident #22 and #52 were considered as suspected abuse and it had to be reported to the abuse coordinator immediately. Interview with CNA N on 04/02/2025 at 02:37 PM revealed she had worked at the facility for [AGE] years; she worked on 500 hall. She stated Resident #1 once inappropriately touched her and she reported this to the Administrator. She stated she was not aware of any other incidents where Resident #1 behaved inappropriately with female residents, other than to Resident #52 sometime in February 2025. She said she received in-service on abuse regarding this incident. She stated Resident #1 never went to other resident's rooms. She stated there were several types of abuse such as physical, sexual, verbal, financial, and she would immediately report any suspected abuse to the abuse coordinator and make sure the residents involved were safe. Observation and Interview with Resident #22 on 04/16/2025 at 11:36 AM revealed she was sitting in her wheelchair and watching TV in the common area. She appeared clean and stated she did not know Resident #1. she stated she never had any experience of inappropriate touch/behavior towards her by anybody. She stated she had no concerns about abuse. Observation and interview with Resident #52 in the dining room on 04/16/2025 at 11:49 AM revealed she was sitting in her wheelchair, ready to have her lunch. Resident #52 stated there was only one incident of an inappropriate behavior since she came to the facility, that was regarding Resident #1 touching her and asking her to come to his room. Resident #52 stated she was not aware of any similar incidents involving Resident #1, she was not afraid of any resident or employees at the facility, and she felt safe. She stated Resident #1 held her hand, asked to go to his room, then moved her hand towards his groin area, she suddenly realized his intention and moved her hand, raised her hand, and got the attention of a nurse. She stated the nurse suddenly separated Resident #1 and took her to her room. Interview with the Administrator on 04/16/2025 at 01:48 PM revealed once she learned about the sexually inappropriate behavior by Resident #1, she interviewed Resident #22 and #52, asked about the inappropriate behavior by Resident #1. The Administrator stated Resident #22 was confused and she did not remember anything about the incident. Resident #52 told the Administrator Resident #1 came to her, grabbed her hand and asked her to go to his room. Resident #52 said no, and the nurse intervened at this point and separated both residents, redirected Resident #1. The Administrator stated Resident #52 never told her about Resident #1 putting Resident #52's hand in Resident #1's groin area. The Administrator stated she was not aware of any previous sexually inappropriate incidents by Resident #1 towards other residents. She stated she had not put any interventions in place from 02/21/2025 till 02/25/2025 regarding Resident #1's behavior but LVN M monitored Resident #1 frequently. She stated once she learned about the incident on 02/25/2025, interventions were in put in place such as: notified medical director, family, 15-minute check on Resident #1, psychiatric services referral, investigated the incident and made sure there were no other similar incidents, provided in service on abuse reporting and reeducated LVN E and LVN M, discharged Resident #1 from the facility on 03/17/2025. She stated she had given verbal waning to LVN E and LVN M for not notifying the abuse coordinator immediately about the abuse incidents which happened on 02/21/2025. Interview with RN S on 04/17/2025 at 12:29 PM revealed there were several types of abuse such as physical, verbal, sexual. She stated inappropriate touch was an example of sexual abuse, and she would immediately report it to the abuse coordinator. She stated not reporting immediately would lead to more abuse incidents. She stated she received in service on abuse twice a month. She stated the only incident she knew was Resident #1 inappropriately touched staff and she did not know of any other incidents. Interview with LVN I on 04/17/2025 at 12:50 PM revealed she was working as a nurse at the facility for 2 years. She stated abuse was in different forms such as verbal, physical, emotional and it could happen between resident to resident or employee to resident. She stated an inappropriate touch was example for sexual abuse, she would immediately report to the Administrator of any abuse because delaying would lead to the abuse to continue. She stated she knew Resident #1 and heard from other staff that he inappropriately touched staff and residents. She stated she was not aware of any similar incidents; she received in service on abuse every two weeks. Interview with ADON H on 04/17/2025 at 2:17 PM revealed there were several types of abuse such as mental, physical, sexual and an example for sexual abuse was inappropriate touch. He stated if he knew about an abuse incident, he made sure the resident was safe, immediately reported to the abuse coordinator/the Administrator because it was a reportable incident to the state. He stated not notifying the abuse coordinator about abuse immediately would put resident at risk for repeated abuse incidents. He stated he received in service every two weeks, most recent one was last week, and there were no incidents of abuse at that time. He stated he learned about Resident #1's inappropriate behavior towards Resident #22 and #52 from the Administrator. Interview with CNA Q on 04/17/25 at 02:33 PM revealed she was working on the 300 hall and abuse was of several types such as sexual, emotional, physical, verbal. An example for sexual abuse was unnecessary touch of body parts, which she would let the Administrator know immediately. She stated not reporting the abuse would lead to repeat such incidents. She stated she received in services on abuse every two weeks. She stated she had one inappropriate touch incident from Resident #1, and she had reported that incident to the abuse coordinator. She stated she was not aware of any abuse incidents at that time. Interview with CNA P on 04/17/25 at 03:13 PM revealed she was working at the facility for a year. She stated abuse had several forms such as physical, verbal, sexual and inappropriate touch was sexual abuse. She stated she would immediately report to the Administrator about any abuse incident and not notifying abuse would put more residents at risk and it affected resident safety. She stated the most recent in-service on abuse was a week ago, she was not familiar with Resident #1, and she was not aware of any such abuse incidents in the facility. Interview with CNA O on 04/17/25 at 03:22 revealed she was working at the facility for [AGE] years. She stated abuse was of several types such as verbal, physical, sexual, neglect. She stated hitting, sexual touch were examples of abuse. She stated she received in service on abuse a week ago, she would immediately notify the Administrator of aby suspected abuse, not notifying would lead to more abuse. She stated she heard about Resident #1's sexually inappropriate behavior towards others but she had not experienced it, and she was not aware of any other such abuse incidents. Interview with RN K on 04/17/25 at 03:27 PM revealed abuse was of various types such as physical, verbal, sexual, mental. She stated inappropriate touch and comments were examples of sexual abuse. She stated she had received in-services on abuse every two weeks and she received the most recent one last week. She stated she would immediately notify the abuse coordinator whenever she learned about abuse, the risk for not notifying the Administrator about abuse would lead to continue the abuse towards more residents. She stated she was not aware of any abuse incidents at the facility. She stated she was not familiar with Resident #1; she learned from other staff about his inappropriate behavior towards females.

Based on observation, interviews, and record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse, to the Administrator of the facility and the State Survey Agency for two (Residents #22 and #52) of 24 residents reviewed for abuse and neglect. LVN E and LVN M failed to immediately report the sexual abuse incidents involving Residents #22 and #52 to the Administrator. LVN M observed an incident of suspected sexual abuse involving Resident #1 and Resident #22 on 02/21/2025 at 09:36 AM and LVN E observed another incident of suspected sexual abuse involving Resident #1 and Resident #52 on 02/21/2025 at 01:34 PM. The administrator learned about these incidents on 02/25/2025 and she self-reported the allegation of sexual abuse to the state agency on 02/25/2025 at 04:00 PM. A past noncompliance IJ was identified on 04/17/2025, and the IJ template was provided to the facility on [DATE] at 01:45 PM. The noncompliance began on 02/21/2025 and ended on 02/25/2025. The facility had corrected the noncompliance before the Incident investigation began on 03/31/2025. This failure could place residents at risk of abuse and neglect. Findings included: 1. Review of Resident #1's face sheet dated 03/31/2025 reflected Resident #1 was a [AGE] year-old male, with an admitted [DATE] and diagnoses of Dementia (memory loss), psychotic disturbance (a mental health condition characterized by a loss of touch with reality, leading to distorted perceptions, thoughts and behaviors), and was discharged on [DATE]. Review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 07 indicating severe cognitive impairment, was independent in transition from sitting to standing position and walking. Review of Resident #1's care plan dated 02/15/2025 reflected Resident #1 displays inappropriate behavior of a sexual manner towards females at times. He has also asked other female residents to go back to his room with him . Monitor resident in activities as needed . Remove other residents from harm and sexual advances as needed . Remove resident from public areas if behavior is demonstrated. 2. Review of Resident #22's face sheet dated 04/02/2025 reflected she was an [AGE] year-old female, with an admitted [DATE] and diagnoses of Dementia (memory loss), psychotic disturbance (a mental health condition characterized by a loss of touch with reality, leading to distorted perceptions, thoughts and behaviors). Review of Resident #22's MDS assessment dated [DATE] reflected Resident #22 had a BIMS score of 02 indicating severe cognitive impairment, was dependent in chair to bed transfers. Review of Resident #22's care plan dated 01/24/2022 reflected resident #22 had a diagnosis of Dementia, 09/19/2022 reflected resident #22 was unable to perform ADL functions independently. 3. Review of Resident #52's face sheet dated 04/02/2025 reflected she was a [AGE] year-old female, with an admitted [DATE] and diagnoses of encephalopathy (brain disfunction leading to symptoms such as altered mental status, memory loss), Cognitive communication deficit (impaired cognitive process). Review of Resident #52's MDS assessment dated [DATE] reflected Resident #52 had a BIMS score of 10 indicating moderate cognitive impairment and she required moderate assistance with chair to bed transfers. Review of Resident #52's care plan dated 01/28/2025 reflected she was taking psychotropic medications for depression and anxiety, had a diagnosis of dementia/Alzheimer's and was at risk for increased confusion. Review of Resident #22's progress note dated 02/21/2025 at 09:36 AM reflected LVN M heard Resident #22 yell No, do not touch me. LVN M observed Resident #1 inappropriately touching Resident #22 and asking her to kiss Resident #1. Review of Resident #52's progress note dated 02/21/2025 at 01:34 PM reflected LVN E observed Resident # 1 grab the hand of Resident #52 and said, come to my room, then attempted to bend over and kiss Resident #52. Record review of the provider investigation report reflected the Administrator completed the investigation on 03/04/2025, notified HHSC, ombudsman, medical director, police department, psych services, responsible parties of Residents #1, #22 and #52, Resident #1's medications were reviewed by the medical director, Resident #22 and Resident #52 were assessed and no emotional distress was noted, staff interviews were conducted, and Resident safe surveys were completed. Record review of the in-service training revealed 63 employees, including LVN E and LVN M, received in service on the topic Reporting abuse neglect and exploitation on 02/25/2025. Record review of the in-service training revealed 92 employees received in-service on the topic ANE reporting response on 03/31/2025. Review of Resident #1's progress note dated 03/04/2025 at 02:53 PM revealed social services had a care plan meeting with Resident #1's family member to address Resident #1's behavior issues and appropriate discharge plan, revealed a 30-day discharge notice was issued to Resident #1's family member . Review of the Q 15-minute check list revealed Resident #1 was checked every 15 minutes from 02/25/25 till 03/17/25. Record review of the physician order dated 02/26/2025 reflected Resident #1 received a new standing order for Prozac 20 mg, once a day, to address his behavior issues. Review of the Quality Assurance Committee sign in sheet revealed the facility had the committee meeting on 04/01/2025 to address the identified issue of staff did not report potential ANE to the administrator immediately. Record review of Resident #1's progress note revealed he had displayed inappropriate behaviors towards females prior to February 2025. An observation and interview with Resident #22 in the facility TV room on 03/31/2025 at 03:59 PM revealed she was sitting in her wheelchair and watching TV. Resident #22 did not remember the alleged incident which happened on 02/21/2025. Resident #22 felt safe at the facility, she was not afraid of any residents or employees. An observation and interview with Resident #52 in her room on 03/31/2025 at 04:15 PM revealed she was sitting in her wheelchair watching TV. Resident #52 stated on an unknown date Resident #1 approached her while she was sitting in her wheelchair in the 500 hallway and told her to go to Resident #1's room, Resident #1 grabbed Resident #52's hands and put her hand in Resident #1's private area. Resident #52 stated she told Resident #1 to stop, and an unknown nurse came and separated both. Resident # 52 stated this was the first such incident, she was not injured, she was not afraid of any residents, and she felt safe. Resident #52 stated Resident #1 did not stay at the same hall and he stayed in 600 hall, she did not have any similar experience from Resident #1 anymore. She stated later ADON H and the Administrator came and spoke to her and assured they were addressing the concern, and she would be safe. Interview with the Administrator on 03/31/2025 at 4:32 PM revealed she had worked at the facility for 3 years and she was the abuse coordinator. She stated she expected all the employees to report to her any suspicion of abuse immediately, all the employees had her contact information available, and all the employees were given in-service training on a regular basis on abuse/neglect. The Administrator stated two female residents, Residents #22 and #52 were inappropriately touched by Resident #1 on 02/21/2025. The Administrator said she first learned about the incident involving Resident # 52 from LVN E on 02/25/2025. As part of the investigation of that incident, she spoke with LVN M on the same day and learned about another incident involving Resident #1 inappropriately touching Resident #22. The Administrator stated both female residents were assessed and they found no injuries, discoloration, pain, or emotional distress. The Administrator stated she educated LVN M on the importance of timely notification of instances where ANE could potentially have taken place. The Administrator stated she instructed staff to complete a 15-minute check on Resident #1 until further notice, reported the alleged incident to the police, and an officer came and spoke with residents. The Administrator stated the incidents were reported to the medical director, responsible parties of each resident who were involved and to the Ombudsman. Resident #1 was referred for psych services and he received new order for medication Prozac. Safe surveys were conducted and ensured no other residents were affected and the residents felt safe and comfortable at the facility. In-service training on ANE and notification was provided to all the employees. The Administrator stated she had a care plan meeting with Resident #1's family and Resident #1 was discharged from the facility. The Administrator stated both incidents involving Residents #22 and #52 were considered as abuse, and abuse was supposed to be reported to the state within 2 hours. She stated she expected the employees to report to her the abuse incident immediately rather than waiting until 02/25/2025. She stated those were the only two incidents involving Resident #1 inappropriately behaving with residents. Interview with LVN E on 03/31/2025 at 05:10 PM revealed she observed the inappropriate behavior of Resident #1 towards Resident #52 on 02/21/2025 when Resident #52 told her about the incident. She stated she did not consider that incident as abuse since Resident #1was attempting to touch Resident #52. She stated she documented the incident in the nurses note on the same day. She stated she sent an email on 02/25/2025 to the Administrator/abuse coordinator notifying her of the alleged incident. She stated she was expected to report any suspected abuse immediately to the abuse coordinator. She stated she was not aware of any sexually inappropriate behavior by Resident #1. She stated she had received in-services on abuse regularly. She stated once she learned about the incident, she separated both residents, redirected Resident #1, and made sure Resident #52 was safe and comfortable. She stated there were several types of abuse such a physical, sexual, verbal, emotional. She stated she would also report abuse to the physician and family of the residents involved. Interview with LVN M on 04/01/2025 at 09:30 AM revealed she had worked at the facility for over two years, and she worked on the 600 hall. She stated abuse was hitting or speaking to a resident inappropriately, and there were several types of abuse such as physical, sexual, emotional. She stated she received in-service training on abuse and the most recent one was in February. She stated she would notify the DON and the Administrator/the abuse coordinator immediately of any suspected abuse/neglect. She stated not immediately reporting abuse can lead to continuation of the abusive behavior towards more residents. She stated if she observed a resident was abused, she would immediately intervene and separate them, redirect the aggressor, and make sure the victim was safe. She stated there would be interventions in place to make sure the aggressor was not repeating the behavior, he/she would be always monitored. She stated she would also report the incident to the physician and family. LVN M stated on 02/21/2025, she was working on the 600 hall nurses' station when she heard Resident #22, who was sitting in her wheelchair on the hallway, yelling don't touch me to Resident #1. She stated she saw Resident #1 touching the side of Resident #22's breast, holding, and pulling her arm, asking her to come to his room. LVN M stated she immediately separated both, took Resident #22 to her room and Resident #1 to his room, educated Resident #1 about inappropriate behaviors and boundaries. She stated she made sure Resident #1 stayed in his room, and monitored him frequently. She stated she did not report this incident to the Abuse Coordinator/the Administrator, but she reported this incident to ADON H, soon after the incident. She stated that was a suspected abuse incident and she was supposed to report it immediately to the abuse coordinator. She stated she had reported this incident she witnessed to the Administrator on 02/25/2025 when the Administrator approached her to ask about a similar incident. An interview with ADON H on 04/01/2025 at 01:34 PM revealed he had worked at the facility for [AGE] years and he was the supervisor for 400, 500 and 700 halls. He stated there were several types of abuse such as physical, mental, sexual, verbal, and the most recent in-service he received on abuse was yesterday. He stated Resident #1 was staying in 600 hall, and one of the nurses had made a complaint about Resident #1 inappropriately talking but they did not have any abuse incidents involving other residents. He stated he learned from the Administrator on 02/25/2025 about Resident #1 holding the hand of a female resident. He stated he was not told by any LVN about this incident. He said he received in-service on abuse and reporting abuse. He stated if an employee witnessed abuse/suspected abuse, his expectation was the employee should immediately separate the residents and made sure the residents were safe, right away call the abuse coordinator on her phone, and notify her, the physician, and family. He stated all the employees had the abuse coordinator's phone number and it was important to report the abuse to the state and have interventions in place to stop similar incidents from happening. He stated the incidents involving Resident #1 inappropriately touching Resident #22 and #52 were considered as suspected abuse and it had to be reported to the abuse coordinator immediately. Interview with CNA N on 04/02/2025 at 02:37 PM revealed she had worked at the facility for [AGE] years; she worked on 500 hall. She stated Resident #1 once inappropriately touched her and she reported this to the Administrator. She stated she was not aware of any other incidents where Resident #1 behaved inappropriately with female residents, other than to Resident #52 sometime in February 2025. She said she received in-service on abuse regarding this incident. She stated Resident #1 never went to other resident's rooms. She stated there were several types of abuse such as physical, sexual, verbal, financial, and she would immediately report any suspected abuse to the abuse coordinator and make sure the residents involved were safe. Observation and Interview with Resident #22 on 04/16/2025 at 11:36 AM revealed she was sitting in her wheelchair and watching TV in the common area. She appeared clean and stated she did not know Resident #1. she stated she never had any experience of inappropriate touch/behavior towards her by anybody. She stated she had no concerns about abuse. Observation and interview with Resident #52 in the dining room on 04/16/2025 at 11:49 AM revealed she was sitting in her wheelchair, ready to have her lunch. Resident #52 stated there was only one incident of an inappropriate behavior since she came to the facility, that was regarding Resident #1 touching her and asking her to come to his room. Resident #52 stated she was not aware of any similar incidents involving Resident #1, she was not afraid of any resident or employees at the facility, and she felt safe. She stated Resident #1 held her hand, asked to go to his room, then moved her hand towards his groin area, she suddenly realized his intention and moved her hand, raised her hand, and got the attention of a nurse. She stated the nurse suddenly separated Resident #1 and took her to her room. Interview with the Administrator on 04/16/2025 at 01:48 PM revealed once she learned about the sexually inappropriate behavior by Resident #1, she interviewed Resident #22 and #52, asked about the inappropriate behavior by Resident #1. The Administrator stated Resident #22 was confused and she did not remember anything about the incident. Resident #52 told the Administrator Resident #1 came to her, grabbed her hand and asked her to go to his room. Resident #52 said no, and the nurse intervened at this point and separated both residents, redirected Resident #1. The Administrator stated Resident #52 never told her about Resident #1 putting Resident #52's hand in Resident #1's groin area. The Administrator stated she was not aware of any previous sexually inappropriate incidents by Resident #1 towards other residents. She stated she had not put any interventions in place from 02/21/2025 till 02/25/2025 regarding Resident #1's behavior but LVN M monitored Resident #1 frequently. She stated once she learned about the incident on 02/25/2025, interventions were in put in place such as: notified medical director, family, 15-minute check on Resident #1, psychiatric services referral, investigated the incident and made sure there were no other similar incidents, provided in service on abuse reporting and reeducated LVN E and LVN M, discharged Resident #1 from the facility on 03/17/2025. She stated she had given verbal waning to LVN E and LVN M for not notifying the abuse coordinator immediately about the abuse incidents which happened on 02/21/2025. Interview with RN S on 04/17/2025 at 12:29 PM revealed there were several types of abuse such as physical, verbal, sexual. She stated inappropriate touch was an example of sexual abuse, and she would immediately report it to the abuse coordinator. She stated not reporting immediately would lead to more abuse incidents. She stated she received in service on abuse twice a month. She stated the only incident she knew was Resident #1 inappropriately touched staff and she did not know of any other incidents. Interview with LVN I on 04/17/2025 at 12:50 PM revealed she was working as a nurse at the facility for 2 years. She stated abuse was in different forms such as verbal, physical, emotional and it could happen between resident to resident or employee to resident. She stated an inappropriate touch was example for sexual abuse, she would immediately report to the Administrator of any abuse because delaying would lead to the abuse to continue. She stated she knew Resident #1 and heard from other staff that he inappropriately touched staff and residents. She stated she was not aware of any similar incidents; she received in service on abuse every two weeks. Interview with ADON H on 04/17/2025 at 2:17 PM revealed there were several types of abuse such as mental, physical, sexual and an example for sexual abuse was inappropriate touch. He stated if he knew about an abuse incident, he made sure the resident was safe, immediately reported to the abuse coordinator/the Administrator because it was a reportable incident to the state. He stated not notifying the abuse coordinator about abuse immediately would put resident at risk for repeated abuse incidents. He stated he received in service every two weeks, most recent one was last week, and there were no incidents of abuse at that time. He stated he learned about Resident #1's inappropriate behavior towards Resident #22 and #52 from the Administrator. Interview with CNA Q on 04/17/25 at 02:33 PM revealed she was working on the 300 hall and abuse was of several types such as sexual, emotional, physical, verbal. An example for sexual abuse was unnecessary touch of body parts, which she would let the Administrator know immediately. She stated not reporting the abuse would lead to repeat such incidents. She stated she received in services on abuse every two weeks. She stated she had one inappropriate touch incident from Resident #1, and she had reported that incident to the abuse coordinator. She stated she was not aware of any abuse incidents at that time. Interview with CNA P on 04/17/25 at 03:13 PM revealed she was working at the facility for a year. She stated abuse had several forms such as physical, verbal, sexual and inappropriate touch was sexual abuse. She stated she would immediately report to the Administrator about any abuse incident and not notifying abuse would put more residents at risk and it affected resident safety. She stated the most recent in-service on abuse was a week ago, she was not familiar with Resident #1, and she was not aware of any such abuse incidents in the facility. Interview with CNA O on 04/17/25 at 03:22 revealed she was working at the facility for [AGE] years. She stated abuse was of several types such as verbal, physical, sexual, neglect. She stated hitting, sexual touch were examples of abuse. She stated she received in service on abuse a week ago, she would immediately notify the Administrator of aby suspected abuse, not notifying would lead to more abuse. She stated she heard about Resident #1's sexually inappropriate behavior towards others but she had not experienced it, and she was not aware of any other such abuse incidents. Interview with RN K on 04/17/25 at 03:27 PM revealed abuse was of various types such as physical, verbal, sexual, mental. She stated inappropriate touch and comments were examples of sexual abuse. She stated she had received in-services on abuse every two weeks and she received the most recent one last week. She stated she would immediately notify the abuse coordinator whenever she learned about abuse, the risk for not notifying the Administrator about abuse would lead to continue the abuse towards more residents. She stated she was not aware of any abuse incidents at the facility. She stated she was not familiar with Resident #1; she learned from other staff about his inappropriate behavior towards females. Review of the facility undated abuse policy titled Prohibition of abuse, neglect, and exploitation standards of practice revealed The Facility will ensure a safe environment for residents by prohibiting ANE. The Facility establishes and implements mechanisms for reporting, investigating, and protecting residents from actual or potential harm. The Facility has designated a person or persons responsible for coordinating and monitoring the ANE prohibition program. This person is the Administrator. Definition: HHSC rules define abuse as: The negligent or willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under Penal Code S21.08 (indecent exposure) or Penal Code Chapter 22 (assaultive offenses), sexual harassment, sexual coercion, or sexual assault. Sexual abuse: Is non-consensual sexual contact of any type with a resident, including, but not limited to, sexual harassment, sexual coercion, or sexual assault. REPORTING:1. Any employee who becomes aware of an allegation of abuse, neglect, or misappropriation of resident property, shall report the incident to the abuse coordinator, Administrator immediately. 2.Any supervisor of an employee or any employee without a supervisor present at the time of the allegation will report the allegation directly to the Administrator immediately. 3. Failure to do so will result in disciplinary action, up to and including termination. 4.The Facility will report allegations to the state agency in accordance with state law.

Based on interview and record review, the facility failed to ensure a discharge MDS was electronically completed and transmitted to the CMS System within 14 days after completion for one (Resident #16) of one resident reviewed for discharge assessments. The facility failed to complete and transmit Resident #16's discharge MDS assessment within 14 days of completion. This failure could place the residents at risk of having incomplete records. Findings include: Review of Resident #16's face sheet, dated 04/02/25, reflected Resident #16 was an [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on 12/05/2024. Review of Resident #16's MDS assessments on 04/02/25 revealed Resident #16 did not have a discharge MDS assessment completed. This MDS record was identified as greater than 120 days late on the resident assessment facility task. An interview on 04/02/25 at 09:41 AM with MDS LVN E revealed Resident #16 was discharged from the facility on 12/05/2024. LVN E stated that she was responsible for completing all MDS assessments. She stated she completed the MDS Discharge assessment on 12/9/24; however, the MDS assessment did not have an RN signature and was not transmitted to CMS. She stated she was aware that MDS assessments needed to be completed in 7 days after resident discharge and transmitted to CMS within 14 days of MDS assessment completion. Failure to complete and transmit MDS assessment in a stipulated time will lead to inaccurate resident census. MDS LVN E stated she will complete and transmit Resident #16's MDS assessment after the interview was completed. In an interview on 04/02/25 at 10:24 AM the DON stated that she was the DON in the facility for the last three weeks. She stated the Facility MDS Nurse was responsible for completing all MDS assessments in a timely manner and it was her expectation that all the MDS assessments were completed and transmitted to CMS within the stipulated time frame. She stated that failure to do so will lead to CMS not being aware if the resident was still residing in the facility. She added as a DON of the facility, she ensured that she signed on all MDS assessments that needed to be transmitted to CMS on a daily basis since she started the DON role of the facility. Review of facility's policy titled Resident Assessment revised on January 12, 2020 reflected, . It is the Standard of Care at this facility to conduct, initially and periodically, a comprehensive, accurate assessment of each resident's functional capacity utilizing the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual .Comprehensive assessments will be completed not less often than once every 12 months (366 days), within 14 calendar days after admission, or within 14 days of a significant change determination . Tracking records and OBRA assessments will be transmitted electronically, in a CMS specified format, within 14 days of the assessment completion. MDS transmission Validation Reports will be saved electronically.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each Resident, consistent with Resident rights, that include measurable objectives and time frames to meet Residents' mental and psychosocial needs for 1 (Resident #32) of 4 residents reviewed for care plans. The facility did not develop and implement a comprehensive person-centered care plan to address Resident # 32's pressure ulcers. This failure could place residents at risk of not having a plan developed to address care needs. Findings include: Record review of Resident #32's MDS assessment dated [DATE] revealed Resident #32 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. Relevant diagnoses included Anemia (Lower amount of healthy red blood cells), Hypertension (High blood pressure), Heart Failure, Hyperlipidemia (high lipid levels ) and Respiratory failure (condition in which lungs are unable to perform their primary function: moving oxygen into the bloodstream and removing carbon dioxide). It also revealed Resident#32 had one Stage 3 pressure ulcer (stage 3 pressure ulcer is a localized area of skin damage that develops when prolonged pressure is applied to the body involving full thickness skin loss, exposing subcutaneous fat) that was present upon admission/entry or reentry. Review of Resident #32's Comprehensive Care Plan, last reviewed 1/29/2025, reflected there was no care plan that addressed Resident #32's pressure ulcer. Review of Resident #32's Physician order dated 3/27/2025 reflected, Coccyx area (tailbone)wound. Clean with saline, pat dry . once a day. Review of Resident #32's Physician order dated 3/20/2025 reflected, Resident Air loss mattress. Interview with LVN G on 04/02/25 at 09:28 AM revealed that Resident #32 had a stage 3 pressure ulcer on his coccyx. She stated that there were wound care orders for Resident #32 to be performed daily. She stated that Resident #32's pressure ulcer should be care planned, but she was not able to find a care plan on Resident #32's electronic health record. She stated the risk of not care planning was lack of communication of possible treatments or approaches for the mentioned care area and failure to provide personalized care to the resident. Interview with MDS LVN E on 04/02/25 at 09:41 AM revealed ADONs and herself were responsible for care planning chronic conditions for the residents. She stated that Resident #32 had a pressure ulcer when he admitted back to the facility from the hospital in March 2025. She stated Resident #32 had pressure ulcer listed on his MDS and wound treatment on physician orders and should have been care planned for it. She also stated the risk for not care planning was potential to miss out on patient centered care and possible worsening of pressure ulcers. Interview with the DON on 04/02/25 at 10:19 AM revealed Nurses, MDS coordinator and ADONs were responsible for care planning and her expectation was that resident care needs needed to be care planned accurately. She stated that care plans paint the story of the resident and is a blueprint for resident care. She stated that there was no great risk for not care planning the pressure ulcer since Resident #32 had wound orders and the nurses would know to take care of it and it would not be missed. Interview with ADON A on 04/02/25 at 11:21 AM revealed that the DON, ADONs and MDS LVN were responsible for care planning. She stated that Resident #32 had a pressure ulcer that needed to be care planned upon his readmission. She stated not care planning can result in not providing adequate, resident centered care to the residents. Record review of facility policy titled, Care planning -Interdisciplinary team revised March 2022, reflected Comprehensive, patient centered care plans are based on resident assessment and developed by the inter disciplinary team.

Based on Observation, interview, and record review, the facility failed to ensure all residents were free of significant medication errors for 1 of 5 residents (Resident #38) reviewed for pharmacy. The facility failed to ensure the medication Lisinopril tablet 2.5 mg, twice a day was given to Resident #38 on 03/29/2025, 03/30/2025 and 03/31/2025. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: Record review of Resident #38's face sheet dated 04/01/2025 revealed he was an [AGE] year-old male with an admitted [DATE] with diagnoses of hypertension (high blood pressure) and heart failure. Record review of Resident #38's MDS assessment dated [DATE] revealed he had a BIMS score of 09 indicating moderate cognitive impairment. Resident #38 needed moderate assistance with chair to bed and toilet transfers. Record review of Resident #38's care plan dated 03/13/2025 revealed he had a history of CHF and is at risk for SOB, chest pain, increased edema (swelling due to fluid buildup in the body) and fluctuations in blood pressure and a diagnosis of hypertension. Record review of Resident #38's order summary dated 04/01/2025 revealed he had a standing order for Lisinopril (medication for lowering blood pressure) 2.5 mg tablet twice a day: 8 AM and 8 PM every day, starting 03/10/2025. Review revealed no physician orders to hold the medication if the blood pressure was outside of certain parameters. Record review of Resident #38's MAR dated 04/01/2025 for Lisinopril 2.5 mg revealed this medication was not administered on 03/29/2025, 03/30/2025 and 03/31/2025 to Resident #38 due to the drug item not available and awaiting pharmacy delivery. The Blood Pressure reading on 03/29/2025 at 8:00 AM was 136/69 and 8:00 PM was 136/63. There was no blood pressure documented for 03/30/2025. On 03/31/2025 the blood pressure for 08:00 AM was 160/71 and 8:00 PM was 148/63. An observation and Interview with Resident #38 on 03/31/2025 at 11:46 AM in his room revealed he was sitting in his wheelchair; oxygen was in use. Resident #38 appeared in clean clothes and he presented no signs and symptoms of pain, discomfort. Resident #38 stated he had a diagnosis of high blood pressure, and he did not receive his medication Lisinopril on 03/30/2025, he could not remember if he received Lisinopril that day morning or the previous days. Resident #38 stated a nurse told him that the medication was not available at the facility. Resident #38 stated he had no negative effects related to high blood pressure at the time of the interview. An interview with the Administrator on 04/01/2025 at 01: 04 PM revealed she had worked at the facility for 3 years. She stated she expected all the residents to receive their medications as per the order from the physician and not getting medications can lead to health issues. She stated she expected all the nurses to make sure the medications were administered to the residents they were responsible for and to notify the supervisor of any concerns they had. She stated the DON was responsible to make sure the nurses were trained, doing their job, and were administering the medications to the residents as per the physician's order. She sated she was not aware that Resident #38 was not getting blood pressure medication lisinopril for 3 days. An interview with RN ADON on 04/01/2025 at 01:34 PM revealed he was the supervisor for Resident #38's hall. He stated he had worked at the facility for [AGE] years. He stated he expected all the residents to receive their medications as per the physician's order and all the nurses were responsible to give the medications as per the order. He stated he expected the nurses who provided medications to contact the pharmacy and reorder the medications at least 72 hours before the medication ran out. He stated if there was a problem in getting the medications in a timely manner or were no medications available, he expected the nurse to contact the pharmacy to find out the reason, notify the supervisor and physician so that the physician can order another medication or advise what to do. He stated he was not aware that Resident #38 did not receive his Lisinopril for 3 days. He stated Resident #38 had a diagnosis of hypertension and not receiving this medication can lead to high blood pressure, affect his kidney and all organ systems negatively, it can lead to a stroke and even death. He stated he expected the nurses to report to the supervisor if there was a problem in getting a medication from the pharmacy and the medication not being available was not an acceptable excuse not to give the medication to Resident #38. He stated all the nurses were given regular in-service training on medication administration and knowing what to do when a medication was not available was considered as a basic nursing knowledge. He stated he was ultimately responsible to make sure all the residents in his hall received their medications as per the physician's order. An interview with RN L on 04/01/2025 at 02:41 PM revealed she had worked at the facility since 2017 and she provided care to Resident #38. She stated Resident #38's Lisinopril was available today but he was not given his Lisinopril medication for the morning because his blood pressure was low. She stated if a medication was not available, she would contact the pharmacy. She said if there was a problem in getting the medication timely, she would immediately notify the physician so that the physician can order another medication or give advice as what to do next. She stated Resident # 38 was diagnosed with high blood pressure and not getting medication can affect the resident negatively, and can lead to stroke. She stated Resident #38 required vitals checked at least once a during the shift. She stated the nurse who was working on Resident #38's hall was responsible to make sure there was enough medicine and if not to call the pharmacy/physician and notify the ADON/supervisor. She stated she did not remember when the last time she received an in service on medication administration was, but she learned the basics about medication administration from the nursing school. An interview with LVN I on 04/01/2025 at 02:56 PM revealed she had worked at the facility for 6 years and she provided care to Resident # 38. She stated she worked the 6 PM to 10 PM shift on 03/29/2025, and she noticed there was no medication Lisinopril available. She said she notified the resident, but she did not contact the pharmacy, the physician, or her supervisor about it. She sated it was not an acceptable excuse not to give a resident their medication because it was not available. She said a medication had to be reordered by contacting the pharmacy when the nurse learns that there were only 7 pills left. She stated if a medication was not available, she was expected to contact the pharmacy, notify the physician and her supervisor. She stated there were no Lisinopril tablets available at the facility for emergency purpose on 03/29/2025. She stated not getting Lisinopril can cause a resident to have high blood pressure and stroke. She stated she received in service training on medication administration but did not remember when the last time she received it was. An interview with the DON on 04/02/2025 at 10:32 AM revealed she had worked at the facility for 4 weeks. She stated she was not aware that Resident #38 was not given his Lisinopril medication for 3 days. She stated she expected all the residents to receive their medications as per the order from the physician and the nurses were responsible to make sure the medication was given to the resident. She stated if a medication was not available, the nurse was expected to contact the pharmacy to reorder, notify the physician when there was no response from the pharmacy and get advice from the doctor as what to do next. She stated not getting blood pressure medication can lead to high blood pressure and stroke. She stated she was responsible to make sure the nurses were doing their job, giving all the medicines to the residents as per the physician's orders. She stated she expected the nurses to order the medications 7 days before the medications ran out. She stated since she started working at the facility, she had meetings with the nurses to train them on medication administration. An interview with RN K on 04/02/2025 at 11:35 AM revealed she had worked at the facility since October 2024, and she provided care to Resident #38 on 03/30/2025 during day shift. She stated Lisinopril was not available at the facility that day, and the resident did not receive that medication during her shift. She stated she contacted the pharmacy but did not get the medication, and she did not call the physician or anybody else at the facility. She stated not getting Lisinopril can cause the blood pressure to go up and can increase the risk for a stroke. She stated the nurse on duty was responsible to give all the medications to the residents as per the physician's order, reorder the medications by contacting the pharmacy, make follow up contacts with the pharmacy regarding reorders and notify the physician and supervisor if a medication was not available to administer. She stated there was no Lisinopril available at the facility for emergency purpose on 03/30/2025. An attempted telephone interview with LVN J on 04/02/2025 at 12:33 PM received no response, left a voice mail requesting a call back. A telephone interview with Resident #38's NP on 04/02/2025 at 02:22 PM revealed she was providing care to Resident #38. She stated she was not aware that Resident #38 did not receive medication Lisinopril for 3 days as per the physician's order, and nobody from the facility contacted her regarding the same. She stated not getting Lisinopril medication can cause high blood pressure and even stroke to Resident #38. She stated she expected the facility to notify her if a resident was going without a medication so that she could order another medication. Review of the facility policy titled Administering Medications dated April 2019 reflected Medications are administered in a safe and timely manner, and as prescribed. The director of nursing services supervises and directs all personnel who administer medications, . Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. The facility failed to ensure food items in the facility walk-in freezer were covered, labeled, and dated. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observation on 03/31/25 at 09:41 AM of the facility walk-in freezer revealed: 1. Frozen ground beef patties inside a cardboard box were not covered and not dated. 2. Frozen oatmeal raisin cookie dough inside a plastic bag in a cardboard box was left open. 3. Frozen meat that looked like Chicken breasts were out of their original packaging and were not dated or labeled. In an interview on 03/31/25 at 09:46 AM Assistant [NAME] F revealed everyone in the kitchen including cooks, dietary aides, and the dietary manager was responsible for covering, dating, and labeling food items in the kitchen. She stated all food items should be covered, labeled, and dated. She added they should add expiration dates and use by dates on opened food items so they can use the food items before expiry. She stated not covering, labeling, and dating food items could cause cross contamination and potentially cause illness in residents. In an interview on 04/01/25 at 01:26 PM, the Dietary Manager stated everyone including cooks and herself were responsible for covering, dating, and labeling all food items in the kitchen. She stated her expectation was all food items in the kitchen should be marked with received date once they arrive at the facility and used by date for leftovers and opened food items. She stated it was her expectation that all food items should be appropriately dated, covered, and labeled by the kitchen staff. She stated that they had the food delivery truck on 03/31/25 and the staff was probably in the process of rearranging items but that should not be an excuse for not covering, labeling, or dating food items in the kitchen. She stated the risk of not dating, labeling, covering food items was cross contamination resulting in food borne illness. She added as the dietary manager, she was responsible for providing in-service regarding dating, covering and labeling food items appropriately. Review of facility's policy titled Food receiving and Storage revised December 2008 reflected, Foods shall be received and stored in a manner that complies with safe food handling practices .7. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) . Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #32) of 1 resident reviewed for catheter care. 1. The facility failed to ensure CNA C and CNA D maintained the foley catheter drainage bag below Resident #32's bladder during a mechanical lift transfer. This failure placed residents at risk for the development and/or worsening of urinary tract infections and dislodgement of the foley catheter. Findings included: Record review of Resident #32's MDS assessment dated [DATE] reflected a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included coronary artery disease, obstructive uropathy (disorder of the urinary tract due to obstructed urinary flow), and hypertension (elevated blood pressure). He had a BIMS score of 04/15 which indicated severe cognitive impairment, required extensive to total assistance with toileting and personal hygiene and was always incontinent of bowel and had a foley catheter. Record review of Resident #32's care plan started date 01/29/25 reflected, Problem. Resident has Foley Catheter and is at risk for increased urinary tract infection. Goal. Foley will remain patent (not kinked) with no signs and symptoms of UTI. approach Keep tubing and foley bag below the bladder . Review of Resident#32's Order Summary report dated 03/12/25, reflected, Foley: Catheter drainage to gravity drainage Observation on 04/01/25 at 11:22 AM revealed CNA C and CNA D entered Resident #32's room to get the resident up for the day. CNA C unhooked the catheter bag from the bed rail and placed it on Resident #32's lap, above the resident's bladder. Urine was observed flowing back toward the resident's bladder. The staff then positioned him over his wheelchair and lowered him into his chair and placed the catheter bag under his wheelchair. In an interview with CNA C on 04/01/25 at 1:12 PM, he stated he was not sure where the catheter bag should have been positioned during the transfer. He stated he was thinking since the catheter bag was on Resident#32's lap, it was below his bladder. He stated having it above the bladder could cause blockage and then he stated the urine could run backwards, and cause development of infection to the resident. In an interview with CNA D on 04/01/25 at 1:22 PM she stated placing Resident#32 foley catheter drainage bag in Residdent#32 lap, was below his bladder . She stated she was trained to always keep the resident's foley catheter below the resident's bladder. She stated failing to do this could cause the urine to back up and might cause an infection. In an interview with the DON on 04/02/25 at 10:27 AM, she stated the facility policy is to keep the foley catheter drainage bag below the resident's bladder all the time. She stated if the CNAs placed the drainage bag on the resident's lap in the sitting position in the sling, during the transfer, for her the drainage bag was below the bladder. She further stated not keeping the foley catheter bag below the residents' bladder, placed them at risk of a urinary tract infection and cross contamination. Record review of the CNA's proficiency check off for residents' peri-care, revealed: CNA C's proficiency check off for peri-care revealed he was proficient in care as of 03/05/25. CNA D's proficiency check off for peri-care revealed she was proficient in care as of 03/07/25. Review of the facility's policy revised 08/2022, and titled, Catheter Care, Urinary reflected Purpose . to prevent urinary catheter-associated complication, including urinary tract infection .To reduce irritation .Maintaining Unobstructed Urine Flow .3. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of medications for 1 (Nursing Medication cart hall 500 ) of 4 medication carts reviewed for pharmacy services. The facility failed to ensure prompt identification of potential diversion of controlled medications when LVN B did not report a damaged blister pack of Lorazepam 0.5 mg (controlled medication). This failure could place residents at risk of not having their medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings included: Record review of Resident#5's Quarterly MDS assessment, dated 01/26/25, reflected she was an [AGE] year-old female with admitted [DATE]. Resident#5's BIMs score was 6/15 which indicated severe cognition impairment. Her diagnoses included diabetes mellitus (elevated blood sugar), dementia (diseases that affect memory, thinking, and the ability to perform daily activities), hypertension (elevated blood pressure). Record review of Resident#5's Physician order summary report dated March 3, 2025, reflected Lorazepam-Schedule IV tablet; 0.5 mg; amt: 0.5 tab= 0.25 mg; oral once a day-PRN with a start date 03/06/25. An observation on 03/31/25 at 2:06 PM of medication carts revealed the blister pack in medication Cart for Hall 500, for Resident#5's Lorazepam 0.5 mg (controlled medication) had 2 blisters pills area seal broken , taped on the back, and there was pills still in the blisters. Review of the controlled medication count sheet dated 03/31/25 for Resident#5's lorazepam 0.5 mg reflected that the count was accurate when compared to the medications in the drawer. In an interview on 03/31/25 at 2:06 PM LVN B stated she was unaware when the blister pack seal became broken. She stated that the seals are easily torn when they are handled every shift to be counted. She stated the medication was supposed to be discarded if opened to prevent potential diversion of controlled medications. In an interview on 04/01/25 at 11:14 AM, the DON revealed she expected if a blister pack medication seal is broken; the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk to residents would be development of infection, and drug diversion. The DON stated charge nurses were responsible to check, every day, the carts for medications with broken seals during the count with the relieving nurses. Review of the facility's Medication Labeling and Storage policy, dated 2001, indicated . 3. If the facility has .deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 48235

48560 Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #32 and Resident #222) observed for infection control. The facility failed to ensure CNA C and CNA D used the required PPE for Resident#32 who was on enhanced barrier precautions due to his foley catheter, and wound , while performing a mechanical lift transfer on 04/01/25. The facility failed to ensure CNA C and CNA D used the required PPE for Resident#222 who was on enhanced barrier precautions due to his foley catheter, and wound, while performing a two person assist transfer on 04/02/25. These failures could place the residents at risk of cross-contamination and lapses in infection control. Findings included: 1- Resident #32 Record review of Resident #32's MDS assessment dated [DATE] reflected a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included coronary artery disease, obstructive uropathy (disorder of the urinary tract due to obstructed urinary flow), and hypertension (elevated blood pressure). He had a BIMS score of 04/15 which indicated severe cognitive impairment, required extensive to total assistance with toileting and personal hygiene and was always incontinent of bowel and had a foley catheter. Further review revealed skin conditions: Resident#32 had one state 3 pressure sore, that was present on admission. Record review of Resident #32's care plan started date 01/29/25 reflected, Problem. Requires enhanced barrier precautions. Goal. Reduce potential for infection. Approach. Educate staff on EBP protocol. Maintain EBP supplies in room. In an observation on 04/01/25 at 11:20 AM there was no EBP signage in front of Resident#32's room, and no PPE supplies outside the room. There was an 8x11 paper on Resident#32's closet door with the reading ENHANCED BARRIER PRECAUTION. The closet was situated at the middle of the wall facing Resident #32's bed. In an observation on 04/01/25 at 11:22 AM CNA C and CNA D entered Resident #32's room with the mechanical lift to provide a mechanical lift transfer. Both staff washed their hands and put on gloves, but no gown. Both staff maneuvered the lift around Resident #32's bed and hooked the sling to the lift. CNA C unhooked the catheter bag from the bed frame and placed it on Resident#32's lap. The staff lifted the resident up with the catheter bag and transferred him from the bed to the wheelchair. CNA C then took the urinary drainage bag and placed it on the wheelchair frame. Both CNAs adjusted Resident#32 in his wheelchair. CNA D washed her hands in the bathroom and took the mechanical lift and left the room. CNA C took Resident#32 to the bathroom and proceeded to make Resident#32's bed. In an interview with CNA C on 04/01/25 at 1:12 PM he stated residents who had foley catheters were under enhanced barrier precautions. CNA C stated, he received training on EBP, and did not know that resident transfer was a form of high contact with the resident, that requires to put on gown. He stated the risk would be spreading germs between residents and staff. In an interview with CNA D on 04/01/25 at 1:22 PM she stated, she received training on EBP, and she knew that she was supposed to put on a gown during resident transfer. She stated, she did not put on the gown, because when she entered the room, Resident#32 was ready for transfer with the sling under him. She stated the risk to the resident was development of infection. 2- Resident #222 Record review of Resident #222's Admission MDS assessment dated [DATE] reflected a [AGE] year-old male initially admitted to the facility on [DATE]. His diagnoses included non-traumatic brain dysfunction, obstructive uropathy (disorder of the urinary tract due to obstructed urinary flow), Wound infection, Parkinson's (progressive neurological disorder), malnutrition. He had a BIMS score of 9 which indicated moderate cognitive impairment. He required extensive to total assistance with toileting and was always incontinent of bowel and had a foley catheter. Resident #222 MDS reflected he had one stage 2 pressure ulcer. Record review of Resident #222's care plan started date 01/29/25, updated on 4/2/25 reflected the following, Problem: [Resident #222] Requires enhanced barrier precautions. Goal: Reduce the potential for infection. Approach: Educate staff on EBP protocol, Maintain PPE supplies in room, Place pink magnet on door frame. Record review of Resident #222's Physician Order dated 3/26/25 reflected, Enhanced Barrier precaution, every shift, day, evening. In an observation on 04/02/25 at 11:20 AM there was no EBP signage in front of Resident#222's room, and no PPE supplies outside the room. There was an 8x11 paper on Resident#222's closet door with the reading ENHANCED BARRIER PRECAUTION. There was a rectangular pink magnet placed on the door outside of Resident #222's room. In an observation on 04/02/25 at 9:43 AM CNA C and CNA D entered Resident #222's room. Both staff washed their hands and donned gloves, but did not wear the gown. CNA C tied the gait belt around Resident #222's waist. The two CNAs helped Resident #222 transfer from the bed to the wheelchair using the gait belt. After the transfer was completed, they readjusted Resident #222's position in the wheelchair and CNA C took off the gait belt. CNA C and CNA D then proceeded to remove gloves, performed hand hygiene, and exited the resident room. In an interview with CNA C and CNA D on 04/02/25 at 09:52 AM, CNA C stated residents who had foley catheters had enhanced barrier precautions. They stated the pink magnet outside the resident door signifies that resident is on EBP. They stated as CNAs they had received training on EBP, and it did not indicate wearing gowns while transferring a resident on EBP since it was not a high contact activity. They stated they performed hand hygiene, donned gloves, and mask. Both CNAs stated because the transfer involves close contact with the resident with attaching and removing the gait belt as well as providing support during the actual transfer, the risk of not donning appropriate PPE during EBP could cause increased infection and possibility of spreading germs between residents and staff. In an interview with the DON on 04/02/25 at 10:27 AM, she stated she had been working in the facility for about a month. The DON stated per the facility policy resident's transfer was not a form of high contact activity with the resident in EBP. She further stated staff were not required to wear gowns for the resident transfer. She stated the risk of not wearing appropriate PPE was potential spread of infection. Record review of in-service documents revealed the facility did in service on EBP for staff on 11/29/24. The in-service topic covered: How Do I know if EBP needs to be used? EBP needs to be donned (put on) prior to beginning any high contact resident care activity on residents with chronic wounds and/or indwelling medical devices. What is not considered a high contact resident care activity? Delivering or picking up a meal tray. Passing ice water. Taking meal orders for tray ticket. Delivering supplies or other items to the resident rooms. Placing requested items within resident reach. Any task that does not require close contact with resident. Record review of the facility's policy, Enhanced Barrier Precautions, with revision date August 2022, reflected, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of transmission of multidrug-resistant organisms .EBPs employ targeted gown and gloves use during high contact resident care activities .3. Examples of high contact care activities requiring the use of gown and gloves for EBPs including a. dressing; b. Bathing/showering; d. changing linens; e. changing briefs or assisting with toileting; f. device care or use (central line, urinary catheter .etc ) and g. wound care.9. staff are trained prior to caring for residents on EBP. 10. Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required. Record Review of US Centers for Disease Control and Prevention website Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes | LTCFs | CDC dated June 28, 2024 reflected the following, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes .2. Enhanced Barrier Precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Standard Precautions still apply while using Enhanced Barrier Precautions. For example, if splashes and sprays are anticipated during the high-contact care activity, face protection should be used in addition to the gown and gloves . Record Review of updated guidance from CMS Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Ref: QSO-24-08-NH dated march 20,2024 reflected, . EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: o Transferring