Every finding on record at River Oaks Health and Rehabilitation Center

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 kitchen (1 kitchen) reviewed for environment. The facility failed to clean puddles of water throughout the kitchen and puddles in the dining area. This failure could place residents at risk of falls. Findings included: During an observation of the dining area on 06/10/26 at 8:30 A.M., puddles of water were revealed from the entry way of the kitchen to the exit door that led to the dining area. No caution signs were placed in the dining area or kitchen area. During an observation on 06/10/26 at 12:00 P.M., plumbers revealed the hole in the back of the kitchen. During an interview on 06/10/26 at 8:35 A.M., the cook stated there was a leak in the kitchen for the last couple of weeks. The cook stated the plumbers came yesterday (06/09/26) and started working on the leak from outside. The cook stated she was not able to find the caution signs for the dining area to prevent residents from getting in the water. The cook stated staff already mopped this morning and the water was already back and everywhere. The cook stated the puddles of water could be a hazard because a resident could slip. During an interview and observation on 06/10/26 at 8:41 A.M., the Dietary Manager stated she reported the leak to the Maintenance Director a couple of weeks ago, but she could not determine what day. The Dietary Manager showed where the water was coming from the wall and now there were multiple puddles of water throughout the kitchen. The Dietary Manager did not believe it would be an infection control concern because the water was clean and on the ground. The Dietary Manager stated this could be an accident and hazard because residents could fall in the dining area Observed multiple puddles from the entry and exit area of the kitchen that led to the dining area. The Dietary Manager stated she would find the caution signs. During an interview on 06/10/26 at 9:40 A.M., the Maintence Director stated there was a leak under the slab in the kitchen. The Maintence Director stated the plumbers were drilling a tunnel so they would not have to cut the slab open. The Maintenance Director stated the facility had a water leak over the last couple of weeks. The Maintence Director stated they had to get bids for the plumbers and the plumbers started on 06/09/26. During an interview on 06/10/26 at 11:36 A.M., the Dietary Aide stated the plumbers started to drill in the back since 06/09/26. The Dietary Aide stated the kitchen had a leak for the last couple of weeks, but she did not know the exact date. During an interview on 06/10/26 at 4:16 P.M., the administrator stated the caution signs were important to have out to prevent residents from falling. The Administrator stated kitchen staff were responsible for keeping absorbing blankets and towels to keep water out of the dining area. Record review of facility's Maintenance Service policy, revised December 2009, reflected The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . 1. Functions of maintenance personnel include, but are not limited to .a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines .b. Maintaining the building in good repair and free from hazards

Based on observation, interview, and record review, the facility failed to ensure residents were free from verbal abuse by Resident #1 for 2 (Residents #2, #3) of 13 reviewed for abuse. The facility failed to protect residents from verbal abuse, threats, and physical abuse by Resident #1. Resident #2 was threatened by Resident #1 on 4/5/2026, 4-25-2026 by Resident #1 saying [Resident #1] was going to have Resident #2 beat up, was not afraid of Resident #2's phone, was going to slap the dog shit out of [Resident #2], and was going to knock the shit out of [Resident #2]. Resident #3 was verbally abused, physically grabbed, and pushed out of the way by Resident #1 on 4-29-2026.Resident #6 was verbally abused and threatened by Resident #1 when he told her I'm going to kick your ass and physically pushed her out of [Resident #1's] way. The Administrator and staff were aware of the abuse and told vulnerable residents with histories of trauma to just avoid the aggressor (Resident #1). On 4-30-2026 at 2:54 PM, an Immediate Jeopardy was identified. While the IJ was removed on 5-1-2026, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.These failures resulted in Resident's #2 and #3 who reported fear and feeling unsafe and placed residents at risk of subsequent abuse, resulting in potential severe physical harm, pain, or mental anguish.Record review of Resident #1's admission record, dated and reviewed on 4-29-2026, revealed a [AGE] year-old male, admitted [DATE] and readmitted [DATE]. Resident #1 had a primary diagnosis of transient cerebral ischemic attach (stroke) and secondary diagnoses of anxiety disorder (mental health condition categorized by excessive worry affecting quality of life), bipolar disorder (mental health condition characterized by significant mood swings), current episode manic severe with psychotic features (a distinct period of abnormally, persistently elevated, or irritable mood and extremely high energy, lasting at least one week like an unrealistic sense of superiority, power, decreased sleep, and racing thoughts with delusions or hallucinations), and intermittent explosive disorder (a mental health condition characterized by recurrent, impulsive, and disproportionate outbursts of rage or aggression). Record review of Resident #1's Quarterly MDS assessment, dated 3-24-2026, reviewed on 04-29-2026, revealed Resident #1 re-entered the facility from a short-term general hospital with a BIMS score of 14 indicating Resident#1 was cognitively intact. The GG, Functional section, revealed Resident#1 could independently move from a sitting position to a standing position and could independently transfer himself from a bed to a chair. The K-Swallowing/Nutritional Status Section, revealed Resident #1 was 6' 4 and weighed 230 pounds. Resident #1 used a wheelchair to ambulate. Record review of Resident #1's most recent care plan with an initial date of 8-25-2021 and a revision date of 9-4-2024, and reviewed on 04-29-2026, indicated Resident #1 had behavior problems of attention-seeking and accusatory behaviors, distorting the truth in attention seeking efforts and/or making false allegations, making negative statements about staff, proposing unrealistic demands, threatening staff with calling the state, inserted himself into staff/other residents' care/affairs causing outbursts, attention seeking behavior, making false allegations, he makes his peers feel uncomfortable or uneasy when around him, and had potential to demonstrate physical behaviors of anger, and poor impulse control. Record review of Resident #1's Event Nurses Note, dated 7-7-2024, reflected Resident #1 had a resident-to-resident incident yelling at his roommate. Record review of Resident #1's Event Nurses Note, dated 9-3-2024, reflected Resident #1 had a resident-to-resident incident verbally threatening another resident yelling for him to get out of his room. Staff explained the resident was his roommate. Record review of Resident #1's Event Nurses Note, dated 12-12-2025, reflected Resident #1 was combative, verbally and physically aggressive by standing up, swinging his hand toward a CNA attempting to hit the CNA. Resident #1 said I will take the shit out of you. Record review of Resident #1's progress notes reflected the following: 3-13-2026 at 8:50 PM - In the last week, the resident experienced verbal behaviors directed toward others 1-3 days . Verbally aggressive with other residents in the hallways. 3-18-2026 at 11:38 PM - In the last week, the resident experienced verbal behaviors directed toward others 1-3 days . 4-5-2026 at 9:58 PM - Resident #1 had a verbal confrontation with another resident witnessed by staff. He was resistant to resolution and intervention. When separated, he claimed the other resident pushed his wheelchair; none of the witnesses saw this happen. During an observation and interview on 4-29-2026 at 12:42 PM, Resident #2 was observed ambulating in a motorized wheelchair in the hallway outside her room. Resident #2 wanted to speak in private and said she did not feel safe around Resident #1. Resident #2 said Resident #1 threatened to have her beat up by his sister on 4-5-2026. Resident #2 then exhibited a video, from her phone, of Resident #1 ambulating in his wheelchair toward Resident #2 saying in a loud voice, I'm not afraid of your phone, I'm going to slap the dog shit out of Resident #2 and I'm going to knock the shit out of Resident #2. Resident #2 said Resident #1 started being aggressive toward her when she observed Resident #1 bullying a non-verbal resident sitting in his wheelchair. Resident #2 said she asked Resident #1 to leave the vulnerable non-verbal resident alone. That was when Resident #1 started to make verbal threats toward Resident #2. Resident #2 said she filed a grievance with the Social Worker on 4-27-2026. The Social Worker told Resident #2 she needed to speak with the Administrator and would get back with her after she spoke with him. Resident #2 said the Social Worker got back with her the same day and said the Administrator said to just avoid Resident #1. Resident #2 said she told the Social Worker she did not feel safe as the facility was not protecting her, she felt lied to by the facility, and wanted the State's phone number and the facility's corporate phone number. Record review of Resident #2's admission sheet, dated and reviewed on 04-29-2026, revealed Resident #2 was a [AGE] year-old female admitted [DATE] and readmitted [DATE]. Resident #2's primary diagnosis was anemia (condition characterized by a deficiency in health red blood cells, leading to insufficient oxygen delivery to the body's tissues) and secondary diagnoses of foot drop, right foot (the inability to lift the front part of the foot, causing it to drag or slap on the floor while walking), heart failure, major depressive disorder (serious mental condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), and generalized anxiety disorder. Record review of Resident #2's Quarterly MDS assessment, dated 3-10-2026, reflected a BIMS score of 15 indicating cognitively intact. The GG-Functional Abilities revealed Resident #2 used a motorized wheelchair to ambulate. Record review of Resident #2's Care Plan, dated 10-17-2025, revealed she had a history of trauma that may have a negative impact. The trauma is r/t: history of life-threatening illness, physical assault [Family Member], physically threatened and sexually assault. Resident #2 was care planned to have a potential for uncontrolled pain due to Fibromyalgia (chronic condition characterized by widespread pain, fatigue, and other symptoms), chronic right arms pain, left leg pain. back pain and neuropathy (nerve damage outside the brain and spinal cord). Record review of the facility's grievance log, reflected Resident #2 filed a grievance on 4-27-2026 stating she wanted Resident #1 to be discharged because Resident #1 was making her stressed and threatened. Resident #2 said on 4-25-2026 Resident #1 held his fist up to her and threatened to physically harm her. Resident #2 said Resident #1 acted aggressively toward her multiple times. The summary of the pertinent findings by the facility stated Resident #2 did record the interaction. In one of the videos, Resident #1 is clearly heard threatening to slap the shit of Resident #2. The corrective action the facility stated it took was to tell both residents to stay away from each other and educate staff to separate them in case of confrontation. Record review of Resident #2's progress note, dated 4-28-2026 at 12:00 PM, revealed the Social Worker stated she followed up with Resident #2's grievance stating regarding the resolution to her grievance. Resident #2 said it was not satisfactory and that avoiding Resident #1 was not possible. She said he threatened her again last night but would not elaborate further. She stated she feels the facility has lied to her and requested contact information for the State and Corporate. During an interview on 4-29-2026 at 12:50 PM, Resident #5 said she was not comfortable around Resident #1 when he comes to the doorway of her room saying he was going to get the facility shutdown. Resident #5 said she was bedbound. During an interview on 4-29-2026 at 3:57 PM, Resident #3 said she was afraid of Resident #1 because he verbally threatened to hit her and was verbally abusive with his words. Resident #3 said the facility knew about Resident #1's conduct but had not done anything about it. Record review of Resident #3's admission record, dated 4-30-2026, reflected a [AGE] year-old female admitted [DATE] and readmitted [DATE]. Resident #3's primary diagnosis was chronic obstructive pulmonary disease (lung disease causing chronic coughing, wheezing, and severe breathlessness due to damaged airways, primarily caused by smoking, air pollution, or genetic factors) and secondary diagnoses of generalized anxiety disorder, glaucoma (a group of eye diseases that damage the optic nerve, often due to high eye pressure, leading to permanent, irreversible vision loss or blindness), and unsteadiness on her feet. Record review of Resident #3's Quarterly MDS assessment, dated 3-9-2026, revealed she had a BIMS score of 15 indicating being cognitively intact. The GG-Functional Abilities section revealed Resident #3 used a wheelchair to ambulate. The J-Health Conditions of Resident #3 revealed she experienced frequent pain. Record review of Resident #3's care plan, dated 6-6-2023, revealed she was care planned for trauma informed care stating she was in a major natural disaster or technological disaster such as fire, tornado, hurricane, flood, earthquake, or chemical spill. During an observation and interview on 4-30-2026 at 2:00 PM, Resident #3 said last night when she was getting her medication by the nurse's station, Resident #1 came up behind her in his wheelchair, grabbed her arm, and cursed at her demanding she get out of his way. Resident #3 was observed to start crying at this point. Resident #3 said she then slapped Resident #1 to let her go. Record review of Resident #3's progress notes, dated 4-30-2026 at 11:06 AM, revealed Resident #3 told the Dietary Manager that [Resident #1] approached [Resident #3] from behind, yelled and used profanity toward [Resident #3], grabbed [Resident #3's forearm, and pushed [Resident #3] while she was in her wheelchair. During an observation and attempted interview on 4-30-2026 at 10:55 PM, Resident #1 was observed to be sleeping in his bed in a private room. During an interview on 4-30-2026 at 11:00 AM, RN A said Resident #1 got up earlier today, ate breakfast, and went back to sleep. RN A said Resident #1 sleeps all day long. In an interview on 4-30-2026 at 11:10 AM, the SW said Resident #2 did not feel safe around Resident #1. The SW said she spoke with the Administrator regarding Resident #2's grievance and the Administrator said because this was the first grievance Resident #2 filed concerning Resident #1's behavior, he did not want to discharge anyone. The SW said the Administrator said for Resident #2 to just avoid Resident #1. The SW said the facility kept residents safe from Resident #1 by redirecting him. In an interview and record review on 4-30-2026 at 11:30 AM, the Administrator said he was an AIT and had worked at the facility since 11-18-2025. The Administrator said he told Resident #2 to just avoid Resident #1 and staff were informed to keep them apart. The Administrator said verbal abuse was to the best of my understanding would be using defamatory words, racial slurs. The Administrator named different types of abuse as being verbal, emotional, financial, mental, and physical. The Administrator said a self-report was not filed by the facility regarding Resident #2's grievance because he was in and out of the office. The Administrator said, I should have filed a self-report, that was my fault. When asked, if he thought the grievance Resident #2 filed regarding Resident #1's threatening her was abuse, the Administrator said, I don't know. When the video and audio recording of Resident #1 threatening to do bodily harm to Resident #2, dated 4-25-2026, was shown to the Administrator, he said, That was abuse. The Administrator said he saw another video today of Resident #1 verbally abusing Resident #2 where former DON (RN B) was trying to redirect Resident #1. The Administrator said RN B did not report this incident to him. The Administrator said in his absence, the DON became the abuse coordinator, and it was elevated to the Area Director of Operations. The Administrator said the facility had not discharged Resident #1 because, Resident #1 had not crossed the line yet that would fulfill the requirement to justify an immediate discharge as he would have to physically assault someone to justify an immediate discharge, in my opinion. The Administrator said the facility did not follow its own Abuse and Neglect Policy because in this particular situation, the SW did not want to add onto his health issues he had been dealing with. The Administrator said the facility protected other residents from Resident #1 by filing self-reports, and I just don't have a lot of answers right now. The Administrator said Resident #1 had never tried to hit anyone. However, the Administrator was shown an event nurse note from the facility's EMR, revealing on 12-12-2025 at 4:02 PM, Resident #1 attempted to hit a CNA by swinging his hand at the CNA, but missed hitting the CNA. The Administrator said he was shocked to learn that. The event note stated, the DON and Administrator were notified of the incident. During an interview on 4-30-2026 at 3:20 PM, the DON said she had worked at the facility for 3 weeks. The DON said she had never heard from staff that Resident #1 was verbally threatening towards residents. The DON said she knew that Resident #1 talked loudly because he was hard of hearing. The DON said if she had known one resident was being verbally aggressive to another one by saying he wanted to hit another resident, she would have put that resident on a one-to-one supervision, notified the Administrator, doctor, and family. In an interview on 4-30-2026 at 3:30 PM, RN B revealed she worked a 12-hour shift from 6:00PM - 6:00AM. RN B said she had not witnessed Resident #1 being verbally aggressive toward other residents, but when something occurred with Resident #1, Resident #1 told her about it. RN B said if she heard one resident threaten another, she would notify the Administrator. RN B said she was present one night recently when Resident #1 got irritated at Resident #2 in the hallway for no reason. RN B said she did not hear Resident #1 threaten Resident #2. Record review and observation of Resident #2's cell phone audio/video recording taken on 4-25-2026, revealed Resident #1 threatened Resident #2 by saying, I'm going to slap the dog shit out of her and I'm going to knock the shit out of you. During the recording, part of a staff member's body was visible beside Resident #2 when Resident #1 said to the staff member [RN B] do something with her. [RN B] was later revealed to be RN B. A copy of this audio/video recording was obtained. In an interview on 4-30-2026 at 5:26 PM, CNA C said she had worked at the facility for 19 years and was familiar with Resident #1's behaviors. CNA C said Resident #1 liked to bully other residents and would push them out of his way, while they were sitting in their wheelchairs. CNA C said she heard Resident #1 say to Resident #6, who was [AGE] years old in a wheelchair, I'm going to kick your ass and pushed her out of his way. CNA C said she reported this to a nurse but not the Administrator. CNA C said Resident #3 told her Resident #1 bullied Resident #3 and hit the back of her wheelchair and Resident #3 told CNA C to report this to the Administrator. CNA C said she reported it to a nurse but did not remember who the nurse was. CNA C said her last in-service on AN was a month ago and yesterday. CNA C said when the facility in-serviced her, they just handed her a piece of paper, asked her to sign it, and left without going over anything. CNA C said Residents #2 and #3 told her they did not feel safe around Resident #1. CNA C said Resident #1 could stand to his feet independently and showered himself. In an interview on 4-30-2026 at 5:50 PM, CNA D said one day staff from the north hallway, where Resident #1 resided, told staff from the south hallway to come assist them in the north hallway because Resident #1 was going off on Resident #2. CNA D said when she arrived on the north hallway, Resident #1 was saying to Resident #2 fuck you and verbally threatened to hurt Resident #2. CNA D said Resident #1 would go off on anyone. CNA D did not know if this was reported. CNA D said she received an in-service on AN last week, but the facility only had her sign a piece of paper and did not go over anything.Review of the facility's Abuse and Neglect Policy dated 3-29-2018 and titled Abuse/Neglect TG 03-1.0 stated: Abuse/Neglect The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.DefinitionsAbuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Adverse event. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof.3. Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability .Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that she will never be able to see her family again, etc. Abuse as defined in 40 TAC 19.101(1) .5. Physical Abuse: Includes, hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Abuse as defined in 40 TAC 19.101(1) . E. ReportingAny person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons.2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. 3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC . This was determined to be an Immediate Jeopardy (IJ) on 04-30-2026 at 2:54 PM. The Interim Administrator was notified. The Interim Administrator was provided with the IJ template on 04-30-2026 at 3:41 PM. The following Plan of Removal (POR) was accepted on 5-1-2026 at 11:59 AM. Date: 4/30/26 Plan of Removal Problem: F600 - Abuse Interventions: Resident #2, #3, #4 was interviewed by the LMSW. No further allegations of abuse were disclosed. Completed 4/30/26. Resident # 1 was placed on 1:1 supervision by the DON. 1:1 will continue until new treatment plan obtained by psych services has been evaluated and deemed effective. Staff performing 1:1 will redirect resident away from any residents if he becomes verbally aggressive. Resident # 1 will be kept physically separated from other resident by room or hall changes and/or alternate dining arrangements as needed. Staff assigned 1:1 will ensure that Resident #1 does not remain in the close proximity of other residents until no signs of verbal threats, intimidation, or aggressive behaviors are demonstrated. Resident #1 will remain on 1:1 until evaluated and cleared by the Psychiatric and/or Attending Physician. Completion 4/30/26. Resident #2, #3, #4 had a head-to-toe assessment completed by the charge nurse. No injuries or signs of abuse were noted. Completed 4/30/26. A Trauma informed care assessment was completed by the Regional Compliance Nurse on Resident #2, #3, #4 and documented in the chart. Telehealth visit or in person visit by psychological services will be completed for Resident #2, #3, #4 by 5/1/26. Completed 5/1/26. On 4/30/26, safe surveys were completed for all residents who are able to be interviewed by the DON/ Regional Compliance Nurse. No additional allegations of abuse from staff or residents were disclosed. Completed 4/30/26. On 4/30/26 staff interviews were conducted by the DON/ Regional Compliance Nurse. No additional allegations of abuse towards residents were disclosed. Completed 4/30/26 The Medical Director was notified of the immediate jeopardy by the DON/Regional Compliance Nurse on 4/30/26. An ADHOC QAPI meeting was completed with the DON, Regional Compliance Nurse, IDT Team and Medical Director to discuss the immediate jeopardy and plan of removal. Completed 4/30/26. The Administrator will be in serviced 1:1 for timely reporting and investigating any allegations on all reportable events. Review of all types of abuse with examples of each type of abuse. New process: the ADO will be notified of all abuse allegations and will report to HHS in a timely manner if Administrator is ill. The DON and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following policy. Completed 4/30/26. Abuse and Neglect Policy- reporting all allegations of abuse to the Administrator immediately. All alleged perpetrators will be suspended pending investigation. Allegations of abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. The alleged perpetrator will remain suspended until the investigation has been completed. Administrator and DON provided specific Inservice that they are responsible to answer and immediately begin investigation for any allegation of Abuse. Administrator and DON on types of abuse with examples. In-services: The following in-services were initiated by Regional Compliance Nurse, DON, and ADON for all staff. Any staff member not present or in-serviced as of 4/30/26 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Competency will be verified via post-test. Completion date 4/30/26. Abuse and Neglect Policy- reporting all allegations of abuse to the Administrator immediately. All alleged perpetrators will be suspended pending investigation. Allegations of abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. The alleged perpetrator will remain suspended until the investigation has been completed. Staff provided specific Inservices on immediately reporting any suspicion, allegation, or witnessed abuse or neglect to the facility administrator, if the administrator does not answer they are to call and report the allegation to the DON. Staff in serviced on types of abuse with examples Surveyor Monitoring: An interview with the DON on 5-1-2026 at 5:14 PM, revealed the facility did not have other residents like Resident #1 but did have some who had some aggression in the past. Shortly after this interview a list of other residents who sometimes had aggression was provided. On 5-1-2026 between 1:44 PM and 1:55 PM, interviews with three residents who were listed as having aggressive behaviors and observations of all those residents revealed no concerns about these residents having aggressive behaviors toward other residents. Between 12:00 PM and 6:40 PM on 5-1-2026, staff covering all shifts and departments were interviewed about types of abuse, identifying possible abuse (verbal and physical), trauma informed care, resident rights, verbal de-escalation, resident-to-resident altercations, and who to report abuse to. The following staff were interviewed, and all were found to be knowledgeable about the above procedures: RN A, Social Worker, DON, RN B, CNA C, CNA D, laundry staff, LVN E, Activity Director, Dietary Aide F, [NAME] G, [NAME] H, RN I, Rehabilitation Director, LVN J, RN K, CNA L, CNA M, CMA N, Acting Administrator, CNA O, Staffing Coordinator, Dietary Aide P, Director of Food & Nutrition, CNA Q, Rehabilitation Tech R, CNA S, CNA T, CMA U, Interim Administrator. In an interview on 5-1-2026 at 5:14 PM, the DON said an IJ was called because the facility did not have interventions in place to protect residents. The DON said staff were in-serviced on abuse, neglect, trauma informed care, resident rights, change of conditions, resident to resident altercations, one-on-one supervision, verbal de-escalation, and how to do it right. The DON said she was in charge for monitoring staff to ensure compliance. The DON said Resident #1 would be on 1:1 supervision until a psychiatrist clears him, the facility no longer feels he is a threat, or he is discharged . The DON said the facility will protect Resident #2 from experiencing trauma from her past by doing assessments if something were to occur, and refer her to psychological and/or social services. The DON said she was going to be the Abuse Coordinator until an Administrator returned to the facility. In an interview on 5-1-2026 at 5:20 PM, the Acting Administrator said the IJ was called because two residents were not getting along in the dining room and arguing. The Acting Administrator said staff were in-serviced on abuse, neglect, exploitation, reporting abuse/neglect timely, and who to report it to. The Acting Administrator said the Administrator (AIT) had been suspended. The Acting Administrator said she and the DON were responsible for ensuring staff were compliant with the POR. The Acting Administrator said Resident #1 would be on 1:1 supervision until the facility found a permanent solution and would ensure Resident #2 would not experience repeat trauma from the past by continuing to do safe surveys to make sure, she feels safe. The Acting Administrator said she would be the Abuse Coordinator until an Administrator returned to the facility and if she was unavailable, the DON would be the Abuse Coordinator. Record review of the facility's EMRs for seven residents (Residents #7, #8, #9, #10, #11, #12, #13) who had aggressive behaviors toward staff were reviewed and no concerns related to abuse of residents were found. Review of the Plan of Removal documentation reflected: 1. Resident #1 was placed on 1:1 supervision until a new treatment plan obtained by psych services can be approved or Resident #1 is discharged .2. Staff who are 1:1 supervision with Resident #1 will redirect Resident #1 away from any residents if he becomes verbally aggressive.3. Staff assigned 1:1 will ensure that Resident #1 does not remain in the close proximity of other residents until no signs of verbal threats, intimidation, or aggressive behaviors are demonstrated.4. Staff were in-serviced on what abuse of any kind is and what to do if they observe any.5. Staff were in-serviced on who to report any type of abuse to and if the Administrator is not available, report it to the DON. On 4-30-2026 at 2:54 PM, an Immediate Jeopardy was identified. While the IJ was removed on 5-1-2026, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, investigate allegations of abuse, and protected residents from physical and psychosocial harm during and after the investigation when residents were verbally and physically abused by Resident #1 for 2 (Residents #2, #3) of 13 reviewed for abuse. The facility failed to identify verbal abuse and intervene when Resident #1 threatened Residents #2 and #3, causing Resident #2 to avoid certain areas of the facility and causing Resident #3 to cry. Resident #1 continued to have access to verbally abuse other residents on multiple occasions.Staff witnessed physical pushing and threats but failed to report the abuse to the administrator. The Administrator and staff told vulnerable residents with histories of trauma to just avoid the aggressor, and did not complete an investigation. On 4-30-2026 at 2:54 PM, an Immediate Jeopardy was identified. While the IJ was removed on 5-1-2026, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.These failures resulted in the harm to Resident's #2 and #3 who reported fear and feeling unsafe and placed residents at risk of subsequent abuse, resulting in potential severe physical harm, pain, or mental anguish. Findings included: Record review of Resident #1's admission record, dated and reviewed on 4-29-2026, revealed a [AGE] year-old male, admitted [DATE] and readmitted [DATE]. Resident #1 had a primary diagnosis of transient cerebral ischemic attach (stroke) and secondary diagnoses of anxiety disorder (mental health condition categorized by excessive worry affecting quality of life), bipolar disorder (mental health condition characterized by significant mood swings), current episode manic severe with psychotic features (a distinct period of abnormally, persistently elevated, or irritable mood and extremely high energy, lasting at least one week like an unrealistic sense of superiority, power, decreased sleep, and racing thoughts with delusions or hallucinations), and intermittent explosive disorder (a mental health condition characterized by recurrent, impulsive, and disproportionate outbursts of rage or aggression).Record review of Resident #1's Quarterly MDS assessment, dated 3-24-2026, reviewed on 04-29-2026, revealed Resident #1 re-entered the facility from a short-term general hospital with a BIMS score of 14 indicating Resident#1 was cognitively intact. The GG, Functional section, revealed Resident#1 could independently move from a sitting position to a standing position and could independently transfer himself from a bed to a chair. The K-Swallowing/Nutritional Status Section, revealed Resident #1 was 6' 4 and weighed 230 pounds. Resident #1 used a wheelchair to ambulate.Record review of Resident #1's most recent care plan with an initial date of 8-25-2021 and a revision date of 9-4-2024, and reviewed on 04-29-2026, indicated Resident #1 had behavior problems of attention-seeking and accusatory behaviors, distorting the truth in attention seeking efforts and/or making false allegations, making negative statements about staff, proposing unrealistic demands, threatening staff with calling the state, inserted himself into staff/other residents' care/affairs causing outbursts, attention seeking behavior, making false allegations, he makes his peers feel uncomfortable or uneasy when around him, and had potential to demonstrate physical behaviors of anger, and poor impulse control.Review of Resident #1's Event Nurses Note dated 7-7-2024, reflected Resident #1 had a resident-to-resident incident yelling at his roommate. Review of Resident #1's Event Nurses Note dated 9-3-2024, reflected Resident #1 had a resident-to-resident incident verbally threatening another resident yelling for him to get out of his room. Staff explained the resident was his roommate. Review of Resident #1's Event Nurses Note dated 12-12-2025, reflected Resident #1 was combative, verbally and physically aggressive by standing up, swinging his hand toward a CNA attempting to hit the CNA. Resident #1 said I will take the shit out of you. Record review of Resident #1's progress notes reflected the following: 3-13-2026 at 8:50 PM - In the last week, the resident experienced verbal behaviors directed toward others 1-3 days . Verbally aggressive with other residents in the hallways. 3-18-2026 at 11:38 PM - In the last week, the resident experienced verbal behaviors directed toward others 1-3 days . 4-5-2026 at 9:58 PM - Resident #1 had a verbal confrontation with another resident witnessed by staff. He was resistant to resolution and intervention. When separated, he claimed the other resident pushed his wheelchair; none of the witnesses saw this happen. During an observation and interview on 4-29-2026 at 12:42 PM, Resident #2 was observed ambulating in a motorized wheelchair in the hallway outside her room. Resident #2 wanted to speak in private and said she did not feel safe around Resident #1. Resident #2 said Resident #1 threatened to have her beat up by his sister on 4-5-2026. Resident #2 then exhibited a video, from her phone, of Resident #1 ambulating in his wheelchair toward Resident #2 saying in a loud voice, I'm not afraid of your phone, I'm going to slap the dog shit out of Resident #2 and I'm going to knock the shit out of Resident #2. Resident #2 said Resident #1 started being aggressive toward her when she observed Resident #1 bullying a non-verbal resident sitting in his wheelchair. Resident #2 said she asked Resident #1 to leave the vulnerable non-verbal resident alone. That was when Resident #1 started to make verbal threats toward Resident #2. Resident #2 said she filed a grievance with the Social Worker on 4-27-2026. The Social Worker told Resident #2 she needed to speak with the Administrator and would get back with her after she spoke with him. Resident #2 said the Social Worker got back with her the same day and said the Administrator said to just avoid Resident #1. Resident #2 said she told the Social Worker she did not feel safe as the facility was not protecting her, she felt lied to by the facility, and wanted the State's phone number and the facility's corporate phone number.Record review of Resident #2's admission sheet, dated and reviewed on 04-29-2026, revealed Resident #2 was a [AGE] year-old female admitted [DATE] and readmitted [DATE]. Resident #2's primary diagnosis was anemia (condition characterized by a deficiency in health red blood cells, leading to insufficient oxygen delivery to the body's tissues) and secondary diagnoses of foot drop, right foot (the inability to lift the front part of the foot, causing it to drag or slap on the floor while walking), heart failure, major depressive disorder (serious mental condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), and generalized anxiety disorder.Review of Resident #2's Quarterly MDS dated [DATE], reflected a BIMS score of 15 being cognitively intact. The GG-Functional Abilities revealed Resident #2 used a motorized wheelchair to ambulate. Record review of Resident #2's Care Plan, dated 10-17-2025, revealed she had a history of trauma that may have a negative impact. The trauma is r/t: history of life-threatening illness, physical assault [Family Member], physically threatened and sexually assault. Resident #2 was care planned to have a potential for uncontrolled pain due to Fibromyalgia (chronic condition characterized by widespread pain, fatigue, and other symptoms), chronic right arms pain, left leg pain. back pain and neuropathy (nerve damage outside the brain and spinal cord).Record review of the facility's grievance log, reflected Resident #2 filed a grievance on 4-27-2026 stating she wanted Resident #1 to be discharged because Resident #1 was making her stressed and threatened. Resident #2 said on 4-25-2026 Resident #1 held his fist up to her and threatened to physically harm her. Resident #2 said Resident #1 has acted aggressively toward he multiple times. The summary of the pertinent findings by the facility stated Resident #2 did record the interaction. In one of the videos, Resident #1 is clearly heard threatening to slap the shit of Resident #2. The corrective action the facility stated it took was to tell both residents to stay away from each other and educate staff to separate them in case of confrontation. Record review of Resident #2's progress note, dated 4-28-2026 at 12:00 PM, revealed the Social Worker stated she followed up with Resident #2's grievance stating regarding the resolution to her grievance. Resident #2 said it was not satisfactory and that avoiding Resident #1 was not possible. She said he threatened her again last night but would not elaborate further. She stated she feels the facility has lied to her and requested contact information for the State and Corporate. In an interview on 4-29-2026 at 12:50 PM, Resident #5 said she was not comfortable around Resident #1 when he comes to the doorway of her room saying he was going to get the facility shutdown. Resident #5 said she was bedbound. In an interview on 4-29-2026 at 3:57 PM, Resident #3 said she was afraid of Resident #1, because he has verbally threatened to hit her and has been verbally abusive with his words. Resident #3 said the facility has known about Resident #1's conduct but has not done anything about it. Review of Resident #3's admission record dated 4-30-2026, reflected a [AGE] year-old female with an original admission date of 11-4-2020 and a re-admission date of 2-27-2023. Resident #3's primary diagnosis was chronic obstructive pulmonary disease(lung disease causing chronic coughing, wheezing, and severe breathlessness due to damaged airways, primarily caused by smoking, air pollution, or genetic factors), and secondary diagnoses of generalized anxiety disorder, glaucoma (a group of eye diseases that damage the optic nerve, often due to high eye pressure, leading to permanent, irreversible vision loss or blindness), and unsteadiness on her feet. Review of Resident #3's Quarterly MDS dated [DATE], revealed she had a BIMS score of 15 indicating being cognitively intact. The GG-Functional Abilities section revealed Resident #3 used a wheelchair to ambulate. The J-Health Conditions of Resident #3 revealed she frequent pain. Review of Resident #3's care plan dated 6-6-2023, revealed she was care planned for trauma informed care stating she had been in a major natural disaster or technological disaster such as fire, tornado, hurricane, flood, earthquake, or chemical spill. In an observation and interview on 4-30-2026 at 2:00 PM, Resident #3 said last night when she was getting her medication by the nurse's station, Resident #1 came up behind her in his wheelchair, grabbed her arm, and cursed at her demanding she get out of his way. Resident #3 was observed to start crying at this point. Resident #3 said she then slapped Resident #1 to let her go. Record review of Resident #3's progress notes, dated 4-30-2026 at 11:06 AM, revealed Resident #3 told the Dietary Manager that [Resident #1] approached [Resident #3] from behind, yelled and used profanity toward [Resident #3], grabbed [Resident #3's forearm, and pushed [Resident #3] while she was in her wheelchair. In an interview on 4-30-2026 at 11:10 AM, the SW said Resident #2 did not feel safe around Resident #1. The SW said she did speak with the Administrator regarding Resident #2's grievance and the Administrator said because this was the first grievance Resident #2 had filed concerning Resident #1's behavior, he did not want to discharge anyone. The SW said the Administrator said for Resident #2 to just avoid Resident #1. The SW said the facility keeps residents safe from Resident #1 by redirecting him. In an interview and record review on 4-30-2026 at 11:30 AM, the Administrator said he was an AIT and had worked at the facility since 11-18-2025. The Administrator said he told Resident #2 to just avoid Resident #1 and staff were informed to keep them apart. The Administrator said verbal abuse was to the best of my understanding would be using defamatory words, racial slurs. The Administrator named different types of abuse as being verbal, emotional, financial, mental, and physical. The Administrator said a self-report was not filed by the facility regarding Resident #2's grievance because he was in and out of the office. The Administrator said, I should have filed a self-report, that was my fault. When asked, if he thought the grievance Resident #2 filed regarding Resident #1's threatening her was abuse, the Administrator said, I don't know. When the video and audio recording of Resident #1 threatening to do bodily harm to Resident #2, dated 4-25-2026, was shown to the Administrator, he said, That was abuse. The Administrator said he saw another video today of Resident #1 verbally abusing Resident #2 where former DON (RN B) was trying to redirect Resident #1. The Administrator said RN B did not report this incident to him. The Administrator said in his absence, the DON became the abuse coordinator, and it was elevated to the Area Director of Operations. The Administrator said the facility had not discharged Resident #1 because, Resident #1 had not crossed the line yet that would fulfill the requirement to justify an immediate discharge as he would have to physically assault someone to justify an immediate discharge, in my opinion. The Administrator said the facility did not follow its own Abuse and Neglect Policy because in this particular situation, the SW did not want to add onto his health issues he had been dealing with. The Administrator said the facility protected other residents from Resident #1 by filing self-reports, and I just don't have a lot of answers right now. The Administrator said Resident #1 had never tried to hit anyone. However, the Administrator was shown an event nurse note from the facility's EMR, revealing on 12-12-2025 at 4:02 PM, Resident #1 attempted to hit a CNA by swinging his hand at the CNA, but missed hitting the CNA. The Administrator said he was shocked to learn that. The event note stated, the DON and Administrator were notified of the incident.On 4-30-2026 at 3:20 PM, the DON said she had worked at the facility for 3 weeks. The DON said she had never heard from staff that Resident #1 had been verbally threatening to residents. The DON said she knew that Resident #1 talked loudly because he was hard of hearing. The DON said if she had known one resident was being verbally aggressive to another one by saying he wanted to hit another resident, she would have put that resident on a one-to-one supervision, notify the Administrator, doctor, and family. Record review and observation of Resident #2's cell phone audio/video recording taken on 4-25-2026, revealed Resident #1 threatened Resident #2 by saying, I'm going to slap the dog shit out of her and I'm going to knock the shit out of you. During the recording, part of a staff member's body was visible beside Resident #2 when Resident #1 said to the staff member [RN B] do something with her. [RN B] was later revealed to be RN B. A copy of this audio/video recording was obtained.In an interview on 4-30-2026 at 5:26 PM, CNA C said she had worked at the facility for 19 years and was familiar with Resident #1's behaviors. CNA C said Resident #1 liked to bully other residents and will push them out of his way, while sitting in their wheelchairs. CNA C said she has heard Resident #1 say to Resident #6, who was [AGE] years old in a wheelchair, I:m going to kick your ass and pushed her out of his way. CNA C said she reported this to a nurse but not the Administrator. CNA C said Resident #3 told her Resident #1 bullied Resident #3 and hit the back of her wheelchair and told her she needed to report this to the Administrator. CNA C said she reported it to a nurse but did not remember who the nurse was. CNA C said her last in-service on AN was a month ago and yesterday. CNA C said when the facility had in-serviced her, they just handed her a piece of paper, asked her to sign it, and left without going over anything. CNA C said Residents #2 and #3 told her they did not feel safe around Resident #1. CNA C said Resident #1 can stand to his feet independently and showered himself. In an interview on 4-30-2026 at 5:50 PM, CNA D said one day staff from the north hallway, where Resident #1 resided, told staff from the south hallway to come assist them in the north hallway because Resident #1 was going off on Resident #2. CNA D said when he arrived on the north hallway, Resident #1 was saying to Resident #2 fuck you and verbally threatened to hurt Resident #2. CNA D said Resident #1 will go off on anyone. CNA D did not know if this was reported. CNA D said she received an in-service on AN last week, but the facility only had her sign a piece of paper and did not go over anything.Review of the facility's Abuse and Neglect Policy dated 3-29-2018 and titled Abuse/Neglect TG 03-1.0 stated: Abuse/Neglect The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.DefinitionsAbuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Adverse event. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof.3. Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability .Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that she will never be able to see her family again, etc. Abuse as defined in 40 TAC 19.101(1) .5. Physical Abuse: Includes, hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Abuse as defined in 40 TAC 19.101(1) . E. ReportingAny person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons.2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. 3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC . This was determined to be an Immediate Jeopardy (IJ) on 04-30-2026 at 2:54 PM. The Interim Administrator was notified. The Interim Administrator was provided with the IJ template on 04-30-2026 at 3:41 PM. The following Plan of Removal (POR) was accepted on 5-1-2026 at 11:59 AM. Facility: [Facility Name] Date: 4/30/26 Plan of Removal Problem: F607 - Development/Implement Abuse/Neglect Polic/Procedures Interventions: Resident #2, #3, #4 was interviewed by the LMSW. No further allegations of abuse were disclosed. Completed 4/30/26. Resident # 1 was placed on 1:1 supervision by the DON. 1:1 will continue until new treatment plan obtained by psych services has been evaluated and deemed effective. Staff performing 1:1 will redirect resident away from any residents if he becomes verbally aggressive. Resident # 1 will be kept physically separated from other resident by room or hall changes and/or alternate dining arrangements as needed. Staff assigned 1:1 will ensure that resident #1 does not remain in the close proximity of other residents until no signs of verbal threats, intimidation, or aggressive behaviors are demonstrated. Resident #1 will remain on 1:1 until evaluated and cleared by the Psychiatric and/or Attending Physician. Completion 4/30/26. Resident #2, #3, #4 had a head-to-toe assessment completed by the charge nurse. No injuries or signs of abuse were noted. Completed 4/30/26. A Trauma informed care assessment was completed by Regional Compliance Nurse on resident #2, #3, #4 and documented in the chart. Telehealth visit or in person visit by psychological services will be completed for resident #2, #3, #4 by 5/1/26. Completed 5/1/26. On 4/30/26, safe surveys were completed for all residents who are able to be interviewed by the DON/ Regional Compliance Nurse. No additional allegations of abuse from staff or residents were disclosed. Completed 4/30/26. On 4/30/26 staff interviews were conducted by the DON/ Regional Compliance Nurse. No additional allegations of abuse towards residents were disclosed. Completed 4/30/26 The medical director was notified of the immediate jeopardy by the DON/Regional Compliance Nurse on 4/30/26. An ADHOC QAPI meeting was completed with the DON, Regional Compliance Nurse, IDT Team and Medical Director to discuss the immediate jeopardy and plan of removal. Completed 4/30/26. The Administrator will be in serviced 1:1 for timely reporting and investigating any allegations on all reportable events. Review of all types of abuse with examples of each type of abuse. New process: the ADO will be notified of all abuse allegations and will report to HHS in a timely manner if Administrator is ill. The DON and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following policy. Completed 4/30/26. Abuse and Neglect Policy- reporting all allegations of abuse to the Administrator immediately. All alleged perpetrators will be suspended pending investigation. Allegations of abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. The alleged perpetrator will remain suspended until the investigation has been completed. Administrator and DON provided specific Inservice that they are responsible to answer and immediately begin investigation for any allegation of Abuse. Administrator and DON on types of abuse with examples. In-services: The following in-services were initiated by Regional Compliance Nurse, DON, and ADON for all staff. Any staff member not present or in-serviced as of 4/30/26 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Competency will be verified via post-test. Completion date 4/30/26. Abuse and Neglect Policy- reporting all allegations of abuse to the Administrator immediately. All alleged perpetrators will be suspended pending investigation. Allegations of abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. The alleged perpetrator will remain suspended until the investigation has been completed. Staff provided specific In-services on immediately reporting any suspicion, allegation, or witnessed abuse or neglect to the facility administrator, if the administrator does not answer they are to call and report the allegation to the DON. Staff in serviced on types of abuse with examples. Surveyor Monitoring: An interview with the DON on 5-1-2026 at 5:14 PM, revealed the facility did not have other residents like Resident #1 but did have some who had some aggression in the past. Shortly after this interview a list of other residents who sometimes had aggression was provided. On 5-1-2026 between 1:44 PM and 1:55 PM, interviews with three residents who were listed as having aggressive behaviors and observations of all those residents revealed no concerns about these residents having aggressive behaviors toward other residents. Between 12:00 PM and 6:40 PM on 5-1-2026, staff covering all shifts and departments were interviewed about types of abuse, identifying possible abuse (verbal and physical), trauma informed care, resident rights, verbal de-escalation, resident-to-resident altercations, and who to report abuse to. The following staff were interviewed, and all were found to be knowledgeable about the above procedures: RN A, Social Worker, DON, RN B, CNA C, CNA D, laundry staff, LVN E, Activity Director, Dietary Aide F, [NAME] G, [NAME] H, RN I, Rehabilitation Director, LVN J, RN K, CNA L, CNA M, CMA N, Acting Administrator, CNA O, Staffing Coordinator, Dietary Aide P, Director of Food & Nutrition, CNA Q, Rehabilitation Tech R, CNA S, CNA T, CMA U, Interim Administrator. In an interview on 5-1-2026 at 5:14 PM, the DON said an IJ was called because the facility did not have interventions in place to protect residents. The DON said staff were in-serviced on abuse, neglect, trauma informed care, resident rights, change of conditions, resident to resident altercations, one-on-one supervision, verbal de-escalation, and how to do it right. The DON said she was in charge for monitoring staff to ensure compliance. The DON said Resident #1 would be on 1:1 supervision until a psychiatrist clears him, the facility no longer feels he is a threat, or he is discharged . The DON said the facility will protect Resident #2 from experiencing trauma from her past by doing assessments if something were to occur, refer to psychological and/or social services. The DON said she was going to be the Abuse Coordinator until an Administrator returned to the facility. In an interview on 5-1-2026 at 5:20 PM, the Acting Administrator said the IJ was called because two residents were not getting along in the dining room and arguing. The Acting Administrator said staff were in-serviced on abuse, neglect, exploitation, reporting abuse/neglect timely, and who to report it to. The Acting Administrator said the Administrator (AIT) had been suspended. The Acting Administrator said she and the DON were responsible for ensuring staff were compliant with the POR. The Acting Administrator said Resident #1 would be on 1:1 supervision until the facility found a permanent solution and would ensure Resident #2 would not experience repeat trauma from the past by continuing to do safe surveys to make sure, she feels safe. The Acting Administrator said she would be the Abuse Coordinator until an Administrator returned to the facility and if she was unavailable, the DON would be the Abuse Coordinator. Review of the facility's EMRs for seven residents (Residents #7, #8, #9, #10, #11, #12, #13) who had aggressive behaviors toward staff were reviewed and no concerns related to abuse of residents were found. Review of the Plan of Removal documentation reflected: 1. Resident #1 was placed on 1:1 supervision until a new treatment plan obtained by psych services can be approved or Resident #1 is discharged .2. Staff who are 1:1 supervision with Resident #1 will redirect Resident #1 away from any residents if he becomes verbally aggressive.3. Staff assigned 1:1 will ensure that Resident #1 does not remain in the close proximity of other residents until no signs of verbal threats, intimidation, or aggressive behaviors are demonstrated.4. Staff were in-serviced on what abuse of any kind is and what to do if they observe any.5. Staff were in-serviced on who to report any type of abuse to and if the Administrator is not available, report it to the DON. On 4-30-2026 at 2:54 PM, an Immediate Jeopardy was identified. While the IJ was removed on 5-1-2026, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for 2 (Residents #2, #3) of 13 reviewed for abuse and neglect. The facility failed to report to the Texas Health and Human Services Commission (THHSC) alleged abuse that occurred when Resident #1 verbally threatened to cause physical harm to Resident #2 on 4-05-2026 and 4-25-2026, and verbally and physically abused Resident #3 on 4-29-2026. These failures could place residents at risk of abuse, neglect, pain, psychosocial harm, and a diminished quality of life. Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for 2 (Residents #2, #3) of 13 reviewed for abuse and neglect. The facility failed to report to the Texas Health and Human Services Commission (THHSC) alleged abuse that occurred when Resident #1 verbally threatened to cause physical harm to Resident #2 on 4-05-2026 and 4-25-2026, and verbally and physically abused Resident #3 on 4-29-2026. These failures could place residents at risk of abuse, neglect, pain, psychosocial harm, and a diminished quality of life. Findings included: Record review of Resident #1's Face Sheet, dated 4-29-2026, revealed a [AGE] year-old male with an original admission date of 8-4-2021 and most recent admission date of 11-17-2025. Resident #1 had a primary diagnosis transient cerebral ischemic attach (stroke) and secondary diagnoses of anxiety disorder, bipolar disorder, current episode manic severe with psychotic features (a distinct period of abnormally, persistently elevated, or irritable mood and extremely high energy, lasting at least one week like an unrealistic sense of superiority, power, decreased sleep, and racing thoughts with delusions or hallucinations), and intermittent explosive disorder (a mental health condition characterized by recurrent, impulsive, and disproportionate outbursts of rage or aggression). Record review of Resident #1's Quarterly MDS dated [DATE], revealed Resident #1 re-entered the facility from a short-term general hospital with a BIMS score of 14 indicating Resident#1 was cognitively intact. The GG-Functional section revealed Resident#1 could independently move from a sitting position to a standing position and could independently transfer himself from a bed to a chair. The K-Swallowing/Nutritional Status Section revealed Resident #1 was 6' 4 and weighed 230 pounds. Resident #1 used a wheelchair to ambulate. Review of Resident #1's most recent care plan with an initial date of 8-25-2021 and a revision date of 9-4-2024, indicated Resident #1 had behavior problems of attention-seeking and accusatory behaviors, distorting the truth in attention seeking efforts and/or making false allegations, making negative statements about staff, proposing unrealistic demands, threatening staff with calling the state, inserted himself into staff/other residents' care/affairs causing outbursts, attention seeking behavior, making false allegations, he makes his peers feel uncomfortable or uneasy when around him, and had potential to demonstrate physical behaviors of anger, and poor impulse control. Record review of Resident #1's progress note dated 4-5-2026 at 9:58 PM, reflected Resident #1 had a verbal confrontation with another resident witnessed by staff. He was resistant to resolution and intervention. When separated, he claimed the other resident pushed his wheelchair; none of the witnesses saw this happen. In an observation and interview on 4-29-2026 at 12:42 PM, Resident #2 said Resident #1 had threatened to have her beat up by his sister on 4-5-2026. Resident #2 said Resident #1 had threatened to harm her physically on 4-25-2026 then exhibited a video/audio recording, from her cell phone, revealing Resident #1 had threatened her by saying I'm not afraid of your phone, I'm going to slap the dog shit out of Resident #2 and I'm going to knock the shit out of Resident #2. In the video, a staff member was seen next to Resident #2 as threats were being made. Resident #1 referred to this staff member as RN B in the video. In an interview on 4-30-2026 at 3:30 PM, RN B admitted she was recently present one night when Resident #1 got irritated toward Resident #2, in the hallway, but denied she heard Resident #1 threaten Resident #2. In an interview on 5-1-2026 at 5:14 PM, the DON was shown the video/audio recording from Resident #2's cell phone revealing that Resident #1 threatened Resident #2. In the recording, the DON heard Resident #1 speak to the staff member, who was present in the video, and referred to the staff member as Ty. The DON then identified the staff member as RN B. Record review of the facility's grievance log revealed Resident #2 filed a grievance on 4-27-2026, stating Resident #2 wanted Resident #1 discharged as Resident #1 makes Resident #2 feel stressed and threatened. On Saturday, 4-25-2026, Resident #2 said Resident #1 held his fist toward her and threatened to physically harm her and/or his family come to the facility to harm Resident #2. Resident #2 said he had done this multiple times in the past. Resident #2 said on 4-25-2026 when Resident #1 threatened her, RN B was present and witnessed the incident. The grievance stated it was forwarded to the Administrator. Record review of Resident #3's admission record dated 4-30-2026, reflected a [AGE] year-old female with an original admission date of 11-4-2020 and a re-admission date of 2-27-2023. Resident #3's primary diagnosis was chronic obstructive pulmonary disease(lung disease causing chronic coughing, wheezing, and severe breathlessness due to damaged airways, primarily caused by smoking, air pollution, or genetic factors), and secondary diagnoses of generalized anxiety disorder, glaucoma (a group of eye diseases that damage the optic nerve, often due to high eye pressure, leading to permanent, irreversible vision loss or blindness), and unsteadiness on her feet. Record review of Resident #3's Quarterly MDS assessment, dated 3-9-2026, revealed she had a BIMS score of 15 indicating being cognitively intact. The GG-Functional Abilities section revealed Resident #3 used a wheelchair to ambulate. The J-Health Conditions of Resident #3 revealed she had frequent pain. Review of Resident #3's care plan dated 6-6-2023, revealed she was care planned for trauma informed care stating she had been in a major natural disaster or technological disaster such as fire, tornado, hurricane, flood, earthquake, or chemical spill. The care plan stated the facility would meet the needs of Resident #3 to prevent recurrence of trauma through the next review by meeting the emotional needs, providing psych services, and communicate all aspects of care being provided and allow Resident #3 to give feedback. In an interview on 4-29-2026 at 3:57 PM, revealed Resident #3 had been verbally abused and threatened with physical harm by Resident #1. Resident #3 said the facility knew about these incidents but had not done anything about them. Resident #3 could not name specific times or dates. In an interview on 4-30-2026 at 2:00 PM, Resident #3 said last night, when she was getting her medication by the nurse's station, Resident #1 came up behind her in his wheelchair, grabbed her arm, and cursed her demanding she get out of his way. Resident #3 said she then slapped Resident #1 to let her go. Record review of Resident #3's progress notes dated 4-30-2026 at 11:06 AM, revealed Resident #3 told the Dietary Manager that on 4-29-2026, while at a nurse's station, Resident #1 grabbed her arm cussing and screaming, and pushed her wheelchair. The note also stated Resident #2 grabbed Resident #1's arm and pushed his hand away. In an interview 4-30-2026 at 11:30 AM, the AIT said he reviewed the grievance filed by Resident #2 regarding Resident #1 threatening her. The AIT said he told Resident #2 to just avoid Resident #1 but did not report it to the THHSC. The AIT said he was not aware of Resident #3 alleging she was abused by Resident #1. The AIT said he should have filed a self-report with THHSC regarding Resident #2's grievance of abuse. The AIT said he had been in and out of the office with health issues as his blood pressure medication had doubled and got on anxiety medication yesterday. The AIT said in his absence, the DON would take his place, and incidents would be elevated to the Acting Administrator, which was his boss. After this interview, the surveyor was informed that the AIT had left the facility and never returned for the rest of the survey. In an interview on 4-30-2026 at 3:20 PM, the DON said she had worked at the facility for 3 weeks and had not heard complaints from staff members that Resident #1 had verbally threatened anyone. In an interview on 5-1-2026 at 5:14 PM, the DON stated the facility failed in reporting alleged abuse because of a lack of training or a bad judgment call. The DON said the risk to residents if the facility did not report alleged abuse was abuse could continue and next time a resident be hit. The DON expected the facility to report alleged abuse according to the rules. In an interview on 5-1-2026 at 5:20 PM, the Acting Administrator said there was a failure of the facility to report alleged abuse timely either because there was a lack of training or bad judgment. The Acting Administrator said the risk to residents for the facility not reporting alleged abuse was it could lead to any type of abuse or neglect. The Acting Administrator said it was her expectation that alleged abuse be reported timely. Review of the facility's Abuse and Neglect Policy dated 3-29-2018 and titled Abuse/Neglect TG 03-1.0 stated: Abuse/Neglect The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.DefinitionsAbuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Adverse event. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof.3. Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability .Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that she will never be able to see her family again, etc. Abuse as defined in 40 TAC 19.101(1) .5. Physical Abuse: Includes, hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Abuse as defined in 40 TAC 19.101(1) . E. ReportingAny person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons.2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. 3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC . Review of (THHSC) Long Term Provider Letter #PL 2024-14 (Replaces PL 2019-17), titled Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC), Provider Type: Nursing Facilities (NF), dated August 29, 2024, stated: A NF must report to CII (Complaint and Incident Intake) the following types of incidents, in accordance with applicable state and federal requirements: Abuse, Neglect . Immediately, but not later than two hours after the incident occurs or is suspected . Review of TULIP (Texas Unified Licensure Information Portal) revealed no reports being filed from the facility for allegations of abuse or neglect concerning Residents#1, #2 or #3 for abuse occurring on 4-5-2026, 4-25-2026, or 4-29-2026, as of 4-30-2026.

Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for one of five residents (Resident #5) reviewed for medication administration. Medication Aide administered (2) Melatonin 5 mg tablets (a supplement used to treat insomnia) to Residents #5 instead of (1) 5 mg tablet as ordered by the physician. This failure could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications. Findings include: Record review of Resident #5's quarterly MDS assessment, dated 03/09/26, revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. The assessment reflected Resident #5 had no cognitive impairment with a BIMS score of 15. The resident had diagnoses which included Non-Alzheimer's dementia (neurogenerative condition distinct from Alzheimer's with primary symptoms in behavior, language, movement, or visual-spatial skills rather than early memory loss), depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life), bipolar disorder (mental illness that causes clear shifts in a person's mood, energy, activity levels, and concentration), schizophrenia (mental disorder characterized by disruption in thought processes and social interactions with symptoms that include hallucinations, delusions, and thought disorder), and chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs which results in swelling and irritation). The MDS also reflected that Resident #5 occasionally had pain that made it hard to sleep. Record Review of Resident #5's Care Plan, dated 02/21/26, reflected:Focus: Resident #5 has Insomnia - Date initiated 05/20/24Goals: Resident #5 will have no interruption in sleep through next review - Date initiated 10/18/2024; Revision Date 02/21/26; Target Date 05/06/26Intervention:Dietary Consult as orderedMonitor/document/report to MD PRN the following s/sx: Edema; weight gain of over 2 lbs a day; neck vein distension; difficulty breathing (Dyspnea); increased heart rate (Tachycardia); elevated blood pressure (Hypertension); skin temperature; peripheral pulses; level of consciousness; Monitor breath sounds for crackles.Obtain lab as ordered; notify MD of reports. Record Review of Medication Regimen Review by the Pharmacist, dated 03/05/26, reflected reduce 5 mg po at hs. The facility Medical Director designated that she agreed with this recommendation on 04/02/26 and signed the recommendation. Record review of Resident #5's April 2026 Physician's Orders reflected Melatonin Oral Tablet 10 mg (Melatonin) Give 5 mg by mouth one time a day related to Insomnia. Record review of Resident #5's MAR reflected that the Medication Aide gave Resident #5 (2) Melatonin 5 mg tablets on 04/02/26-04/03/26, 04/06/26-04/10/26, and 04/13/26-04/14/26, instead of (1) Melatonin 5 mg tablet. Interview with the Medication Aide on 04/15/26 at 4:07 PM revealed that she was the evening Monday through Friday Medication Aide for Resident #5 and had been employed at the facility for seven months. The Medication Aide stated that she gave Resident #5 two 5 mg Melatonin tablets. She stated that the order reflected 10 mg and had always been 10 mg. However, she did not question it because it did not change though the tablet changed. The Medication Aide revealed that she was trained to follow the MAR. The Medication Aide stated that she used simple math and gave Resident #5 (2) 5 mg tablets to equal the 10 mg order on the MAR. The Medication Aide stated that if she saw something that looked incorrect, she would ask her nurse, and she was unaware that a gradual dose reduction was attempted on Resident #5. The Medication Aide revealed that it was her responsibility to ensure the resident received the correct medication at the right dose at the right time. The Medication Aide stated that if the resident did not receive the correct dosage of Melatonin, the resident would not sleep and complain about not sleeping. Interview with RN B on 04/15/2026 at 4:31 PM revealed she had been employed for about one month and was not aware a new order was received for Resident #5's Melatonin because the Medical Director and pharmacist recommended a Gradual Dose Reduction for it. RN B stated that she works the 6 AM - 6 PM shift and had not reviewed the night shift medication order. RN B stated that if she saw the order, she would have called the doctor to get a clarification order. RN B stated that Resident #5 could be experiencing negative side effects of Melatonin if she was receiving too strong a dosage. RN B revealed that it was the nurse's responsibility to input the correct order from the physician. RN B stated that Melatonin is a natural sleep medication with signs/symptoms of too high a dosage being fatigue and agitation. RN B stated that she had not seen Resident #5 sleepy or overmedicated. Interview with ADON C on 04/15/2026 at 4:49 PM revealed that she had been employed at the facility for about 5 months and was normally the nursing staff responsible for reviewing the pharmacy recommendations. ADON C stated the Regional Compliance Nurse input the new order into the EHR. ADON C said the incorrect order entry into the EHR caused the Medication Aide to dispense the wrong medication dosage. ADON C stated it was her responsibility to input the correct orders for the Gradual Dosage Reductions into the EHR. ADON C revealed the resident could be over medicated with Melatonin leading to increased falls. ADON C stated that she had not seen Resident #5 fatigued or sleepy. ADON C stated that the residents' doctors were responsible for explaining Gradual Dose Reductions to their residents. ADON C stated that this was a medication error, and the family, DON, and Medical Director would be notified. Interview on 04/15/2026 at 5:07 PM revealed that the Regional Compliance Nurse entered the pharmacy recommendation order into the Resident #5's EHR. The Regional Compliance Nurse stated she decreased the order but did not change the Melatonin 10 mg tablet to a 5 mg tablet. The Regional Compliance Nurse stated she assisted ADON C enter the pharmacy recommendations. The Regional Compliance Nurse revealed that Resident #5 was at risk for continuing to receive a higher dose of Melatonin than recommended. The Regional Compliance Nurse stated that the Gradual Dose Reduction would be effective 04/15/26 when she received her dosage that night. And the nursing staff would report the medication error to the family and the physician. The Regional Compliance Nurse revealed that the nursing department was responsible for ensuring that Gradual Dose Reductions were completed correctly. Interview on 04/15/2026 at 5:13 PM revealed that the DON's first day of employment at the facility was on 04/07/2026. The DON stated she would review the pharmacy recommendations in the future to ensure they are entered correctly into residents' EHR. The DON also stated that she would in-service the nursing staff on following orders and verifying orders and obtaining clarification orders when necessary. Because she was new to the position of DON, she did not know the last date the nursing staff were in-serviced on following orders and verifying orders. Interview on 04/16/2026 at 3:03 PM with the Medical Director revealed she agreed with the pharmacist to attempt a Gradual Dose Reduction for Melatonin from 10 mg hs to 5 mg hs. The Medical Director stated that she did not believe that there was any negative effect on the resident since she was already on 10 mg. The Medical Director stated that the facility would now attempt the 5 mg Gradual Dose Reduction. The Medical Director stated that it was best to reduce polypharmacy when possible. The Medical Director stated that polypharmacy could increase falls, so they would again attempt to decrease the Melatonin to 5 mg. Interview with Resident #5 on 04/17/2026 at 9:33 AM revealed that she slept well the previous night. Resident #5 stated she had not noticed being groggy in the daytime and did not ask to have her medication changed. Resident #5 stated that the Medical Director had not spoken with her about a Melatonin Gradual Dose Reduction. Record Review of Medication Administration and General Guidelines policy, dated March 2025, reflected: ProcedureMedications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or personnel authorized by state laws and regulations to administer medications.Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the physician is contacted for clarification prior to the administration of the medication. The interaction with the physician is documented in the nursing notes and elsewhere in the medical record as appropriate. 6. All current medications and dosage schedules, .are listed on the resident's medication administration record (MAR).

Based on observation, interview, and record review, the facility failed ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 9 insulin pens with correct open dates. The facility also failed to keep 2 of 5 medication carts locked, in accordance with currently accepted professional principles.Insulin pens in south hall nurse cart and north hall nurse cart were labeled incorrectly.Medication cart on south hall was left unlocked and unattended.Treatment cart on north hall was left unlocked and unattended.These failures could result in adverse reactions to residents, injuries, medication errors.Findings included:In an observation on [DATE] at 9:01 AM, south hall nurses' medication cart was left unlocked. RN A was sitting behind the nurses' station. Medication cart included 4 insulin pens. There was a Novolin R insulin pen for Resident #30 which was labeled [DATE] under exp date line.In an interview on [DATE] at 9:05 AM, RN A stated the date [DATE] was supposed to be an open date of the pen. She stated she did not know why the date was written under expiration date line on the pen. She stated the risk of giving residents potentially expired insulin included ineffectiveness of medication. She stated an opened insulin pen would expire in 28 days after. She also stated medication cart should always be kept locked to prevent unauthorized access. She stated she forgot to lock her medication cart. In an observation of north hall nurses' medication cart on [DATE] at 9:15 AM, five insulin pens were inside the cart. Resident #44's insulin pen was labeled [DATE] on the line that said exp date. In an interview with ADON C on [DATE] at 9:15 AM, she stated nurses should not label insulin pens open date under the line of expiration date. She stated it could cause confusion on when the actual open date was. She stated all nurses should label insulin pens where it said open on date or put an open date on a different spot, but not on the line of expiration date. She stated insulin pens expired after 28 days of opening. In an observation on [DATE] 1:35 PM, nurses' cart in south hall was left unlocked. There was no one at nurses' station. There were no residents around the area at the time. In an interview on [DATE] 1:40 PM, the DON stated all carts should be kept locked always when not in use because residents could get into the cart and get medication out. She stated it's a safety risk. She stated only authorized persons could access the carts. She stated she expected all her staff to be vigilant and practiced locking all carts when they were not in use.In an observation on [DATE] at 8:15 AM, treatment cart was unlocked and unattended. Treatment cart was placed across north hall nurses' station. There were no nurses at the nurses' station at the time of observation. Inside of treatment cart included wound care dressings, wound cleanser, cream, and scissors. In an observation on [DATE] at 8:54 AM, treatment cart was still unlocked and unattended.In an interview on [DATE] 10:16 AM, ADON D stated all carts should stay locked at all times regardless if there were people around the cart or not. She stated for treatment cart, there were biologicals & sharp objects which could put residents at risk for injuries if residents get ahold of those objects. She was not sure who had the treatment cart today because all nurses shared the treatment cart. She stated the treatment cart should not have stayed unlocked when not in use.Record review of facililty's Medication labels:, dated in 2025, revealed the policy stated each prescription medication label includes:. date medication is dispensed, [and] expiration date.Record review of the facility's Medication storage in the facility, dated in 2025, revealed the policy stated that medications and biologicals are stored safely, securely. The medication supply is accessible only to license nursing personnel. or staff members lawfully authorized to administer medications.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure that food stored in the freezer was labeled and dated. 2. The facility failed to remove the food thermometer prior to food service. These failures had the potential to affect residents by placing them at risk for cross-contamination and food borne illnesses. Findings included:Observation on 04/14/2026 at 9:22 A.M. revealed during the initial tour the following items were found in the reach in freezer not labeled or dated: - two bags of frozen pancakes removed from original boxes and placed in plastic freezer bags- two bags of chicken nuggets removed from the original boxes not labeled or dated - one bag of hushpuppies not labeled or dated.Observation on 04/15/2026 at 11:10 A.M. revealed initial service line temperature for puree Broccoli was 137 degrees. This item was removed from service line, placed in facility oven for additional warming. Item was removed from the oven placed back on service line and re-temped at reheated 163 degrees. [NAME] C did not remove the thermometer. Observation on 04/15/2026 at 11:28 A.M. revealed lunch service started. The food thermometer was still laying in the pureed broccoli. Observation on 04/15/2026 at 11:42 A.M. revealed [NAME] C removed the food thermometer from pureed broccoli. Interview on 04/16/2026 at 2:04 A.M. with Dietary Manager revealed the risk of not removing the food thermometer from the food item could cause it to explode in the food. All food should be labeled and dated to ensure food was served by best used by date to reduce food borne contaminations. Interview on 04/17/2026 at 9:06 AM with [NAME] C revealed food should be labeled with date received and used by so that expired food is not cooked also just in case there was a recall on food. The risk is contaminated food being served to the residents. If you leave the thermometer in the food, it could break and contaminate the food. Record Review of policy Food Received and Storage revealed Labeling and dating food items: If food is removed from its original container, it must be labeled to include the name of the food item Date all food items with the date it was received All dates must include the month, the day, and the year If a food manufacture's label states an expiration date, circle it so it is easily noticeable.

Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's needs related to indwelling catheter for 1 of 5 residents (Resident #38) reviewed for care plans.Resident #38 was not care planned for indwelling catheter.This failure could result in improper care to residents which could lead to infection.Findings included:Record review of Resident #38's face sheet on 04/15/2026 1:19 PM revealed the resident was admitted on [DATE]. One of the listed admitting diagnoses was Present of an indwelling catheter.Record review of Resident #38's admission note, dated 3/30/2026, documented by ADON C, revealed the resident was admitted with a urinary catheter size 16.In an observation on 04/14/2026 10:56 AM, Resident #38 was sleeping in bed. Resident #1 had a catheter bag. Catheter bag and tubing were in clean condition. Record review of Resident #38's provider progress note, dated 3/31/2026, revealed the provider had put in the following orders: Continue Foley catheter care, monitor urine output and characteristics, maintain catheter hygiene, monitor for infection, reassess need for continued catheter use.Record review of Resident #38's care plan, dated 3/31/2026, revealed the resident did not have a comprehensive care plan related to catheter care. In an interview on 04/16/2026 at 11:28 AM, RN B stated there should be a care plan for residents who had indwelling catheters. She stated the nurses should check for urine output, sediments, color, and measure flow rate every shift. She stated the risk of not having a care plan for the resident's catheter was the nurses could give improper care for that catheter. She also stated the nurses would not know to check for specific things including output, color, sediments. She stated the risks to residents included infection, urine obstruction, which could lead to hospital admission. In an interview on 04/16/2026 at 11:48 AM, RN A stated she was assigned to take care of Resident #38 the past 3 days. She stated she was aware that the resident had a urinary catheter. She stated she was not aware that he was not care planned for it. She stated at the end of every shift, she checked for urine output, sediments, urine color. She stated the risk of not having a comprehensive care plan for the resident was infection. She stated the risk of not having a comprehensive care plan could affect continuation of care for the resident because the nurses would not know to take care of the catheter. In an interview with ADON C on 04/16/2026 12:09 PM, she stated residents should be care planned for having an indwelling catheter. She stated the care plan was a way that a new nurse working with a resident knew how to care for the resident, making sure the urine output was documented, sediment was documented. She stated it's the nurse and nurse manager's responsibility to make sure catheters were care planned. She stated in-service on catheter care was provided monthly or when there was an incident. In an interview on 04/16/2026 at 1:05 PM, the DON stated there should be a comprehensive care plan for residents who had catheters. The nurses should make sure the urine was flowing, the site was not irritated, the site had no sign of infection. She stated the risk to residents included infection. She stated the nurse management team was responsible for developing a care plan for residents. She stated she just started at the facility and did not know Resident #38 did not have a care plan for his urinary catheter. Record review of facility's Comprehensive care planning, policy, unknown date, revealed the policy stated the comprehensive care plan will describe. the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. Care plans will be person-centered and reflect the resident's goals for admission and desired outcomes.Record review of facility's Catheter care policy, unknown date, revealed the policy stated to review the resident's plan of care daily for changes.

Based on observation, interview, and record review, the facility failed to attempt to use alternatives prior to installing a side or bed rail, obtain informed consent prior to installation, ensure correct installation, use and maintenance of bedrails for 1 (Resident #9) of 5 residents reviewed for bedrails. The facility failed to obtain a bed rail assessment and informed consent prior to the installation of Resident #9's bedrails. These failures could place residents at risk of entrapment or injury.Findings included: Record Review of Resident #9's Nursing Home Comprehensive MDS assessment, dated 03/11/26, reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. His MDS reflected he had a BIMS score of 15, which indicated he had no cognitive impairment. Resident #9's active diagnoses included type 2 Diabetes Mellitus (when the body cannot use insulin correctly and sugar builds up in the blood), cerebrovascular accident (occurs when blood flow to the brain is interrupted or vessel bursts, causing rapid brain death), acquired absence of left and right legs below the knee, and dependence on renal dialysis (relying on regular life-sustaining hemodialysis to remove waste and excess fluid when kidneys fail). His MDS did not address that he utilized bed rails. Record Review of Resident #9's undated care plan, reflected the following: Focus: [Resident #9] has an ADL Self-Care Performance Deficit r/t Bilateral AKA.Interventions: Bed Mobility: requires max assist from staff x1 for assistance. Date initiated: 03/12/26. Record Review of Resident #9's EHR, dated 04/16/26, reflected no Side Rail Evaluation. Observation on 04/14/26 at 1:25 PM revealed that Resident #9 had half bedrails on both sides of his bed. Interview with the Maintenance Supervisor on 04/16/2026 at 10:50 AM revealed that the previous DON told him to place the bedrails on the resident's bed. The Maintenance Supervisor stated that he told her that he needed to see the signed consent. The Maintenance Supervisor stated that he was told by the previous DON that she had it, but he was never shown the signed consent. The Maintenance Supervisor stated that the importance of ensuring that there was a signed consent was to show that the resident had been evaluated for the bedrails and gave consent for them to be placed on the bed. The Maintenance Supervisor stated he should have notified the Administrator before installing the bedrails when he was not shown a signed consent. The Maintenance Supervisor stated that he checks the rails weekly to ensure that they are securely placed. Interview with RN B on 04/16/2026 at 11:33 AM revealed she had been a nurse for five months and was Resident #9's current dayshift nurse. RN B stated that she was not aware that Resident #9 had half bedrails. RN B said that she did not believe that half bedrails were a restraint because it did not prevent Resident #9 from getting out of bed. RN B stated that Resident #9 required a mechanical lift to be transferred into and out of bed, so she did not think the bedrails were a restraint. RN B stated that she did not know what the facility's policy stated about bedrails. RN B said that a resident could get their arm stuck in the bedrail and get hurt. RN B also stated that before bedrails were placed on a bed, an assessment was supposed to be completed for the resident. RN B said that Resident #9 should have bedrails listed on their care plans as well. Interview with ADON C on 04/16/2026 at 12:10 PM revealed that she was not aware that Resident #9 had bedrails. ADON C stated that Resident #9 should have an assessment for the bedrails as well as a care plan, and a consent. ADON C stated that she would notify the resident's POA, DON, and physician. ADON C revealed that bedrails could be a risk to residents because they could get their heads caught in the rails and be injured. ADON C stated that it was the nurses' responsibility to ensure that all documentation was completed for residents with bedrails as well as document any changes that could happen to the resident. ADON C revealed that if changes occurred, nurses should notify their ADON and DON. Interview with the DON on 04/16/2026 at 1:06 PM revealed that residents with half bedrails should have a bedrail assessment, a consent, a care plan intervention, and nurse documentation. The DON stated that she was unaware that these were not completed on Resident #9 who had half bedrails on both sides of this bed. The DON stated that she started working at facility on 04/07/26 and has not been able to complete chart audits. The DON revealed that it is all of nursing's responsibility to ensure that all of these are completed on residents with bedrails because they are considered restraints. The DON said that the physician and responsible party should be notified when residents have bedrails. The DON also stated that the facility policy was that every shift should document that the bedrails are used correctly. The DON also stated that quarterly assessments for bedrails should be completed. And if a change in condition occurred, the nurse should notify the ADON, DON, physician, and responsible party. The DON revealed that therapy should work with the resident to show them how to correctly use the bedrail. The DON then stated that after the resident demonstrated to therapy and the nursing department that they correctly know how to use the bedrails, the maintenance supervisor could install the bedrails on the resident's bed. The DON stated she was unsure if other interventions were attempted before the bedrails were placed on the bed. The DON revealed that Resident #9 could get tangled up in the bedrail if not used correctly. Interview with Resident # 9 on 04/17/2026 at 11:36 AM revealed that he did not request the bedrails. Resident #9 stated that no staff member came to speak with him about the bedrails or provide him with a bedrail consent or conduct a bedrail assessment on him. Resident #9 was unaware that therapy should provide training on the proper way to use the bedrail. Record Review of undated Bed Rails policy reflected: .The facility will attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements:Assess the resident for risk of entrapment from bed rails prior to installation.Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.Ensure that the bed's dimensions are appropriate for the resident's size and weight. Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.Assessment: Prior to use of a bed rail the resident will be assessed to ensure the proper rail is utilized for the resident's need.The facility will re-evaluate the use of the rail on a periodic basisBased on the resident assessment, the interdisciplinary team (IDT) will make the determination for the plan of care as it relates to bed rails.Consent - The resident and/or resident representative will provide consent for the use of rails prior to installation.Follow the manufacturers' recommendations and specifications for installing and maintaining bed railsThe facility will conduct regular inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment and ensure rails are installed according to manufacturer recommendations. When bed rails and mattresses are used and purchased separately from the bed frame, the facility must ensure that the bed rails, mattress, and bed frame are compatible.The facility will ensure that all bed rails in service will meet this criteria. Any bed rail determined to be out of compliance will be removed from service.

Based on observation, interviews, and record reviews, the facility failed to help family and visitors understand safe food handling practices reviewed for Resident #8 personal refrigerator. The facility failed to ensure that Resident # 8's in room refrigerator was at a safe cooling/reheating processes meeting food safety temperature standards.These failures had the potential to affect the residents by placing them at risk for cross-contamination and foodborne intoxication.Findings Included:Record review of Resident #8's admission Record revealed an [AGE] year-old female admitted on [DATE] with a primary diagnosis of Parkinson's Disease without Dyskinesia, and secondary Dementia in other diseases classified elsewhere. Record review of Resident #8's Care Plan dated 04/06/2026 revealed; on a Regular diet and chooses to eat all meals in her room. Interventions monitor and document meal intake.Record review of Resident # 8's MDS Nursing Home Quarterly assessment dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment. Section GG- Functional Abilities: A. Eating- the ability to use suitable utensils to bring food and /or liquid to the mouth and swallow food and /or liquid once the meal is placed before the resident. Setup or clean-up assistance- helper sets up on cleans up; Helper assists only prior to or following the activity. Observation on 04/14/2026 at 11:00 AM revealed Resident #8 had a personal refrigerator in her room. When opened, the interior of the refrigerator did not feel cool. There was no inside thermometer or temperature log. Observation and interview on 04/14/2026 at 1:59 PM with Maintenance Supervisor revealed Resident #8's personal refrigerator temperature was taken by Maintenance Supervisor and showed 48.9 degrees. The temperature control was turned to 1. Interview on 04/16/2026 at 10:41 AM with Maintenance Supervisor revealed the family member or responsible party was responsible for maintaining personal refrigerators. Interview on 04/16/2026 at 1:20 PM with DON revealed residents monitor their own refrigerators. Nursing should help with the content. The risk of having content in the refrigerator was she could get sick. Direct care staff should throw away spoiled food.Interview on 04/16/2026 at 1:46 PM with Housekeeper Supervisor revealed personal refrigerators were cleaned by a member of housekeeping when alerted by the DON. Housekeeping will go in and remove items from the refrigerator that are expired with the resident in the room (resident rights). Review of policy Personal Refrigerator dated 2022 revealed; Housekeeping can assist the resident and/or family member by inspecting the refrigerators at least weekly and assist with removal of outdated food items and cleanliness. The refrigerator compartment should be maintained at temperature of 35-41 degrees. The freezer compartment should be maintained at zero degrees or less, or food frozen to a solid state. Temperatures can monitored by the use of a thermometer designed for a refrigerator/freezer that can be purchased from a department store.

Based on observation, interview, and record review, the facility failed 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 catheter care for 1 of 6 residents (Resident #38) reviewed for infection control.RN A picked up Resident #38's catheter bag on the floor and hung it back on the resident's bed, failing to replace the catheter bag. This failure could place residents at risk for infection. Findings included:Record review of Resident #38's face sheet on 04/15/2026 1:19 PM revealed the resident was admitted on [DATE]. One of the listed admitting diagnoses was Present of an indwelling catheter.Observation on 04/14/2026 at 1:52 PM revealed the catheter bag and catheter tubing of Resident #38 was on the floor next to the resident's bed. The resident was sleeping. The DON was walking by the room at the same time as surveyor. The DON saw the bag on the floor and she informed RN A of the situation and walked to the other hall. RN A performed hand hygiene, donned PPE and went in the room, picked up the catheter bag & hung it back on the bed. RN A then removed her PPE, performed hand hygiene and left the room. In an interview on 04/14/2026 at 1:55 PM, RN A stated the risk to the residents if catheter bag and tubing were on the floor included infection. When she was asked why she did not remove the bag and tubing that were on the floor in Resident #38's room, she stated she should have done that. She could not give a clear answer why she did not change the catheter bag out. She stated the bag was already contaminated because it was on the floor.In an interview on 04/14/2026 at 2:00 PM with ADON D, she stated if she saw a catheter bag on the floor, she would immediately remove it because it was already contaminated. She stated the bag should not be used anymore and she would get another bag to change it. She stated it's an infection risk to the resident. She expected her nursing staff to follow the facility's policy when providing catheter care for residents. She stated in-services on catheter care was being done monthly or as needed.In an observation on 04/14/2026 at 2:15 PM, a new catheter bag was hanging above the floor, to the side of the bed of Resident #38. Record review of Resident #38's care plan, dated 3/31/2026, revealed the resident was not care planned for urinary catheter. Record review of Resident #38's provider progress note, dated 3/31/2026, revealed the provider had put in the following orders: Continue Foley catheter care, monitor urine output and characteristics, maintain catheter hygiene, monitor for infection, reassess need for continued catheter use.Record review of the facility's Catheter care policy, unknown date, revealed the policy stated be sure the catheter tubing and drainage bag are kept off the floor.

Based on interview and record review, the facility failed to ensure the clinical records were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 2 of 6 residents records (Resident #1 and Resident #2) reviewed for treatment documentation. 1. The facility failed to document on Resident #1's and Resident #2's Treatment Administration Record, when their catheter bags were emptied and the amount emptied on the night of 10/03/25 and the night of 10/11/25. This failure could affect the residents' medical record not being an accurate representation of the resident's medical condition or medical needs. Findings include: Record review of Resident #1's face sheet, dated 10/16/25, reflected an [AGE] year-old female, who admitted to the facility on [DATE]. Resident #1 had diagnoses which included, Parkinson's Disease (progressive neurological disorder that affects movement), Dementia (group of conditions that cause a decline in cognitive abilities like memory, thinking, and reasoning), and Parastomal Hernia (bulge that occurs in the abdominal wall). Record review of Resident #1's Treatment Administration Record, dated 10/16/25, reflected no documentation on her catheter bag being emptied or the amount drained from the bag, during the night shift on 10/03/25 and 10/11/25. The Treatment Administration Record reflected LVN A was the nurse responsible for documentation on the night of 10/03/25 and 10/11/25. Record review of Resident #2's face sheet, dated 10/16/25, reflected a [AGE] year-old male, with an initial admission date of 06/12/24, and a readmission date of 11/29/24. Resident #2 had diagnoses which included, Dementia (group of conditions that cause a decline in cognitive abilities like memory, thinking, and reasoning), Benign Prostatic Hyperplasia (enlarged prostate glands), and Major Depressive Disorder (mental health condition with persistent feeling of sadness, hopelessness, and loss of interest in activities). Record review of Resident #2's Treatment Administration Record, dated 10/16/25, reflected no documentation on his catheter bag being emptied or the amount drained from the bag, during the night shift on 10/03/25 and 10/11/25. The Treatment Administration Record reflected LVN A was the nurse responsible for documentation on the night of 10/03/25 and 10/11/25. In a telephone interview on 10/16/25 at 11:44 AM, LVN A stated she did work at night on 10/03/25 and 10/11/25. She stated she remembered an aide emptying the catheter bags on those nights but stated she could not remember who the aides were who emptied the bags. LVN A stated she was responsible for documenting the emptying and how much was drained. LVN A stated she failed to document the drainage of the catheter bags on the Treatment Administration Records. LVN A stated the risk of not documenting the drainage of the catheter bags was it would appear to others that it was not completed. In an interview on 10/20/25 at 12:17 PM, the Administrator stated all staff knew the importance of documentation. The Administrator stated the risk of missed documentation on the Treatment Administration Record was staff did not have enough information to properly care for the residents. In an interview on 10/20/25 at 12:23 PM, the DON stated all staff were trained on documentation and the importance of documentation. The DON stated the risk of no documentation was inaccurate information. The DON stated failed documentation would not provide a true picture of what actually took place. Record review of the facility's policy titled, Perineal Care, dated 05/11/22, reflected the following: An incontinent resident of urine and/or bowl should be identified, assessed, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible.It is essential that residents using various devices, absorbent products, external collection devices, etc., be checked (and changed as needed) on a schedule based upon the resident's voiding pattern, professional standards of practice, and the manufacturer's recommendations. Conclude. 33. Document

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals were stored in locked compartments and accessed only by authorized personnel for 1 of 4 residents (Resident #1) reviewed for medication storage. Resident #1 had two unidentified pills on his bedside table on 06/17/25 and did not self-administer his own medications. This failure could place residents at risk of inadequate therapeutic outcomes or decline in health. Findings included: Record review of Resident #1's face sheet dated 6/17/25 revealed a [AGE] year-old male admitted on [DATE]. His diagnoses included type 2 diabetes (the body has trouble controlling blood sugar and using it for energy), chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Record review of Resident #1's annual MDS assessment dated [DATE] revealed a BIMS score of 8 out of 15 which indicated he was moderately impaired. In an observation and interview on 06/17/25 at 10:36 a.m. of Resident #1 in his room revealed two unidentified pills on his bedside table. Resident said that he was not aware of the pills on his left side bed table. He said they gave him too many pills and maybe one or two fell out when he was taking them. In an interview and observation on 06/17/25 at 10:36 a.m. the Wound Care nurse said the two pills should not be left at the resident's bedside. She said that she would take them out of the room. She removed both pills and put them in her biohazard bag. She stated the resident had been at risk of receiving a double dose of medication or taking medication without the knowledge of the facility. In an interview on 06/17/25 at 11:00 a.m., the LVN stated she was the nurse for Resident #1. She said that she had given the resident pain medication at 09 AM and it was not time for more. She said she always goes to the right side of his bed and did not see the medication on the left side table. She said if she had she seen the two pills she would have taken them out of the room. She said the risk of medication at the bedside was that the resident could get double dosed. In an interview on 6/17/25 at 1:39 p.m. the acting DON said the expectation was that the nursing follow protocol to administer medication, watch them take the medication, if the resident refuse, document it and notify the doctor. She stated she had already started the in-service with the staff regarding administering medications. The risk to the resident when medication was left in the room would be that the resident could take the medication and have side effects, and no one would know that he had taken it or what he took. The person responsible to ensure medication was administered properly would be the nurse administering the medication. In an interview on 06/17/25 at 4:09 p.m. the Administrator said she the expectation was to administer the medication and watch the resident take the medication. If they refused, try again and if the resident refused again dispose of the medication properly. The risk was a potential side effects and could cause imbalance or worse sickness. The person responsible to ensure medication was administered properly would be the person passing medications. She stated they have already started doing in-service with the med aides and nurses and department heads to ensure they know not to leave medication in the room with a resident. Record review of the facility's undated Medication Administration policy read in part, .i.e. observes the resident take the medications Record review of the facility's Storage of Medication policy undated read in part, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on interview and record review, the facility failed to ensure all allegations of abuse were reported to the State Survey agency and the administrator of the facility, immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse for 1 of 1 resident reviewed for abuse and neglect for one (Resident #1) of 1 resident reviewed for abuse. The facility did not report immediately to the State Survey agency when Resident #1 accused LVN A touched him inappropriately on 03/08/25 and LVN A did not report the allegation immediately to the Administrator. These failures could place residents at risk for abuse, neglect, and exploitation. Findings included: Review of Resident #1's Face Sheet dated 04/24/2025 indicated a [AGE] year-old male readmitted on [DATE], with initial admission on [DATE]. Admitting diagnoses included Cerebral Infarction Unspecified (a blood vessel supplying blood to the brain has been blocked, leading to brain tissue damage. the cause and location unknown); Heart Failure, Unspecified (a condition where the heart cannot pump enough blood to meet the body's needs, and the specific type or cause is not clearly documented); Bipolar Disorder, Current Episode, Depressed Moderate (periods of intense mood swings, including both manic/hypomanic episodes and depressive episodes). Record review of Resident #1's Change of Condition MDS dated [DATE] noted BIMS Score to be 14/15 with memory intact. Functional ability r/t catheter care is Resident #1 has an indwelling catheter which is managed by the nursing staff in relation to changing the catheter, tubing, and bag as needed. Resident #1 is always incontinent of bowel movements and requires incontinent care by the CNAs. Review of the facility's Provider Investigation Report, dated 03/21/25, revealed the incident occurred on 03/08/25 where Resident #1 alleged LVN A touched him inappropriately. Report indicated resident had a history of making false accusations and calling 911. Findings were unfounded. In an interview on 04/24/2025 at 12:50 pm, Resident #1 revealed that LVN A needed to change his catheter bag and the tubing due to leaking. Resident #1 could not remember what day the incident of abuse occurred. Resident #1 denied ever saying that LVN A touched him inappropriately. In an interview on 04/24/2025 at 4:40 pm the ADM revealed an incident occurred between Resident #1 and LVN A on 03/08/2025 at 12:00 pm where Resident #1 alleged LVN A inappropriately touched Resident #1. ADM first learned of the alleged incident on 03/10/2025 from a note that had been placed on her office door by LVN A. An assessment was completed on Resident #1 on 03/10/2025 and an investigation was started. Reported to HHSC on 03/10/25. The ADM admitted that the incident was not reported on 03/08/2025, but the staff have been in-serviced to contact administration immediately with all accidents and incidents to that she can determine the need to report. Internet search of [state database] revealed discrepancies in reporting timeline. Incident was reported on 03/10/25, which was two days after the incident first occurred. Review of facility's In-service, dated 03/11/25, relating to Abuse/Neglect, types of abuse, and timely abuse of any alleged abuse reviewed LVN A was in-serviced. Review of LVN A's written statement, dated 03/10/25, revealed the allegation Resident #1 had against her occurred on 03/08/25. Record review of the facility's Abuse/Neglect policy revised 03/29/2018 revealed in part: F. Investigation - Comprehensive investigations will be the responsibility on the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. The Administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC.

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 included measurable objectives and time frames to meet residents' medical, nursing, mental and psychosocial needs, for 1 Resident (Resident #2) of 1 resident reviewed for care plans. The facility did not provide interventions as outlined in Resident #2's comprehensive person-centered care plan to address Resident #2's weight loss issues with not interventions including nutritional supplements to improve weight. These failures could place residents identified at risk for weight loss at risk for their medical, physical, and psychosocial needs not being met. The findings were: Record review of Resident #2 Face Sheet, dated 04/24/2025, revealed a [AGE] year-old admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #2's diagnoses included Other Sequelae Following Cerebrovascular Disease (long -term consequences and complications that can result from a stroke or other cerebrovascular issues, including impaired movement, speech difficulties, memory loss, and other neurological deficits); Essential (Primary) Hypertension (high blood pressure where no specific underlying cause can be identified); Type 2 Diabetes Mellitus Without Complications (an individual who has been diagnosed with type 2 diabetes, but has not developed any long-term health problems (complications) that can arise from high blood sugar levels). Record review of the facility's Physician's Order List, dated 04/24/2025, listed Resident #2's diet as, regular texture, regular consistency. Record review of Resident #2's Assessment, by the facility's Dietitian, dated 09/11/2024, revealed Resident #2 had an admission weight of 184.2 pounds, with weight history stable. Nutritional Goal: Gradual weight loss 5% current body weight over the next 60 days 2. No s/s dehydration 3. Maintain adequate nutrition. Record review of Resident #2's Quarterly MDS assessment, dated 01/29/2025, revealed Resident #2's BIMS (cognitive assessment) score of 15 indicated intact cognition. Eyesight was severely impaired and assistance was needed from staff for set up and clean up for eating. Resident #2 had the ability to feed herself. No swallowing disorder and no significant weight loss/gain were noted. Record review of Resident #2's comprehensive care plan, dated 03/26/2025 and revised 04/10/2025, revealed: Resident has potential for weight loss due to refusal of most meals and prefers to eat a sandwich (grilled cheese). Goal: Resident will maintain ideal weight and receive proper nutrition daily x 90 days. Interventions include: Determine food preferences and provide within dietary limitations. Encourage meal completion and document amount consumed. Monitor weight per facility protocol. RD assess per facility protocol. Serve diet and snacks as ordered. The facility failed to implement interventions as outlined in the care plan. Record review of Resident #2's electronic chart listed the following weights recorded on the following dates: -04/09/2025: 166.4 lbs. (pounds) -03/10/2025: 171.1 lbs. -03/06/2025: 170.1 lbs. -01/08/2025: 175.1 lbs. -12/09/2024: 179.4 lbs. -11/08/2024: 175.2 lbs. -10/07/2024: 178.1 lbs. -09/06/2024: 184.2 lbs. -08/08/2024: 183.6 lbs. The percentage of Resident #2's weight loss is calculated as: 1 month - 03/10/25 - 04/09/25 2.75% weight loss 3 month - 01/08/25 - 04/09/25 4.95% weight loss 8 month - 08/06/24 - 04/09/25 9.37% weight loss (10% in 6 months is considered significant weight loss) Record review of nursing progress note dated 04/23/2025 at 11:28 am revealed that Resident #2, Resident has a trend of eating <51%. Res reports she is eating her own food in addition to [facility] meals. She denies nausea, vomiting, or difficulty swallowing. Appetite is good. In an interview on 04/24/2025 at 12:20 pm Resident #2 said she did not like the food because the food does not taste good. Resident #2 stated that she likes to eat snacks her family member brings and go out to eat with her family. In an interview on 04/24/2025 at 2:30 pm the ADM said that their company's policy is to address residents who have a 10% or greater weight loss in six months. Resident #2 has not had that much of a weight loss according to their company policy, which the facility would be prompted to provide interventions if a resident experienced significant weight loss. ADM revealed that the facility provides Resident #2 a grilled cheese sandwich. In an interview on 04/24/2025 at 2:40 PM the Dietitian said that she visits the facility once a month. She stated she only sees the residents who had a significant weight loss to provide recommendations for them. The Dietitian stated that she did make a recommendation to the Speech Therapist to evaluate Resident #2 for swallowing issues for a possible reason resident was not eating, but she did not document the conversation. The Dietitian said the nursing staff could make the decision for supplements. The Dietitian stated she will investigate this issue with the resident. In an interview on 04/24/2025 at 3:00 PM Resident #2's family member said that she has had concerns with resident not wanting to eat. Family member was aware of Resident #2's weight loss and knows that she does not care for the food. Family member brings her snacks to eat. Family member stated resident was much larger when she moved into the facility and has gradually lost weight. She stated that Resident #2 could lose some weight but has lost so much weight. Family member will speak to Resident #2 about eating her meals better. Record Review of facility's Resident Weight policy revised 02/13/2007 revealed in part, An acute care plan for weight loss will be initiated and the clinical record reviewed for possible need of significant change of condition MDS assessment. Assess the resident for possible reason for weight loss .

Based on interview and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range unless the resident's clinical condition demonstrated that this was not possible for 1 (Resident #2) of 1 resident reviewed for weight loss. Resident #2 had a 9.37% weight loss in 8 months between 8/6/24 and 4/9/25 with no documentation from the Dietitian on nutritional concerns or recommended interventions to address Resident #2's weight loss. This failure could place residents at risk of not having needs addressed and/or met r/t weight loss. The findings were: Record review of Resident #2 Face Sheet, dated 04/24/2025, revealed a [AGE] year-old admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #2's diagnoses included Other Sequelae Following Cerebrovascular Disease (long -term consequences and complications that can result from a stroke or other cerebrovascular issues, including impaired movement, speech difficulties, memory loss, and other neurological deficits); Essential (Primary) Hypertension (high blood pressure where no specific underlying cause can be identified); Type 2 Diabetes Mellitus Without Complications (an individual who has been diagnosed with type 2 diabetes, but has not developed any long-term health problems (complications) that can arise from high blood sugar levels. Record review of the facility's Physician's Order List, dated 04/24/2025, listed Resident #2's diet as, regular texture, regular consistency. Record review of Resident #2's Assessment, by the facility's Dietitian, dated 09/11/2024, revealed Resident #2 had an admission weight of 184.2 pounds, with weight history stable. Nutritional Goal: Gradual weight loss 5% current body weight over the next 60 days 2. No s/s dehydration 3. Maintain adequate nutrition. Review of Resident #2's electronic medical record revealed no Dietitian notes from 09/11/24 to 04/24/25. Record review of Dietary Profile dated 04/16/2025 completed by the Director of Food and Nutrition revealed Resident #2's appetite is poor, favorite meal is lunch, and no chewing or swallowing issues. Resident's current weight to be 166.4 taken on 04/09/2025. Noted resident has had a weight loss of 8 lbs. in the last 6 month. Resident #2 on a regular diet with no supplements noted. Record review of Resident #2's Quarterly MDS assessment, dated 01/29/2025, revealed Resident #2's BIMS (cognitive assessment) score of 15 indicated intact cognition. Eyesight was severely impaired and assistance was needed from staff for set up and clean up for eating. Resident #2 had the ability to feed herself. No swallowing disorder and no significant weight loss/gain were noted. Record review of Resident #2's comprehensive care plan, dated 03/26/2025 and revised 04/10/2025, revealed: Resident has potential for weight loss due to refusal of most meals and prefers to eat a sandwich (grilled cheese). Goal: Resident will maintain ideal weight and receive proper nutrition daily x 90 days. Interventions include: Determine food preferences and provide within dietary limitations. Encourage meal completion and document amount consumed. Monitor weight per facility protocol. RD assess per facility protocol. Serve diet and snacks as ordered. The facility failed to implement interventions as outlined in the care plan. Record review of Resident #2's electronic chart listed the following weights recorded on the following dates: -04/09/2025: 166.4 lbs. (pounds) -03/10/2025: 171.1 lbs. -03/06/2025: 170.1 lbs. -01/08/2025: 175.1 lbs. -12/09/2024: 179.4 lbs. -11/08/2024: 175.2 lbs. -10/07/2024: 178.1 lbs. -09/06/2024: 184.2 lbs. -08/08/2024: 183.6 lbs. The percentage of Resident #2's weight loss is calculated as: 1 month - 03/10/25 - 04/09/25 2.75% weight loss 3 month - 01/08/25 - 04/09/25 4.95% weight loss 8 month - 08/06/24 - 04/09/25 9.37% weight loss (10% in 6 months is considered significant weight loss) Record review of nursing progress note dated 04/23/2025 at 11:28 am revealed that Resident #2, Resident has a trend of eating <51%. Res reports she is eating her own food in addition to hospital meals. She denies nausea, vomiting, or difficulty swallowing. Appetite is good. In an interview on 04/24/2025 at 12:20 pm Resident #2 said she did not like the food because the food does not taste good. Resident #2 stated that she likes to eat snacks her family member brings and go out to eat with her family. In an interview on 04/24/2025 at 2:30 pm the ADM said that their company's policy is to address residents who have a 10% or greater weight loss in six months. Resident #2 has not had that much of a weight loss according to their company policy. ADM revealed that the facility provides Resident #2 a grilled cheese sandwich. In an interview on 04/24/2025 at 2:40 PM the Dietitian said that she visits the facility once a month. She only sees the residents who are having a significant weight loss to provide recommendations for them. The Dietitian said that she did make a recommendation to the Speech Therapist to evaluate Resident #2 for swallowing issues for a possible reason resident is not eating, but she did not document the conversation. The Dietitian said the nursing staff could make the decision for supplements. The Dietitian stated she will investigate this issue with the resident. In an interview on 04/24/2025 at 3:00 PM Resident #2's family member said that she has had concerns with resident not wanting to eat. Family member is aware of Resident #2's weight loss and knows that she does not care for the food. Family member brings her snacks to eat. Family member stated resident was much larger when she moved into the facility and has gradually lost weight. She agrees that Resident #2 could lose some weight but has lost so much weight. Family member will speak to Resident #2 about eating her meals better. Record Review of facility's Resident Weight policy revised 02/13/2007 revealed in part, Significant Weight Loss, The facility review resident weights after monthly weights are obtained, to determine residents with significant weight changes. A significant weight change will be defined as 5% or greater in one month, 7.5% or greater in three months, or 10% or greater in six months. The Weight change will be recorded on the appropriate weight watcher's form along with interventions, and follow-up will also be recorded in the designated location. The physician and family will be notified.

Based on observation, interview and record review, the facility failed to prepare food by methods that conserve nutritive value, flavor, texture and appearance for 3 or of 5 (Residents #4,# 12 and #18) residents reviewed for regular diets. The facility failed to ensure that regular diets served were prepared by methods that conserve nutritive value, flavor, texture, and appearance. This failure could place residents on regular diets at risk for a decrease in quality of life and possible weight loss. Findings included: Review of Resident #4's Admission Record reflected she was a [AGE] year-old woman, admitted on [DATE], with a primary diagnosis of Atrial Fibrillation (irregular heart rhythm). Review of Resident #4's Care Plan dated 11/25/2024 reflected Intervention provide diet as ordered. Review of Resident #4's MDS dated [DATE] reflected Resident #4's BIMS score was 15 (cognitively intact). Review of Resident #4's Order Summary Report reflected Resident #4 is on a regular diet, regular texture, regular consistency. Review of Resident #12's Admission Record reflected an [AGE] year-old woman admitted to the facility on [DATE] with a primary diagnosis of Type 2 diabetes mellitus without complications. Review of Residents #12's Care Plan dated 11/15/2024 reflected focus; Resident #12 has Diabetes Mellitus. Intervention; Educate regarding medications and importance of compliance. Review of the MDS dated [DATE] reflected Resident #12 had a BIMS score of 14(cognitively intact). Review of the Order Summary Report reflected Resident #12 was ordered Regular Diet, Regular texture, Regular consistency. Review of Resident #18's Admission Record reflected a [AGE] year-old male admitted on [DATE] with a primary diagnosis paraplegia. Review of Resident #18's Care Plan dated 01/06/2025 reflected focus; Resident #18 has Diabetes Mellitus. Interventions; Dietary consult for nutritional regimen and ongoing monitoring. Review of Resident #18's MDS dated [DATE] reflected Resident #18 had a BIMS score of 15(cognitively intact). Review of Resident #18's Order Summary Report reflected regular diet, regular texture, Regular consistency, Large portion. Observation on 01/28/2025 at 12:12 PM sample tray revealed bar-b-que chicken, potato casserole, coleslaw, biscuit, and desert. Potato dish revealed potatoes were crunchy in texture and the coleslaw was not set in form and unpalatable. Observation and interview on 01/28/2025 at 12:16 with Resident #4 revealed she had eaten 50% of her meal. She stated the potatoes were not cooked and crunchy. She consumed less than 50% of the coleslaw. Observation and interview on 01/28/2025 at 12:18 PM with Resident #12 revealed she had eaten less than 50% of the coleslaw and did not eat any of the potatoes. She stated when they serve her food like this it makes her want to slap them. She stated that she has voiced her concerns regarding the food, but it doesn't do any good. Observation and interview on 01/28/2025 at 12:20 PM with Resident # 18 revealed he only ate the chicken. When asked how his lunch was, he responded you try it when told that a simple tray was consumed by the surveyor he responded, then you know this is bullshit. Interview on 01/28/2025 at 12:22 PM with the dietary manager revealed after tasting the potato casserole, she stated not all of them were the same exact texture. Potatoes were supposed to be soft. She stated that she does not like coleslaw, but it tastes like coleslaw. She stated that the coleslaw has a mix used to prepare it. The potato comes in a box, and you cook it in the oven. She stated that she does not taste the food before it is served but she will eat it after residents were served. Interview on 01/28/2025 at 12:34 PM with the cook revealed potato dish was mixed in bowl then layered in casserole dish. She stated that she should have layered the mixed potatoes in two shallower dishes instead she combined she combined the potato mix into one deep pan. She stated she used the deeper dish instead of two shallow pans to conserve space on the steamtable. She stated the potatoes were done (cooked to time and temperature) the potatoes on top were soft, however, as she started to serve the potato casserole I noticed they [potatoes] got a little harder . She stated the coleslaw normally had a coleslaw dressing, but they were out so she made her own dressing for the coleslaw. The dressing contained 1 cup of mayo, tablespoon of lemon juice and sprinkle of salt and pepper. She stated that she did not taste coleslaw because she does not eat coleslaw. Interview on 01/30/2025 at 3:10 PM with the DON revealed she stated that she has not tasted the food. They do provide supplements and fortified meals for residents at risk of weight loss. The risk of not serving meals that residents enjoy eating was weight loss, skin issues and a decline in ADL's. Interview on 01/30/2025 at 4:10 PM with the Administrator revealed her expectation was that the dietary staff follow the recipes for preparing food and taste the food before serving it to the residents. The risk to the residents was weight loss. Record review of Weekly menu dated week 1 revealed Tuesday lunch; BBQ Chicken Quarter, Party Potato Casserole, creamy diced coleslaw, garlic cheese biscuit, margarine, banana pudding w/wafers and iced tea. Record review of the facility policy titled; Test tray evaluation form dated 2012 revealed; 3. Once the food temps have been taken and recorded, the overall appearance of the tray should be assessed. Then all foods should be tasted. Once all scores have been completed, the form should be returned to the dietary service manager or administrator. 4. Results of the test trays will be used to determine where improvements to the tray line or food production process need to be made.

51047 Based on observation, interview and record review, the facility failed to maintain an infection prevention and control measure designed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #21) during medication administration, and 3 of 16 residents (Residents #27, #32, #40) reviewed for infection control in that: 1.MA A attempted to perform hand hygiene in another resident's room after measuring blood pressure on Resident #21 who was on Enhanced Barrier Precaution (EBP). 2.MA A did not sanitize blood pressure machine after it was used to measure blood pressure for Resident #21. 3. LVN D failed to ensure EBP procedure was followed throughout the wound care treatment and dressing change for Resident #27. LVN D did not put on his gown for PPE when he returned to complete wound care on Enhanced Barrier Precautions. LVN D failed to ensure two used towels with blood on them were handled with care and in a bag and not rolled in a ball and placed in his left arm pit after completion of wound care for Resident #27 4. RN E failed to sanitize her hands after touching Resident #32's radio that was inside his pants before getting and covering Resident #40 in a blanket and moving his bedside table. These failures could place residents and nursing staff at risk of transmission of communicable diseases and infections. Findings include: Record review of Resident #21's face sheet, dated 1/30/2025 revealed, resident was a [AGE] year-old male admitted on [DATE] with type 2 diabetes, obstructive uropathy (a condition in which the flow of urine is blocked), and leukemia (cancer of blood cells). Record review of Resident #21's care plan, dated 12/30/2024, revealed that Resident #21 was on enhanced barrier precautions, with the goal of no transmission of infection from or to the resident. One of the interventions included performing hand hygiene before entering the room and prior to leaving the room. Observation on 1/29/2025 at 07:30 AM, before medication pass, MA A entered Resident #21's room to measure blood pressure. Resident #21 was on EBP as marked by the posting at the door. MA performed hand hygiene and proceeded to don gown, mask & glove respectively and entered Resident #21's room with the blood pressure measuring machine. Upon completion, MA A did not perform hand hygiene when exiting the room but instead MA A attempted to enter a different resident's room to wash his hands. The surveyor then stopped him from entering another resident's room. MA A stated that he will go wash his hands at the nurse's station. Observation on 1/29/2025 at 07:40 AM, MA A put the blood pressure cuff used to measure blood pressure on Resident #21 on top of 3 other blood pressure cuffs in the basket included in the blood pressure machine. MA A only wiped down the cuff used to measure Resident #21 blood pressure. CMA A did not wipe down the remaining cuffs and the machine. Interview with MA A on 1/29/2025 at 8:00 AM, MA A stated that he has been in-serviced about providing care for resident on EBP multiple times. MA A also stated that he did not want to use hand sanitizer after measuring Resident #21's blood pressure and wanted to wash his hands. MA stated he should have sanitized all the remaining blood pressure cuffs, but he did not. MA A stated he understood the surveyor stopped him from washing hands in another resident room to prevent the spread of infection after providing care to Resident #21. Record review of Resident #27's face sheet dated 01/29/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included peripheral vascular disease (this is a circulation condition that causes vessels to reduce blood flow to the limbs), chronic venous hypertension idiopathic (this is a brain condition that is caused by a buildup of spinal fluid around the brain), ulcer of left lower extremity, and diabetes mellitus (uncontrolled blood sugars) due to underlying condition with diabetic polyneuropathy (a complication of diabetes that affects multiple nerves in the body). Record review of Resident #27's quarterly MDS dated [DATE] revealed a BIMS score of 14, which indicated cognitive status was intact. MDS also revealed Resident #27 was a 2 person plus extensive assist for bed mobility, transfers, toileting. Resident #27 was coded as having venous and arterial ulcers present. Record review of Resident #27's January 2025 physician orders reflected dressing change 3 times a week and as needed for right lower leg and left lower leg. Cleanse with hibiclens, rinse and pat dry. Apply Betadine to scabbed over areas. Collagen to open areas. Roll with gauze. Record review of Resident #27's care plan, dated 11/26/24, revealed, the resident was on enhanced barrier precautions for wounds. The goal would be no transmission of infection from one or another resident. Interventions included: Gloves and gowns should be donned if any of the following activities were to occur linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. Perform hand sanitation before entering the room and prior to leaving the room. Observation on 01/29/25 at 11:10 AM, LVN D and wound NP were at the bedside, both wearing PPE. LVN D placed a bath towel on each leg of Resident #27. LVN D was wearing PPE for EBP. He removed the old dressings and cleaned Resident #27's leg wounds and pat dried the wounds with the bath towel. Blood was seen oozing from some areas of Resident #27's wounds. LVN D then left Resident #27's bedside and went outside the room to the treatment cart. LVN D took his PPE off before he left the room. When he returned, he put on his gloves and continued wound care. LVN D did not wear a gown when he returned to continue wound care. After LVN D was finished with Resident #27's dressings, he took the bath towels from underneath Resident #27's legs with some blood on them and rolled them and tucked them under his left arm pit. In an interview with the wound NP on 01/29/25 at 11:30 AM, she stated having some bleeding on some for Resident #27's wounds were a good sign because it showed that he was getting blood flow to the extremities (legs). She stated that CDC a couple of years ago or last year started to do Enhanced barrier precautions, gowns, gloves and even mask, as layer of protection against those with chronic should wounds and indwelling lines to prevent in to prevent infection of MDROS to residents with chronic issues including wounds. She stated a gown, and gloves should be worn for EBP infection control. In an interview with LVN D on 01/29/25 at 01:04 PM, he stated he was one of the infection control preventionist, and he was aware of what Enhanced barrier precautions and just forgot to wear his gown when he returned to finish Resident #27's wound care. He stated he did not mean to put the soiled towels in his arm pit, he was actually looking for a bag to put them into. He stated EBP was followed to prevent transfer of infections from clothing to dressing. He stated the gown was used as a barrier to prevent MDRO's infections., He stated the towels were contaminated after use and the risk for not following EBP was Infection. Resident #32 Record review of Resident #32's face sheet dated 01/30/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses were cerebral palsy (a congenital disorder of movement, muscle tone, or posture), abnormal posture, lack of coordination, difficulty speaking, and [NAME]-[NAME] syndrome (this is a genetic disorder that causes intellectual disability, and shortness in height), and attention deficit hyperactivity disorder. Record review of Resident #32's quarterly MDS dated [DATE] revealed a BIMS score could not be complete due to cognitive impairment. She had no indicators of delirium, depression, or behaviors. Resident #32 had impaired range of motion, both upper and lower body, on both sides of his body, and was completely dependent on staff for all his ADLs and movement in bed. Resident #32 was always incontinent of bowel and bladder. Record review of Resident #32's care plan initiated 07/07/22 with a revision date of 12/26/24 revealed Resident #32 had a communication problem (non-verbal. The goal was to be able to make basic needs known by gestures on a daily basis. The interventions were to anticipate and meet his needs, residents required hands to communicate; staff would ensure availability and functioning of adaptive communication. Record review of Resident #40's face sheet dated 01/30/25 revealed a [AGE] year-old male with an initial admitted [DATE] and readmitted [DATE]. His diagnoses included epilepsy (seizure disorder), paraplegia (paralysis), enlarged prostatic with lower urinary infection, metabolic encephalopathy (this is a brain disorder caused by a chemical imbalance in the blood that affects brain function, anemia and hematemesis (low blood count and vomiting of stomach content mixed with blood). Record review of Resident #40's quarterly MDS dated [DATE], revealed cognitive skills for daily decision making was a 0 which indicated he was severely impaired. It was further revealed he was extensively dependent on two staff for bed mobility and was totally dependent on one staff for eating. Record review of Resident #40's care plan initiated 01/28/25 revealed Resident #40 was on Enhanced Barrier Precautions for wounds. The goal for Resident #40 was there would not be any transmission of infection from or to the resident. The interventions were; Gloves and gown should be worn if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity, perform hand sanitation before entering the room and prior to leaving the room, Posting at the residents room entrance indicating the resident is on enhanced barrier precautions, and therapy should use gown and gloves, when transfer training, mobility training, or other high-contact activity. Observation on 01/28/25 at 09:32 AM to 10:24 AM, revealed Resident #32 at the nurse station in his wheelchair. He was listening to the radio that was placed inside his sweatpants at the nurse station. Resident #32 took the radio out of his pants and handed it to RN E. RN E stated Resident #32 had lost his radio channel. She took the radio and went to the medication cart and opened her computer. Resident #40 started to complain that he was cold, and he needed extra blankets. RN E set Resident #32's radio on top of the medication cart and went to the cart in the hallway with linen and took a blanket off the cart. RN E did not perform hand hygiene after touching the radio that was inside Resident #32's pants. RN E took the blanket to Resident #40's room and covered him. RN E pushed Resident #40's bedside and placed the call light within reach. RN E then left Resident #40's room. RN E did not sanitize her hands. She returned to the medication cart and picked up Resident #32's radio and resumed programing the radio. Interview with RN E on 1/30/2025 at 10:06 AM she said she had been at the facility for 2.5 years. She stated she did not perform hand hygiene after she touched Resident #32's radio because she forgot. She stated she then proceeded to enter Resident #40's room to assist him with his blanket without performing hand hygiene. She stated she always does hand hygiene, but she got distracted. She also said the radio was not inside Resident #32's brief, it was in his pants . She stated the purpose of hand hygiene was to promote cleanliness, prevent cross contamination, and infection control for residents and staff. She has had in-service on hand hygiene before. She stated hand hygiene must be done between each resident's care. Interview on 01/29/25 at 09:30 AM the regional compliance nurse wanted to clarify the confusion between isolation & enhanced barrier precaution. She stated that MA A did not have to wear gown and mask when measuring blood pressure on Resident #21. She also agreed that he should perform hand hygiene right after he left Resident #21 room and not enter another resident's room to wash hands to prevent the spread of infection. She stated she provided one-on-one in-service training on hand hygiene with MA A. Interview with the DON on 01/30/25 at 3:34 PM, she stated all staff had all been trained and in- serviced on infection control, hand hygiene, and EBP. She stated the expectation was that they do what they are supposed to do following the infection control policy. She stated infection control monitoring was done by the nursing administration which included the ADON, wound nurse and herself. She stated the purpose for EBP, sanitization of equipment, and hand hygiene was to prevent infection control. Interview on 01/30/2025 at 4:14 PM with the Administrator, she stated her staff has had hand hygiene training. The facility has hallway hand sanitizer, staff were to wash hands when hands were visibly soiled, perform hand hygiene between resident care, medication pass and tray pass during mealtimes. The purpose was to stop the spread of infection. She said the facility provides in-service training on infection control anytime facility identifies an infection control issue; DON also provides in-service training on infection control randomly. Record review of facility's Infection Control Policy & Procedure, Hand Hygiene section, dated 03/2024, some situations that require hand hygiene includes before and after direct resident contact, upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse of blood pressure . Record review of facility's Infection Control Policy & Procedure, Resident care equipment and articles section, dated 3/2024, Non-invasive resident care equipment is cleaned daily or as needed between use. Record review of facility's Enhanced Barrier Precautions, dated 4/1/2024, Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities.

Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable for 1 of 4 resident (Resident # 1) reviewed for activities of daily living. The facility failed to ensure Resident #1 was provided care and services for hygiene. This failure could place residents at risk for poor self-esteem, infections, socialization, ADL decline and diminished quality of life. Findings included: Record review of Resident#1's face sheet dated 12/20/24, reflected; Resident#1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident#1 was diagnosed with paranoid schizophrenia (a type of psychosis, which means your mind doesn't agree with reality), bipolar disorder (A serious mental illness characterized by extreme mood swings) They can include extreme excitement episodes or extreme depressive feelings)., other symptoms and signs involving appearance and behavior, unspecified Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, cognitive communication deficit(Impaired functioning of one or more cognitive process such as: attention, memory, organization, problem solving/reasoning and executive functions) unsteadiness on feet, muscle wasting and atrophy(thinning of muscle mass), not elsewhere classified, multiple sites. Record review of Resident#1's quarterly MDS, dated [DATE] reflected; Resident#1 had a BIMS score of 15, which indicated cognition intact. Section C-Cognitive patterns reflected, Resident#1 was coded at a 2 for behavior present, fluctuate (comes and goes) for disorganized thinking (rambling, irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) and inattention- resident had difficult focusing attention for example, easily distracted. Section E- behavior reflected, Resident#1 had Delusions (misconceptions or beliefs that are firmly held, contrary to reality). Section Functional abilities reflected, Resident#1 was coded refused for bath and showers. Resident#1 was coded independent for other functional activities. Section N-Medications coded 1 for yes : Antipsychotics were received on s routine basis only Record review of Resident#1's care plan dated 10/10/24, reflected focus Resident #1 has an ADL self-care deficit r/t bipolar with agitative behavior. Goal: Resident :will maintain current level of function .:Intervention: Bathing: the resident is is independent with showering in the evenings, but requires supervision. Record review of Resident#1's progress note s dated 07/01/24 to 12/23/24 , reflected: 07/02/24: Patient refused shower. Patient stated, I don't need one. by LVN E 07/02/24: Resident refused shower by by LVN E 07/04/24: Patient refused shower by LVN E 07/09/24: Patient refused shower. Patient stated, I don't need one. by LVN E 07/11/24: Patient refused shower. Patient stated, I don't need one by LVN E 07/16/24: Refused shower. Patient stated, [NAME], I don't need one. By LVN E 07/18/24: Patient refused shower. Patient stated, I'm not dirty. I'm not going to take a shower here. by LVN E 07/23/24: Resident refused shower. by LVN E 07/25/24: patient refused shower. Patient stated, I don't stink. by LVN E 07/30/24: Patient refused shower. Patient stated, I don't smell. You smell. Why don't you go take one. By LVN F 08/01/24: patient refused shower. Patient stated, I don't need one. by LVN E 08/06/24: Refused shower. by LVN E 08/08/24: Patient refused shower. Patient stated, I don't smell. by LVN E 08/20/24 : Patient refused shower. Patient stated, No! by LVN E 08/31/24: Patient refused shower. Patient stated, I don't need one. by LVN E 09/03/24: Patient refused shower. I do not stink! by LVN E 09/05/24: Patient refused shower. Patient stated, [NAME], I don't think so. by LVN E 09/10/24: Patient refused shower. I don't need one. by LVN E 09/17/24: Patient refused shower. Patient stated, No! by LVN E 10/01/24: Patient refused shower. Patient stated, I don't stink! by LVN E 10/17/24: patient refused shower. Patient stated, I don't stink! by LVN E 10/24/24: Patient refused shower. Patient stated, I don't smell! by LVN E 10/27/24: Observed resident standing in doorway requesting trash receptacle to be placed near her door because she had items to place in trash. When barrel was brought to door resident placed a plastic bag of urine with a knot tying the bag closed. When asked why she was putting urine into a bag stated My bathroom works but I don't used the public system. By RN G 10/29/24: Patient refused shower. Patient stated, I'm clean! I don't need to take a shower! LVN E 11/05/24: Patient refused shower. Patient stated, I am clean. LVN E 11/13/24: Resident refused to take shower. LVN E 11/14/24: Patient refused shower. Patient stated, I don't need one. LVN E 11/21/24: Patient refused shower x 3. Patient stated, I told you. I don't stink. LVN E 11/26/24: Patient refused shower x 3. Patient stated, Do you think I stink? Why don't you take a shower! LVN E 12/03/24: Patient refused shower x 3. Patient stated, I'm not taking a shower. LVN E 12/10/24 : Patient refused shower x 3. Patient stated, I don't need a shower. You need a shower. LVN E 12/19/24: DON, administrator, Guardian and PCP met and discussed behaviors and how [Psych MD.] and NP had expressed their concerns about the resident's safety.Dr. is in agreement with psych recommendations. [PCP] also feel that resident is a threat to self and others. Concerns reagrding her environment were also discussed. The Guardian is in agreement that the resident needs to be evaluated at a hihger of level of care. After the discussion, we called for ambulance per [PCP]order and [NP] recommendation. arrived on scene, the Guardian presented them with a copy of her court documentation noting guardianship. They assessed the resident, called their physician and he agreed with transfer. Resident was verbally aggressive toward paramedic. She actually voided in a water pitcher while they were in attendance. When asked why she was doing that (she has a bathroom in her room) she replied that she was measuring her urine output. When offered to have the pitcher of urine emptied, she refused to allow it stating that she needed ice cubes to preserve it. At this point Paramedic called for PD back up. Resident was verbally aggressive and resistant even with the police in sight. Administrator was able to calm her down. Record review of the Hospital record dated, 12/23/24 reflected: Resident #1 was awake and alert and refused vital signs, to change clothes and bathe on 12/20/24, 12/21/24,12/22/24 and 12/23/24. 6 facilities have been sent Resident#1 paperwork and 2 have so far declined for behaviors . Record review of Letter from Director of clinical care of psychiatric services, dated 12/19/24 reflected: Resident#1 has been under psychiatric care services since November 25,2019 .Over the course of the last few months, she has been refusing to take her antipsychotic medication. Her behaviors have increased including delusions, defecting, and urinating in plastic bags and placing them in dresser drawers in her room. Patient refuses showers and exhibit a strong odor, staff are not sure of the condition of her skin or hair. She refuses to allow staff into her room and the facility had to have police intervention to remove prescription medication from the patient room. The patients behaviors including aggression, threats to staff, paranoia, and delusions have increased with refusals. Her current setting is unable to effectively address psychiatric needs. I recommend transferring the patient to a higher level of care for psychiatric care and mental health management. Interview on 12/19/24 at 6:30 PM RN I, stated Resident#1 refused all care from staff. Resident#1 would not take showers or allow staff to clean resident room. RN I, stated Resident#1 refused all care. RN I, stated staff would try to educate resident on the importance of bathing and resident would cuss staff out. Interview on 12/20/24 at 5:33 AM LVN J stated Resident#1 refused care from staff and was aggressive. LVN J stated staff would make three attempts to provide Resident#1 care. Interview on 12/20/24 at 11:30 AM with the Administrator and DON, both stated they cannot meet the resident's needs. The Administrator stated they did not know what they were going to do about the resident and they were waiting on Corporate. The Administrator stated she has been here since July 2024 and the resident has refused care, aggressive towards staff and would not let staff in her room. The Administrator stated the last couple of months of gotten worse. Attempted to interview and observation on 12/23/24 at 8:30 AM reflected Resident#1 at the hospital. Resident#1 was not able to answer questions about the facility. Resident#1 had a odor of urine that could be smelled from the doorway. Resident#1 hair was oily, greasy and her legs and feet appeared to be dry and ashy. Interview on 12/23/24 at 9:30 AM hospital social worker stated she was told that the facility was not taking the resident back . The Hospital social worker stated the guardian stated she did not receive discharge information. Interview on 12/23/24 at 11:30 AM the Director of guardianship stated they did receive immediate discharge information on 12/20/24 around 4pm and they will appeal the decision. The Director of guardianship stated the facility needed a warrant and needed the guardian approval. The Director of guardianship stated they granted it because the facility said they would take the resident back and now it will be hard to place her because of her behaviors, she has been at the facility for 9 years. Attempted to call Resident#1 guardian at 11:43 AM on 12/23/24 and not able to leave voicemail. Attempted to call Psy MD on 12/23/24 at 11:44 AM and received no return call. Attempted to call PCP on 12/23/24 at 11:47 AM and received no return call. Attempted to call NP on 12/23/24 at 12:13 PM and received no return call. Interview on 12/23/24 at 12:25 PM with on-call ombudsman stated the facility had contacted the ombudsman office and needed to do an emergency discharge for Resident#1. Ombudsman stated the facility stated they could not meet Resident#1 needs. Interview on 12/23/24 at 1:00 PM, the SS stated she started to work for the facility at the beginning of October and was told about Resident#1 behaviors. The SS had contacted Guardian to speak with Resident#1 and she never did. Interview on 12/23/24 at 1:30 PM LVNE stated Resident#1 refused all care from staff. LVN E stated three attempts would be made throughout the day to provide care to Resident#1. LVN E stated when Resident#1 refused care it was documented in the progress notes. Interview on 12/23/24 at 2:00 PM the Admin A stated that Resident#1 cannot come back unless she was stable and the hospital records showed adjustments on medications. The Admin A stated the Psy MD stated it would be easier for Resident#1 to transfer to a state hospital from the hospital. The Administrator stated they cannot meet her social, mental and psychology needs there.

Based on observation, interview, and record review the facility failed to ensure the resident had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one of six residents (Resident#1) reviewed for environment. 1. The facility failed to properly clean and maintain a sanitary and comfortable environment free of foul odors for Resident#1 room. 2. The facility failed to maintain a safe environment for Resident#1 room. These failures could place residents at risk for a diminished quality of life due to the lack of a well-kept, home-like environment. Findings include: Record review of Resident#1's face sheet dated 12/20/24, reflected; Resident#1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident#1 was diagnosed with paranoid schizophrenia (a type of psychosis, which means your mind doesn't agree with reality), bipolar disorder (A serious mental illness characterized by extreme mood swings) They can include extreme excitement episodes or extreme depressive feelings)., other symptoms and signs involving appearance and behavior, unspecified Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, cognitive communication deficit(Impaired functioning of one or more cognitive process such as: attention, memory, organization, problem solving/reasoning and executive functions) unsteadiness on feet, muscle wasting and atrophy(thinning of muscle mass), not elsewhere classified, multiple sites. Record review of Resident#1's quarterly MDS, dated [DATE] reflected; Resident#1 had a BIMS score of 15, which indicated cognition intact. Section C-Cognitive patterns reflected, Resident#1 was coded at a 2 for behavior present, fluctuate (comes and goes) for disorganized thinking (rambling, irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) and inattention- resident had difficult focusing attention for example, easily distracted. Section E- behavior reflected, Resident#1 had Delusions (misconceptions or beliefs that are firmly held, contrary to reality). Section Functional abilities reflected, Resident#1 was coded refused for bath and showers. Resident#1 was coded independent for other functional activities. Section N-Medications coded 1 for yes : Antipsychotics were received on s routine basis only Record review of Resident#1's care plan dated,10/10/24 reflected focus . hoarding r/t Paranoid Schizophrenia, Bipolar, Non-Compliant with behavior w/cognitive impairment. Goal: fewer episodes of writing on walls/furniture. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Focus at risk for falls r/t Gait/balance problems, cognitive impairment, psychoactive medication drug usage. Goal: falls and/or injuries minimized thru management of risk factors while maintaining maximum independence and quality of life. Interventions: Anticipate and meet the resident's needs . Follow facility fall protocol. Record review of Resident#1's progress notes dated 07/01/24 to 12/23/24, reflected Progress note dated 11/07/24 by SS reflected Resident#1 allowed a staff to sweep a small part of the entry way to her room, but is still refusing staff to change her bedding and perform housekeeping inside her room. Progress note dated 11/14/24 b y SS reflected resident#1 is still resistive to housekeeping in her room and to proper hygiene. Progress note dated 11/27/24 by SS reflected, Resident#1 IDT team met to discuss the ongoing concerns regarding this resident. She continues to deny access to housekeeping staff to clean her room. The nursing staff is unable to complete the skin assessments and the resident continues to be non-compliant for hygiene. Attempts to care for this resident completed in-house by the facility have failed. Psych services advised that the state hospital may better fitthis resident's needs. Progress note dated 12/03/24 by SS reflected Housekeeping reported that this resident is defecating behind her bedroom door after noticing poop on the floor. While they were cleaning her room, they also noticed that this resident is also urinating in the trash can in her room. This resident is not allowing maintenance in her room to check if the restroom is working. Observation on 12/20/24 at 5:35 AM revealed a strong smell of urine that permeated the South 3 hallway . Observed HK C open Resident#1 door. The smell of urine and feces that came from the room was overwhelming. Observed urine in cups, clothes, pizza boxes personal items thrown around the room and no free space to walk from one end of the room to the next. Observed writing on the wall inside and outside the resident room. Interview on 12/20/24 at 5:41 AM, the HK C stated Resident#1 had gone to the hospital yesterday. The HK stated Resident#1 would not allow staff in her room to clean it for a long time. The HK C stated Resident#1 would cuss and get aggressive with staff. The Housekeeper stated Resident#1 allowed her to swap up feces one time behind the door and told her to get out. The Housekeeper stated she removed a bucket of dirty linen from Resident#1's room that resident took from the hallway and put in her room. The Housekeeper stated Resident#1 had refused services since she been here.HK C stated they let the nurse staff and Admin A know that resident was refusing care. HK C would come back to the resident room later and see if you would allow HK C not clean room. Interview on 12/20/24 at 6:20 AM the HKSP D stated Resident#1 did not allow staff in her room to assist her with anything. The HKSP D stated Resident#1 took BM'S in plastic bags and would urine in cups. The HKSP D stated she was going to try and clean Resident#1 room today. HKSP D stated when Resident#1 refused services we let the DON B and Admin A know and try again later to provide housekeeping services. Attempted to interview Resident#1 on 12/23/24 at 8:30 AM at the hospital. Resident#1 was not able to answer questions about the facility. Observation on 12/20/24 at 11:15 AM the HKSP D bagged up Resident#1's personal items and removed items Resident#1 had took from the facility that was left in the highway for example: pillowcases, sheets, wipes and trash bags. Interview on 12/20/24 at 11:20 AM, the Admin A and DON B stated Resident#1 had been in the facility since 2015. Since she has been there, she would hoard, constantly refuse showers, nail care, dental care, vision care, and refuse housekeeping, maintence and nursing staff access to her room. The DON B stated Resident#1 would creep out of her room [ROOM NUMBER] pm to 6am and grab linen, wipes, any staff or residents' personal items that were left out. The DON B stated she had taken a resident's radio that was found in her room. The Admin A and DON B both stated that since August they had noticed a big change of condition and her behaviors had gotten worst like voiding in plastic bags - BM and Urine, odor progressively worst since July. Resident#1 would not let staff in the room. The DON B stated the smell of Resident#1 room overwhelmed her and she had no idea she had all that stuff in there. The DON B stated several residents did complain about Resident#1's odor (Residents with the complaints were not confirmed). Admin A and DON B stated they held meetings with the IDT, guardian, Psy MD, NP, PCP about Resident#1 behavior and it was determined the facility can not met Resident#1 needs, The Admin A and DON B stated the room was not sanitary. Interview on 12/23/24 at 1:00 PM, the SS stated she started to work for the facility at the beginning of October and was told about Resident#1 behaviors. The SS had contacted Guardian to speak with Resident#1 and she never did. Attempted to call Resident#1 guardian at 11:43 AM on 12/23/24 and not able to leave voicemail. Attempted to call Psy MD on 12/23/24 at 11:44 AM and received no return call. Attempted to call PCP on 12/23/24 at 11:47 AM and received no return call. Attempted to call NP on 12/23/24 at 12:13 PM and received no return call. Record review of facility's admission packet Nursing Facility Residents; Rights, dated 11/2021, reflected .you have the right to: live in safe, decent and clean conditions

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 4 residents (Resident #1) reviewed for abuse . The facility failed to protect Resident #1 from physical abuse by Resident #2. This failure could place residents at risk of abuse, injury, and emotional distress. The noncompliance was identified at PNC. The noncompliance began on 11/25/2024 and ended on 11/25/2024. The facility had corrected the non-compliance by monitoring Resident #1 and Resident #2 every 15 minutes and issuing a discharge notice to Resident #2. Findings include: 1. Record review of Resident #1's admission record, dated 12/11/2024, reflected a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1 had diagnoses which included severe dementia with behavioral disturbance, anxiety disorder, and mixed obsessional thoughts and acts. Record review of Resident #1's quarterly MDS assessment, dated 11/25/2024, reflected a BIMS score of 0, which indicated severe cognitive impairment. Record review of Resident #1's care plan, dated 11/12/2024 , reflected Resident #1 had impaired cognitive function (i.e. impaired judgement related to dementia), has a behavioral problem (i.e. urinating on floors, throwing food on walls, pull call light out of wall), has a mood problem, has potential to demonstrate physical and verbal behaviors (i.e. hitting staff, pushing cleaning cart into people, yelling, throwing items related to anger secondary to dementia), is an elopement risk/wanderer and is at risk for injury due to wandering aimlessly. Record review of Resident #1's skin assessment, dated 11/25/2024, reflected scattered dark colored bruising on the right forearm from the elbow to the wrist, right hand 2nd finger, and left eye extended to below the eye socket. 2. Record review of Resident #2's admission record, dated 12/11/2024, reflected a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2 had diagnoses which included depression, anxiety disorder, bipolar disorder and intermittent explosive disorder. Record review of Resident #2's most recent optional state assessment MDS, dated [DATE], reflected a BIMS score of 15, which indicated intact cognition. Record review of Resident #2's care plan, dated 10/18/2024, (with 12/10/2024 revisions) reflected behavioral problem evident by verbally abusive behaviors, and is/has potential to be physically aggressive and verbally aggressive related to impulse. Record review of Resident #2's Notice of Immediate Discharge, dated 12/03/2024, reflected Resident #2 would be discharged on [DATE] due to recent and ongoing behaviors which included verbal and physical aggression towards other residents and staff. Record review of provider investigation report, dated 11/25/2024, reflected in part, Dietary Manager reported to the ADM that she was sitting in her office when she heard someone hollering, she stepped out to see what was going on. When she got to the dining room area, she witnessed [Resident #2] holding onto [Resident #1's] hand. The Dietary Manager separated the two residents, made sure that [Resident #1] was safe, then reported the incident to the ADM. When questioned, [Resident #2] denied the allegation. When questioned, [Resident #1] was able to identify [Resident #2] as his aggressor. [Resident #1] stated that a white man with long hair, mean, was here in hallway and in a wheelchair, twisted his arm and punched him in the eye. [Resident #1] looked over his shoulder and pointed at [Resident #2]. Further investigation, documentation, and evidence indicate/confirm the allegation happened . Observation and interview on 12/10/2024 at 11:21 AM, revealed Resident #2 was in the dining room . Resident #2 stated he and Resident #1 were in the dining room area, next to the beverage dispensers where residents could get beverages themselves. Resident #2 stated, Apparently, I grabbed his (Resident #1) hand . that is what the kitchen lady (dietary manager) told me; but did not recall the action. Resident #2 took a cup out of Resident #1's hand and Resident #1 was nasty and had behavioral actions in the dining room area where he had urinated on the floor and stuck his fingers into the beverage dispensers. When asked about if staff members were present for the incident, Resident #2 stated there were never staff members in the dining room area , but he informed staff members of Resident #1's actions prior to the alleged incident. Resident #2 was aware of the 30-day discharge notice and further stated they (the facility) want me out and he did not appeal the discharge. He stated he would understand why he would get kicked out if the incident had happened. Resident #2 continued to deny the incident and did not think there was an incident. Observation and interview on 12/10/2024 at 12:47 PM, Resident #1 was in the dining room, drinking coffee. Resident #1 indicated he only spoke Spanish. The State Surveyor attempted to use the language line with an interpreter and google translate, but Resident #1 stated he was deaf. At 12:54 PM, the Laundry Aide entered the dining room and told the State Surveyor she spoke to Resident #1. She translated Resident #1 said he was good, but hungry and that he fell , but nobody hurt him. The State Surveyor asked when he fell , Resident #1 stated he did not know when and it had been days and to forgive him because he could not communicate. Interview on 12/10/2024 at 1:14 PM, the Dietary Manager stated she had been in her office at the time of the altercation between Resident #1 and Resident #2. She stated she heard a different distress like scream. She opened her door and went to the dining room and saw Resident #2 holding onto Resident #1's wrist, identifying the scream was from Resident #1. The Dietary Manager told Resident #2 to back away from Resident #1, Resident #2 responded by saying He (Resident #1) touches all the things we fucking use and fucking eat. The Dietary Manager took Resident #1 to his room to get him into a safe area and had Resident #2 go to the tv area. She then reported the incident to the ADM. Interview on 12/10/2024 at 1:36 PM, LVN A stated he did the assessments on the residents following the incident. LVN A stated Resident #1 had bruises on his right forearm and bruises to the left eye that looked new based on its coloring . He did not recall Resident #1 having bruises that significant prior to the incident. LVN A stated Resident #2 did not have bruises or scratches. LVN A stated he saw the video of the incident and stated Resident #2 did hit Resident #1. Observation and interview on 12/10/2024 at 2:58 PM, with the Administrator, revealed she was able to receive a video of the incident on 11/26/2024. Surveyors viewed the video with the Administrator. The video revealed Resident #1 and Resident #2 were in the dining room on 11/25/2024. Resident #1 was seen in his wheelchair and rolled to the beverage dispensers. Resident #2 was seen in his wheelchair, and he watched Resident #1 go to the beverage dispensers. Resident #2 then rolled to the beverage dispensers where Resident #1 was. Resident #1 and Resident #2 had initially interacted without physical altercation, and then Resident #2 punched Resident #1 in the face. Resident #1 rolled backwards in his wheelchair and tried to get away from Resident #2, but Resident #2 held onto Resident #1. The ADM stated after she watched the video and confirmed the allegation was true, she questioned Resident #2 about the incident again. He denied it. She then showed Resident #2 the video, and he then stated, I guess you got me. He was then notified with a 30-day discharge. Interview on 12/10/2024 at 4:05 PM, RN C stated he was in-serviced on resident to resident altercations. He stated he was not there for the incident with Resident #1 and Resident #2 and was still monitoring both residents every 15 minutes. RN C stated they were still monitoring to ensure no other incidents would happen, not only with Resident #1 and Resident #2, but with other residents. Interview on 12/11/2024 at 10:27 AM, RN B stated she was not there when the incident with Resident #1 and Resident #2 happened. She stated she had been in-serviced on resident to resident altercations and they were doing 15 minute interval checks for both residents. She said they documented where each resident was, and if needed they could preemptively redirect. Interview on 12/11/2024 at 2:39 PM, the ADM stated to prevent resident to resident altercations, they in-serviced staff on de-escalation, customer service and redirection. She stated some residents got to the point where their medications needed to be reviewed. She said some residents needed a dementia unit and Resident #2 did not understand dementia. Record review of resident to resident monitoring dated 11/25/24 and 11/26/24 reflected no staff had seen an altercation between Resident #1 and Resident #2. Record review of inservices dated 11/25/2024 reflected staff were inserviced on the topics of De-escalation training and Abuse and Neglect Record review of the facility's policy titled, Abuse/Neglect revised 3/29/18, reflected in part; The resident has the right to be free from abuse, neglect, misappropriation of resident property as defined in this subpart .Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals . Resident to Resident The above policy will apply to potential resident-to-resident abuse. Provider letter 19-17 will be reviewed to determine if resident-to-resident abuse occurred

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 for three (Residents #10, #17 and #457) of 26 residents and three (South 1 (cold zone), South 3 (cold zone) and Warm Zone halls) of six halls reviewed for infection control. 1.LVN A, DON G and ADON Q failed to completely review Resident #10's Hospital Discharge documents and was unaware the resident had a [CONDITION(S)] diagnoses, until HHSC Surveyors notified the facility. The facility failed to ensure Resident #10 had Contact Isolation Precautions on the resident's room door, with door closed and other PPE measures in place to prevent cold zone residents from [CONDITION(S)] exposure. The facility failed to place Resident #10 in the warm zone for droplet precautions with an unknown COVID-19 status to prevent cold zone residents from possible COVID-19 exposure. 2.The facility failed to have contact isolation precautions in place for Resident #17 diagnosed with ESBL and VRE. The facility failed to ensure Resident #17 was on the warm zone hall for COVID-19 droplet precautions to prevent other residents from possible COVID-19 exposure. 3. The facility failed to ensure The Warm Zone hall had appropriate signage indicating it was a warm hall zone and type of PPE needed to enter. The facility failed to ensure their Cold Zone residents did not have to enter the Warm Zone Hall to get therapy, where the Therapy Room was located. The facility failed to ensure LVN A doffed PPE prior to exiting Resident's #10 and #17's rooms. The facility failed to ensure LVN A sanitized the Glucometer after each use. CNA BB failed to prevent cross contamination when she failed to follow proper PPE precautions, she entered resident #10's room then went to other resident's rooms afterwards to deliver meal trays. An Immediate Jeopardy (IJ) was identified and the IJ template was provided to the facility 08/11/21 at 5:36 PM, the facility was informed that a Plan of Removal would need to be completed. While the IJ was lowered on 08/14/21 at 12:25 PM the facility remained out of compliance at a severity level of Actual harm that was not Immediate Jeopardy and a scope of Widespread due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. These failures placed all residents at risk of increased infections and antibiotic resistant illnesses, which could decrease their psycho-social well-being and quality of life. Findings included: 1) Review of Resident #10's face sheet revealed a [AGE] year-old male who admitted [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's Quarterly MDS Assessment date 06/01/21 revealed the resident had a BIMS score of 15 with no cognitive impairments, extensive two person assistance, always incontinent to bladder and frequently incontinent to bowel . Review of Resident #10's Hospital Discharge Summary undated revealed, admitted [DATE], for Primary Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Medication: IV [MEDICATION(S)] HCL 250 ML . start 08/09/21 and stop 09/13/21 .Assessment and Plan: 08/03/21 [CONDITION(S)] PCR screen positive Left heel wound . Review of Resident #10's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . All meals are to be served in room, every shift for COVID monitoring. Review of Resident #10's Care Plans revealed, Risk for COVID-19 infection due to probable/possible exposure, pressure injury related to mobility, [CONDITION(S)], ADL self-care performance deficit related to [CONDITION(S)], diabetes mellitus II Observation on 08/11/21 at 8:43 AM, on the Cold Zone hall, CNA BB with a surgical mask, no gown or other PPE, entered Resident #10's room to deliver their breakfast tray and moved items on the bedside table to make way for the meal tray but the resident stated they did not want Breakfast. CNA BB exited the room and placed Resident #10's breakfast tray back onto the meal cart, without sanitizing her hands and then she went to Resident #47's room and poured the resident a cup of coffee and without sanitizing her hands she proceeded to get another tray off of the cart and entered Resident #28's room and delivered it, which resulted in cross contamination exposure from Resident #10 to the other residents on the cold zone hall. Observation of Resident #10 on 08/11/21 at 9:00 AM, the resident was on the Cold Zone hall with a droplet precautions notice on the resident's door that was opened and PPE kit in place and no contact isolation precautions in place. Observation and interview on 08/11/21 at 11:45 AM, revealed Resident #10 had an isolation cart outside the door and signage posted droplet precautions, the door was opened, no trash or biohazard container present, and no contact isolation precautions in place. Resident #10 stated he had not received the COVID-19 vaccination and not planned to get it either because they did not want it. Interview on 8/11/21 at 9:59 AM revealed, LVN A stated she received a Hospital report on 8/10/21 about Resident #10 and the resident arrived around 11:30 AM or 12:00 PM and stated she did not know Resident #10 had [CONDITION(S)]. Resident #10's Hospital nurse did not mention the resident had [CONDITION(S)] and added she reviewed the resident's medications but did not look at his hospital Discharge records. She stated she notified DON G and ADON Q about Resident #10's re-admission and to take antibiotics, with a PICC line and called and texted the Resident's doctor to review the resident's medications and was told the orders would stay the same. She stated DON G told them when a resident admitted with contact isolation they were to document it in the 24 hour Nursing book located at the nurse's station and get the medical records guy to put out the PPE cart to be placed by the resident's door. Interview on 08/11/21 at 10:00 AM, Resident #10's NP stated she was not aware of any of their residents who had [CONDITION(S)] with IV [MEDICATION(S)] orders, she said she was on call yesterday and received the call from the nurse about Resident #10's re-admission. Interview on 08/11/21 at 11:52 AM, Resident #10's NP stated after she reviewed the resident's medication list, she saw the order for IV [MEDICATION(S)] that did not state why he needed it (but the resident had been on IV [MEDICATION(S)] before for chronic wound infections) and for the resident to follow up with the infectious disease Doctor within 1 -2 weeks. She stated Resident #10's Physician was on leave but the physician spoke to DON G today 08/11/21 about setting up the resident's IV [MEDICATION(S)] treatments because the medication had not been received from the pharmacy yet. The NP stated she would like to be aware when a resident had IV [MEDICATION(S)] orders soon after they admit and not sure why they were just notified this day 08/11/21 about Resident #10. She stated she reviewed Resident #10's medication list because that was what the nurse faxed and not the resident's hospital records and added they did not have any resident's with [CONDITION(S)]. Interview on 08/11/21 at 12:13 PM, DON G stated after the charge nurse put the residents orders into the system, she and ADON Q were responsible for reviewing the resident discharge paperwork and said she was not sure how their [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated Resident #10 readmitted from the hospital yesterday 08/10/21 and she had not reviewed their discharge orders. For a resident with contact isolation orders, they usually tried to review the resident's discharge paperwork by the next day or sooner and for residents with contact isolation orders they have to set up contact isolation cart with gowns, shoe covers, gloves with everything in there, biohazard bins in the resident's room and then inform the nurses to notify staff to update the resident's status. She stated Resident #10 was isolated to his room but not sure if the resident was getting therapy and spoke to Resident #10's doctor about their hospital orders and antibiotic and no new orders for anything and added the Doctor should already be aware Resident #10 had [CONDITION(S)]. She stated Resident #10 was on IV [MEDICATION(S)] for [CONDITION(S)] of his foot and added she had not spoken to the NP on call but spoke to Resident #10's Doctor. Interview on 08/11/21 at 12:27 PM, ADON Q stated Resident #10 had [CONDITION(S)], she found out from DON G who looked over his hospital records. the floor nurse was either LVN A or LVN B and the only thing said about Resident #10 was if they would get a wound vac. She stated she and DON G were responsible for reviewing admission paperwork from the hospital, she stated she reviewed most of Resident #10's Hospital paperwork right after he readmitted but was busy and overwhelmed with what she had to do that Tuesday 08/10/21 because she made resident round visits with the wound care Doctor which was an all-day process. Interview on 08/11/21 at 2:00 PM, the DON G stated Resident #10 was on droplet and contact precaution and typically the resident did not want to be in the Quarantine Warm Zone Hall. She stated the resident was on contact isolation with the boxes with bag inside his room and PPE kit outside the resident's room door and added she and ADON Q were working on getting Infection Control Certification and no sure who the Certified Infection Preventionist was. Interview on 08/11/21 at 5:22 PM, the DON G stated her expectations when it came to admitting residents with [CONDITION(S)] or other infectious diseases was to first review the orders, do an assessment completed within a few hours. She stated it was important to know what went on with the residents and up to the resident's Charge Nurse to review the hospital records and added she and ADON Q were mainly responsible for also reviewing hospital discharge paperwork. Interview on 08/11/21 at 5:30 PM, the Administrator K stated they reviewed the resident's discharge paperwork to make sure they met the resident's needs by setting up the room for any precautions they had. She stated the nurse received the resident's Paperwork then ADON Q or DON G reviewed it and added she expected the resident's paperwork to be reviewed by the next day if the resident admitted late in the night but if the resident admitted early she expected the resident records to be reviewed the same day. She stated, Honestly HHSC showed up and they were busy and may not have reviewed Resident #10's paperwork. Observation of Resident #10 on 08/11/21 at 5:49 PM, the resident was on the Cold Zone hall with Contact and Droplet precautions notice was on the resident's door that was opened, with a PPE kit in place and two boxes with hazard bags inside of the resident's room. 2) Review of Resident #17's face sheet, dated 08/16/21 revealed, A [AGE] year old female who admitted to this facility 01/15/08 and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #17's Quarterly MDS assessment dated [DATE] revealed, BIMS 10 with moderate cognitive impairment, extensive 1-2 person assistance, always incontinent to bladder and frequently incontinent to bowel and at risk of developing pressure ulcers/injuries and no unhealed pressure ulcers/injuries. Review of undated Care Plan for Resident #17 reflected Impaired visual function related to [CONDITION(S)] Left eye, [CONDITION(S)], functional bladder incontinence related to impaired mobility, diabetes mellitus ( No care plan for ESBL or VRE or contact or droplet precautions) Review of Resident #17's Hospital Discharge paperwork undated revealed, The resident admitted [DATE] for A-Fib .diagnosed for Severe [CONDITION(S)], acute [MEDICATION(S)] .VRE [CONDITION(S)], GPR bacteremia likely contaminant .Plan: VRE Urinary tract infection/[CONDITION(S)]/retroperitoneal abscess. Continue [MEDICATION(S)]. Will complete 10 day source .page 40 of 49 Contact isolation precautions: [CONDITION(S)] continuous .'. Review of Resident #17's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .active 08/12/21. Review of Resident #17's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .discontinued 08/12/21. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Clean J/P drain site once daily related to [CONDITION(S)] .Contact Isolation related to ESBL in urine (Enterobacterales are a large order of different types of bacteria (germs) that commonly cause infections both in healthcare settings and in communities. Examples of germs in the Enterobacterales order include Escherichia coli (E. coli) and [CONDITION(S)] pneumoniae) .Resident requires strict isolation for COVID monitoring in a single occupancy room. All therapy and treatments are to be provided in the room. All meals are to be served in the room every shift for COVID monitoring . Observation of Resident #17 on 08/10/21 at 1:10 PM, Resident #17 was on the Cold Zone Hall with droplet precaution notice on the resident's door with a PPE kit and no contact isolation precautions in place. Observation of Resident #17 on 08/11/21 at 12:15 PM, Resident #17 was on the Cold Zone Hall with droplet precaution notice on the resident's door with a PPE kit and no contact isolation precautions in place. Observation of Resident #17 on 08/11/21 at 5:50 PM, Resident #17 was on the Cold Zone Hall with Droplet and Contact isolation precautions notice on the resident's door with a PPE kit. Interview on 08/11/21 at 5:22 PM, the DON stated she was aware Resident #17 had ESBL but the resident did not want to move and knew ESBL required contact isolation but unable to explain why there was no contact isolation notice and other precautions already in place. Interview on 08/11/21 at 10:28 AM, the Administrator K stated they just found out Resident #10 had [CONDITION(S)] she just asked DON G who looked at the resident's hospital discharge paperwork and [CONDITION(S)] diagnosis, the resident readmitted yesterday. The Administrator K stated , for residents with [CONDITION(S)] and ESBL she would have to pull the facility's policy but knew Resident #10 and #17 should be on contact isolation in their rooms and added she was not sure how Resident #10's [CONDITION(S)] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she knew the therapy room was on the Quarantine Warm zone hall and not sure why because it was located there before she started working at this facility. Interview on 08/11/21 at 5:30 PM, the Administrator K stated she was aware Resident #10 and Resident #17 had droplet precautions, but they were not moved to the warm zone hall because they did not want to move. She stated ESBL and [CONDITION(S)] required contact isolation but was unable to explain why the contact isolation precautions were not already in place for these residents. prior to 08/11/21. Interview on 08/15/21 at 8:48 AM, Resident #10's Doctor and facility Medical Director stated the Administrator K contacted her Wednesday 08/11/21 about Resident # 10 re-admission issues then on Thursday 08/12/21 because they had an IJ related to Resident #10's not on being on proper precautions with being in a room and not vaccinated and not in right hall. DON G also called her Wednesday 08/11/21 morning around 7:00 AM and it was more patient care related about starting Resident #10's IV treatments and that the resident had [CONDITION(S)]. She stated if a resident had [CONDITION(S)] they should be on contact isolation with antibiotics and they should be isolated until the antibiotic was completed and added Resident #10 should have been on contact isolation when he readmitted [DATE]. She stated she told DON G Resident #10 needed to be on contact isolation until his antibiotic treatment ended and said this facility should have an Infection Preventionist, they used to and not sure if they still did. She stated the same went for Residents with ESBL, the resident would need to be on contact isolation until their antibiotics were completed. She stated if a resident admitted from the hospital with unknown COVID-19 status, the resident should be on a warm zone hall, for droplet precautions, Resident #10 should have been on the warm zone. She stated Resident #10's infection would be the second layer of infection and aware of Resident #17 with ESBL should be on the warm zone also. She stated it would be safer for the facility's therapy room to be on the cold zone than warm zone. She stated when a resident admitted to the facility the nurse sent the Resident's clinicals of pending admits, then once admitted the nurse sent the resident's medication list notified her when they admit. She stated the nurse had to notify her or her NP within a couple of hours and added droplet precautions were in the air and had to wear PPE to protect the eyes, mouth, nose and needed a gown, gloves, eye protection and mask and for contact isolation was just making contact with a person and gloves and gown needed but with COVID-19 mask also needed. 3)Observation of the warm hall on 08/11/21 at 8:27 AM, on the Warm hall/Isolation hall, CMA C entered Resident #457's room without donning Personal Protective Equipment. The room door had a bright yellow Droplet precaution Sign. The CMA C exited the room, donned PPE and re-entered Resident #457's room, then exited the room wearing the same PPE and without proper hand hygiene. CMA C then opened the medication cart and touched the medication bubble packs and over-the- counter medication containers. Interview with CMA C on 08/11/21 at 9:03 AM, stated the warm hall/isolation hall was where residents were housed upon return from hospital or newly admitted residents. CMA C stated staff were supposed to don face shield, mask, gown, and gloves. CMA C stated he should not have entered room Resident #457's room without donning PPE. CMA C stated he was not supposed to wear PPE into the hall. CMA C stated he should have doffed PPE prior to exiting room. CMA C stated he had been in-serviced on doffing and donning of PPE last week. CMA C stated failure to don and doff PPE correctly placed residents/staff at risk for infection. Observation on 8/12/21 at 8:33 AM during routine medication pass revealed LVN A donned PPE and enter Resident #10's room located on the Warm Hall, carried a Glucometer, test strip and alcohol swab. Resident #10 had Contact and Droplet precautions posted on the door and LVN A exited this room wearing PPE then placed the Glucometer on the top left side of the medication cart without sanitizing it, then touched and opened the medication cart to obtain the Flex-pen with insulin. LVN A then re-entered Resident #10's room to administer the insulin without following the proper PPE policy. Observation on 8/12/21 at 8:37 AM revealed LVN A donned PPE and enter room [ROOM NUMBER] with Glucometer contaminated with blood from Resident #10. LVN A exited room [ROOM NUMBER] wearing PPE and place Glucometer on top left of medication cart without sanitizing glucometer. Interview with LVN A on 8/12/21 at 9:42 AM stated she should not have exited Resident's room wearing PPE. LVN A stated she should have discarded the contaminated PPE in the Resident's room before exit. LVN A stated, should I clean the Glucometer after each use? followed by she was supposed to clean the Glucometer with a sanitizing wipe after each use. Interview on 8/13/21 at 10:35 AM with LVN B stated residents with infectious process would have a sign posted on resident door. Stated there would be a PPE kit outside the resident's room. LVN B stated PPE should be donned prior to entry and doffed prior to exit. LVN B stated failure to follow protocol placed residents/staff at risk for exposure to infectious process. LVN B stated Glucometers should be cleaned with sanitizing wipes after each use. Review of the Facility's Operational Policy and Procedural Manual dated 2001 MED-PASS, INC. (Revised September 2005). Infection Control-Personal Protective Equipment - Gowns, Aprons, Lab Coats Discarding Used Gowns 2. When gowns are used, they must be used only once and discarded into appropriate receptacles located in the room in which the procedure was performed. Location of 6. For easy access, gowns, aprons, and lab coats are maintained at: a. Central Supply b. Nurses' Stations c. Isolation Rooms Record review of the facility's Policy and Procedure: IC.1.029 TITLE: Cleaning, Disinfecting and Sterilizing Resident Care Equipment DEPARTMENT: Infection Control Facility has a process to ensure shared or non-dedicated equipment is cleaned and disinfected after use according to manufacturer's recommendations. CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements: Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use. Clean outside of meter using a lint free cloth dampened with soapy water or IPADisinfecting-1:10 dilution of water and bleach (or bleach wipe), dampen a paper towel and thoroughly wipe down the meter or use Super Sani-Cloth® & Sani-Cloth® HB Germicidal disposable wipes. Review of the facility's Policies and Practices - Infection Control Revised 2005 revealed, Policy statement .the facility's infection control policies and practices are intended to facility maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections .'. Review of the facility's Infection Control Program standards of Practice revision dated 11/17 revealed, Standard of Practice: is to prevent the spread of infection and provide appropriate education for staff and residents concerning infection control. To monitor infections and facility areas of infection and provide isolation precautions as directed by the CDC Long Term Care recommendations and according to regulatory guidelines F880 . Review of the CDC Campaign to prevent Antimicrobial resistance in Healthcare Settings dated 2005 and provide by the facility revealed, .Prevent Transmission: Step 9 Isolate the pathogen- use standard precautions .contain infectious body fluids (use approved droplet and contact isolation precautions) . Review of the facility's Infection Control Coordinator Policy Revised date 2005 revealed, Policy statement: The Infection Control Coordinator is responsible for coordinating the implementation and updating of our established infection control policies and practices .3. The infection Control Coordinator shall keep abreast of changes in the infection control guidelines and regulations to ensure our facility's protocols remain current and aid in preventing and controlling the spread of infections . Review of the facility's Equipment and Supplies Used During Isolation dated September 2005 revealed, Policy Statement: Appropriate equipment and supplies will be used to maintain sanitary conditions while isolation precautions are in effect . Review of the facility's Personal Protective Equipment dated September 2005 revealed, .Policy Interpretation and Implementation: .4. A supply of protective clothing and equipment is maintained at each nurses station. Employees who fail to use personal protection equipment when indicated may be disciplined in accordance with our facility's personnel policies. Review of the facility's Personal Protective Equipment - Gowns, Aprons, Lab Coats dated September 2005 revealed, All personnel must use gowns, aprons and lab coats when soiling of thee clothing with blood, body fluids, secretions, or excretions is likely to occur during treatments . Review of the facility's COVID-19 Policy and Procedure Updates undated revealed, .Full PPE should be worn per CDC guidelines for the care of any resident with known or suspected COVID -19 symptoms or diagnosis . An Immediate Jeopardy (IJ) was identified and the IJ template was provided to the facility 08/11/21 at 5:36 PM, the facility was informed that a Plan of Removal would need to be completed. While the IJ was lowered on 08/14/21 at 12:25 PM the facility remained out of compliance at a severity level of Actual harm that was not Immediate Jeopardy and a scope of Widespread due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. The facility's Plan of Removal last Resubmitted version dated 08/12/21 at 6:57 PM was approved and revealed: [Facility Name] August 11, 2021 Attention: Program Manager Re: Plan of Removal of Immediate Jeopardy - Infection Control The following is a plan of removal, which has been immediately implemented at [Facility Name] to remedy the immediate jeopardy as a result of the alleged deficient practices, which was imposed on August 11, 2021 at 5:39pm. All staff in-serviced on Infection Control and Prevention Policies & Procedures related to Multidrug Resistant Microbial Organisms on August 11, 2021, by Administrator, /Director of Nursing (DON), and/or designee (s). All staff members not present, during time of in-service will not be permitted back to work until in-service and competency test is complete. All weekend only staff will be in-serviced with competency test to follow prior to working his/her next shift. DON and/or designee will observe infection control practices of 5 random staff members performing care in the warm zone or isolated rooms per week for the next 4 weeks and periodically thereafter to ensure proper infection control and prevention compliance. Any abnormal findings will be immediately addressed and brought to the QAPI committee. All staff in-serviced on Donning/Doffing PPE when providing resident care for those on contact isolation on August 11, 2021 by Administrator and DON. All staff members not present, at time of in-service will not be permitted back to work until in-service and competency test is complete. All weekend only staff will be in-serviced with competency test to follow prior to working his/her next shift. Donning/Doffing supplies, gloves, face shields, and masks placed outside each resident room in isolation carts. DON and/or designee will monitor donning/doffing practices of 5 random staff members per week for the next 4 weeks and periodically thereafter to ensure proper Donning/Doffing compliance. Any abnormal findings will be immediately addressed and brought to the QAPI committee. All staff in-serviced on Contact Isolation Policies & Procedures including proper signage to indicate isolation precautions on August 11,2021 by Administrator and DON. All staff not present, at time of in-service will not be permitted back to work until in-service and competency test is complete. All weekend only staff will be in-serviced with competency test to follow prior to working his/her next shift. Resident's requiring isolation precautions were immediately moved to the warm zone and Contact/Droplet isolation signage placed on resident #10's doorway entry on August 11, 2021, to further indicate appropriate isolation practices. Proper signage placed on all other resident doorway entries to indicate proper isolation precautions related to the resident's specific isolation criteria. Contact isolation precautions immediately implement for resident #10 on 8/11/2021 to include donning/doffing appropriate PPE (gowns, gloves, face shield and mask) prior to providing care to resident. Infection control & prevention meetings will be held by facility interdisciplinary team members weekly during standards of care meeting. DON and/or designee to monitor 5 resident contact isolation rooms per week and periodically thereafter to ensure contact isolation practice compliance. Any abnormal findings will be immediately addressed and brought to the QAPI committee. Administrative Staff (Administrator, DON, Assistant Director of Nursing) & Floor Nursing Staff in-serviced on Admission Policies & Procedures related to general admissions process, admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrative staff & floor nurses not present at time of in-service will not be permitted back to work until in-service and competency test is complete. All weekend only staff will be in-serviced with competency test to follow prior to working his/her next shift. Facility immediately implemented admit checklist to prevent admitting/re-admitting a resident with an infectious disease. Admit checklist includes verifying resident diagnoses. DON/ADON will review all referral paperwork to verify resident diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . If infection prevention/isolation practices are required for new/ readmitted resident, DON and/or designee will immediately notify charge nurse of the admission and assist with appropriate isolation room setup. Administrator/DON and/or designee to monitor all new/re-admits to ensure admission process, orders, and communicable disease admit compliance. Any abnormal findings will be immediately addressed and brought to the QAPI committee. All residents have the potential to be affected by the this alleged deficient practice. The Medical Director, was initially made aware August 11, 2021 of the immediate jeopardy, and has been involved in the development of the plan to remove. These conversations are considered a part of the QA process. Next schedule QA meeting set for August 16, 2021 at 12pm. All in-servicing began 8/11/21 and will be completed prior to the start of the employee's next shift. All weekend only staff will be in-serviced with competency test to follow prior to working his/her next scheduled shift. All in-servicing indicated in POR was completed on 8/11/21 for all shifts including weekend only staff. In-serving related to POR will be ongoing monthly for the next 6 months and quarterly thereafter. Competency test related to POR in-servicing are in place and ongoing for all staff prior to the start of that individuals shift on 8/12/21. All weekend only staff members competency test will be completed during all staff COVID testing date 8/13/21 and prior to the start of his/her next shift. All competency test Following is a list of all in-servicing completing pertaining to the alleged deficient practice: 1. All staff in-serviced on Infection Control and Prevention Policies & Procedures related to Multidrug Resistant Microbial Organisms 2. All staff in-serviced on Donning/Doffing PPE 3. All staff in-serviced on Contact Isolation Policies & Procedures including proper signage to indicate isolation precautions 4. Administrative staff & floor nurses in-serviced on Admission Policies & Procedures related to general admissions process, admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Following is a list of competency test/checks to be completed at the conclusion of in-service 1. Infection Control and Prevention Policies & Procedures related to Multidrug Resistant Microbial Organisms Competency Test 2. Donning/Doffing Competency Test 3. Contact Isolation Polici [TRUNCATED]

Based on observation, interview and record review, the facility failed to maintain patient care equipment in safe operating condition for 67 Residents (Residents #1-#67) of 87 residents reviewed for Full Code Status when the facility's only AED was nonfunctional. 1. LVN G failed to notify administration or obtain replacement pads after the AED (automated external defibrillator) was used, and replacement pads were not in the facility. 2. LVN D and LVN F failed to report to administration when conducting daily crash cart checks that revealed the AED was nonfunctional. An immediate Jeopardy was identified on 12/21/16. While the IJ was removed on 12/22/16, the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy and a scope of pattern because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures could affect the 67 residents who were full code status at risk for a decreased survival rate in the event of a [MEDICAL CONDITION] or possible death. Findings included: An observation on 12/21/16 at 2:10 PM with ADON A revealed the facility's only AED revealed the green light was not illuminated indicating the AED was operational. An observation on 12/21/16 at 2:20 PM with ADON A revealed the AED was in the case, however was disconnected from the battery. Defibrillator pads were not in the AED. On 12/21/16 at 2:30 PM, the Maintenance Supervisor was asked why the battery was disconnected; he said I disconnected the battery on 12/08/16 because the AED kept beeping. In addition he further stated, The AED will continue to beep if there are no pads attached and confirmed he had not connected it because there were no replacement defibrillator pads in the facility. On 12/21/16 at 4:45 PM, LVN G stated he used the last AED pads on 12/14/16. He stated he went to Central Supply on 12/14/16 and no replacement pads were available. LVN G stated he had not notified anyone that the AED was out of pads. On 12/21/16 at 4:05 PM, LVN F was asked if she performed the Crash Cart Check on 12/14/16, she stated, Yes, around midnight. I signed my signature on the Crash Cart Checklist and wrote, No under the column Defib green light. The green light on the AED reveals it is ready for immediate use (battery and defibrillator pads are connected). She confirmed she had not notified anyone. Review of the Crash Cart Check list reflected from 12/15/16 through 12/21/15 LVN D signed her name as completing the checklist. Under the column, Defib green light, she wrote no without further documentation. On 12/21/16 at 4:15 PM an attempt was made to contact LVN D for an interview. At the time of exit a return phone call was not received. On 12/21/16 at 2:12 PM, ADON A (DON designee) for the South Station (where AED was located) was asked if she would expect the AED to be functional at all times, she stated, Yes. She further stated, I do not see the blinking green light (indicating full functional status of AED). In addition she stated, I was tired and did not check to see if there were pads in the AED. In the event of a Full Code, she confirmed she was not aware if the AED was operational and ready for immediate use because she did not check it per facility policy. She acknowledged that the AED is a part of the CPR process. On 12/21/16 at 2:35 PM, the Regional Nurse was asked if she would expect the AED to be functional at all times, she stated, Yes. In addition she stated, The CPR process included the use of an AED. An additional interview at 4:15 PM revealed she does not recall if the use of the AED is part of the curriculum or in the current AHA (American Heart Association guidelines for Basic Life Support (BLS) Cardiopulmonary Resuscitation (CPR). A copy of the Facility's Cardiopulmonary Resuscitation (CPR) policy dated February 2015 provided by the administrator revealed the following: .The facility will follow current American Heart Association (AHA) guidelines regarding CPR According to the American Heart Association (AHA) the website: http//Heart.org/answersbyheart the heart must be defibrillated quickly, because a victim's chance of survival drops by seven to ten percent for every minute a normal heartbeat is not restored The AHA Chain of Survival are: Immediate recognition of [MEDICAL CONDITION] and activation of the emergency response system. Early CPR with an emphasis on chest compressions and Rapid defibrillation The facility's undated Owner Manual for the Defibrillator Edition 13 provided by the Administrator revealed the following: Blinking: standby mode (ready for use); Solid: in use; and Off: Needs attention (chirps and i-button flashes) After each use: The single-use pads must be replaced after being used remove the battery for five seconds, then reinstall it to run the battery insertion self-test to check the operation of the (AED). When the rest is complete, check that the green light is blinking The green Ready light will be blinking to show the (AED) is ready for use On 12/21/16 at 3:40 PM the Director of Transportation (DOT) returned with defibrillator pads obtained from another facility. An observation on 12/21/16 at 3:40 PM revealed the battery and defibrillator pads were connected to the AED and the green light was illuminated. On 12/21/16 at 5:35 PM, the Administrator and Regional RN Consultant were notified of the IJ and plan of removal was requested. On 12/22/16 at 11:15 AM, the Administrator was notified the facility's Plan of Removal (POR) was accepted. The POR reflected the following immediate action including the following: On 12/21/16 at 3:00 PM a copy of the Direct Supply Purchase order was provided by the Administrator revealed: Replacement Pads and Cartridge for Onsite AEDs, Quantity 2. On 12/21/16 ADON B initiated re-education to the licensed nurses, (use of the AED, inform DON and Central Supply Supervisor that the AED was used so new pads could be ordered, Crash Cart Checklist for the AED; including contacting the DON immediately if the AED Green Light is not illuminated. Post tests were utilized to verify staff competency. All licensed nurses who were not present and educated, will not be allowed to work until they have completed the education. On 12/21/16 Education was provided by the Administrator to the Supervisor of Central Supply to keep no less than one extra set of AED pads on hand and available for nursing staff in the Central Supply room. The facility will ensure that there is an extra set of AED pads on hand at all times. The extra set of pads will be kept in Central Supply and a weekly report will be given in the Standards of Care meetings on how many AED pads are available for use. After hours the Central Supply Key will be kept on the South Station for staff availability to replace the pads after hours. The DON/designees will verify the Crash Cart Check List daily and validate the AED is functional by verification of the illuminated green light no less than once a week. If nonoperational, refer to the user manual for troubleshooting. To verify the facility implemented their POR, the following was conducted: Interviews conducted on 12/22/16 at 11:20 AM, with ADON A, ADON B, RN H, LVN E, LVN F, LVN G, LVN I, LVN J, LVN K, LVN L, LVN M, LVN N, LVN O, and LVN P revealed they attended the Crash Cart Checklist in-service on 12/21/16. All staff interviewed was found to have an understanding of the importance of a properly functioning AED and what to do if it is nonoperational. Observation of the central supply room on 12/22/16 revealed a replacement set of AED pads. On 12/22/16 at 11:30 AM the Administrator revealed she ensured facility policies and procedures were followed by physically being on the floor with the DON and other facility leadership, observing care and staff interactions with residents, seeking resident feedback. She stated the DON was mostly responsible for monitoring and ensuring the crash cart was adequately stocked and properly maintained. The Administrator said the DON checked the crash cart on a monthly basis and that she occasionally checked the crash cart herself. The Administrator stated that although she was not completely sure how the Immediate Jeopardy happened, she believed it was partially attributable to lapses in communication and that staff should have followed up to see why replacement pads were not ordered or in central supply. The Administrator stated in the future the facility would follow their Plan of Removal and Plan of Correction, monitor staff, and remind staff to take responsibility for following up on problems that are not being addressed. Interview with the Medical Director on 12/22/16 at 12:00 PM revealed he had been the facility's Medical Director for about 16-[AGE] years. The Medical Director stated he was not aware the facility did not have a functioning AED, and was surprised to learn about the Immediate Jeopardy. He stated he had gone over the AED manufacturer 's training with facility staff, and he expected that the AED would be involved in all full code events. The Medical Director said he had not given much thought about the process of replacing AED pads, but would make sure to be involved with the AED status in the future. On 12/22/16 at 1:30 PM, the Administrator was notified the IJ was removed. While the IJ was removed on 12/22/16, the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy and a scope of pattern because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. According to the list of Full Code Residents provided by the Administrator on 12/21/16, 67 residents were Full Code Status.