Every finding on record at Sorrento

Based on observation, interview, and record review, the facility failed to reasonably accommodate resident #1s needs and preferences by failing to ensure the call light was maintained within reach for 1 of 5 residents reviewed. This had the potential to affect the resident's safety and timely access to assistance.Based on observation, interview and record reviews the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferenceshad the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 4 residents (Resident #1) reviewed for resident safety. The facility failed to ensure Resident #1 had access to a call light to summon assistance as needed. This deficient practice could place residents at risk for delayed staff response, unmet needs, injury, and falls. Findings include: Record review of Resident #1's face sheet, dated 5/19/26, revealed an [AGE] year-old female with an admission date of 7/20/2025. Resident #1 had diagnoses which included brain tumor, (Abnormal growth of cells within the brain or surrounding tissues. It can affect memory, thinking, speech, movement, balance, vision, behavior, and the ability to perform daily activities), osteoarthritis (A degenerative joint disease caused by the breakdown of cartilage in the joints), arthritis, (A general term for inflammation or disease of one or more joints), pain, (An unpleasant physical or sensory experience that may result from injury, illness, chronic disease, or other medical conditions), anxiety, (A mental health condition caused by excessive worry, nervousness, fear, or apprehension), and malnutrition risk (Refers to the likelihood that a person may not receive the adequate nutrition to meet their body's needs). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS (Brief Interview for Mental status) score of 3 out of 15, which indicated severe cognitive impairment. Record review of Resident #1's Care Plan, dated with revisions on 5/22/2026, revealed assistance required for transfers/toileting/bed mobility, limited right-side use, increased fall risk, attempts self-transfers, diagnoses included brain tumor, and malnutrition risk. The call light remains within reach and for staff to respond promptly. Observation on 5/19/2026 at 9:33 a.m. revealed Resident #1 sleeping in bed. The bed was observed in a lower position, and bilateral mats were in place. The call light was observed hanging between the mattress/bed frame extended toward the floor and out of reach. Surveyor attempted a second time to interview Resident #1 on 05/19/2026@11:40an revealed Resident #1 was still sleeping. Interview on 05/19/2026 at 9:45 a.m. with RN Registered Nurse revealed Resident #1 would not be able to reach the call button because it was out of her reach. She would not be able to call for assistance and something bad could happen. Interview on 05/19/2026 at 10:05 a.m. with LVN (Licensed Vocational Nurse) A revealed Resident #1 would not be able to use the call light because it was out of reach. Resident #1 wouldn't be able to ask for help and she could get injured. Interview on 5/19/26 at 5:18 p.m. with the DON revealed his expectations of the staff were to answer the call lights in a timely manner and have it within reach for the residents. They were to attach it to their blanket or wherever the resident wanted it attached, or close to the hand if they're compromised. If they're not able to reach the call button, they won't be able to tell us what their needs were. The DON stated he was sure the policy for call lights was in training or a checklist for staff. Record review of the Facility Policy Record, date implemented on 10/01/2025 and revised on 12/01/2025, revealed the facility policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Staff will ensure the call light is within reach of residents and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on interview and record review, the facility failed to consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 1 of 1 resident council reviewed. The facility failed to follow up on concerns and requests expressed in resident council meetings September 2025 through November 2025. The facility failed to provide the resident council group with a response, actions, and rationale taken regarding their concerns. This failure placed residents at risk of not having their grievances followed up and addressed. Findings included: Review of the Resident Council minutes reflected the following with no documentation of the facility's responses to the grievances:09/30/2025 reflected: 3) New Business New Concerns socks missing.informed about van out of commission due to window shattered. Resident Notes included specific details of numerous articles of clothing missing or lost and not returned once it left for laundry. Food service addressed concerns with separating side salad on a separate plate, serving hot food with only hot food on one plate and a separate plate only severing cold foods; bread separated from meal; and baking a variety of cookies including sugar free and ensuring they were soft instead of hard.10/30/2025 reflected: food - salad bad.lunch served late 200 hall/100 hall.morning shift doesn't answer lights.In an interview on 11/29/2025 at 4:15 PM, the DON stated the new Social Worker took over activities this week as the former Activities Director resigned due to medical reasons. He stated the Social Worker would be temporarily responsible for working with the resident council group and addressing group grievances. He stated he would need to locate the resident council group grievance forms. He stated the ED and DON would assign individual and group grievances to the department heads specific to the grievance to address.In an interview on 11/29/2025 at 5:25 PM, the DON stated he and the Assistant ED were tasked with handling grievance requests. He stated the grievances were addressed, sometimes not the answer the resident may want, but the management team always did their best to find a solution and provide a response to the resident. He stated the grievance process provided the residents with an opportunity to discuss concerns in a constructive way. He stated all staff were aware that if a resident requested to write a grievance they could submit on their behalf electronically or they could provide the resident with a paper form to fill out. He stated he would need to circle back on the specific details of the council group grievances.In an interview on 11/30/2025 at 10:50 AM, CNA A stated if a resident was not allowed to file a grievance it would make them feel terrible, like no one cared. She stated if the facility didn't provide a response to the residents' grievances it could make them wonder if staff even cared or if the grievance form went into the trash.In an interview on 11/30/2025 at 10:59 AM, CNA B stated she has received training in the last week on resident rights. She was knowledgeable of resident rights and stated staff should always respect a resident's decisions, so they didn't feel bad. She stated if a resident was not allowed to file a grievance, they would feel wronged as they had a right to say what they wanted and don't want and address concerns. She stated if the facility didn't provide a response to the residents' grievances it could make them feel bad and feel as if they are not being heard.In an interview on 11/30/2025 at 11:36 AM, the ADON stated she had been employed 45 days at the facility. The ADON stated she received resident rights training during her new hire onboarding, she was knowledgeable of Resident Rights, and she provided examples. The ADON stated resident grievance forms were designated at the nurses' stations and could be filled out on paper or electronically. She stated grievances were worked on by the ED, she would make sure the right department was correcting it, and a conclusion was usually received by the end of the day. She stated the residents were notified of the outcome and are involved in every step of the process. She stated typically either the ED, DON, or herself would notify the resident of the resolve if there was one. She stated if resident grievances were not addressed by the facility, it could make the residents feel hopeless.In an interview on 11/30/2025 at 11:58 AM, the AED stated she had been employed three weeks at the facility. The AED was knowledgeable of resident rights, she provided examples, and she stated she has educated the nursing staff on the topic. She stated she received resident grievances often and was responsible for speaking to the residents. She stated at times she would have residents come up to her and verbally notify her of a grievance, she would ask for details, and if something could be solved immediately, she would take care of it herself and enter a progress note in their chart. She stated, if necessary, she would conduct an in-service with the nursing staff and educate staff if they were doing something that was not correct and do their best to correct it. She stated all grievances, individual and resident council group grievances would give residents updates, notify them of the process, would talk to them about what needs to be corrected. She stated she liked to communicate with the residents every step of the way. She stated if a resolution was not a good outcome, she would involve the Ombudsman to help figure out a solution or compromise. She stated if resident grievances were not addressed by the facility, residents could become angry or frustrated. She stated grievances identified in the resident council meetings such as missing socks or missing clothing went directly to the laundry department, they searched for the missing clothing and at times the resident would go and help look for missing clothes. She stated all individual resident grievances were documented, and the facility would try to fix it right away. She stated any grievances brought up in resident council were addressed. She stated she was unsure whether the resident council grievances are documented, if they were addressed, and where they were stored. She stated as far as she knows the resident council group grievances have been addressed, she stated she was not sure what occurred with the resident council group grievances prior to coming into this position, but they were addressed right away at this time. In an interview on 11/30/2025 at 12:21 PM, LVN A stated she had been employed for four months at the facility. LVN A stated she was trained on resident rights about a month back and when onboarding as a new hire. She was knowledgeable of resident rights, she provided examples and stated if the resident was not afforded their rights in a facility they would not thrive, and their behavior and mood can change drastically and negatively. She stated residents file grievances often and all resident grievances should be addressed as that was the resident's voice.In an interview on 11/30/2025 at 12:48 PM, RN A stated she was educated in resident rights about a week ago, she was knowledgeable of the topic and provided examples. She stated if a resident was not allowed to exercise their rights it could have a negative mental impact on them. She stated resident grievances are important and handled quickly. She stated if resident grievances were not addressed by the facility, it could leave them in frustration and stress if having to repeat themselves.In an interview on 11/30/2025 at 1:33 PM, the DON stated he had been employed three months with the facility. He stated the ED was currently on leave and he was overseeing the facility. He stated the AED was new to the facility and he was helping with training her. He stated all new hires during their onboarding received resident rights education as well as periodically or if an incident occurred that required it. He stated he was part of the management team and conducts in-services with the nursing staff. He was knowledgeable of resident rights, he provided examples and stated if a resident was not allowed their rights, it would have a negative impact on them and in this setting every staff member has an obligation to be properly on these rights. The DON stated the residents could submit grievance via paper or electronic format, he stated the notification of resident rights was also a part of the resident's admission packet and provided them information on grievances. He stated individual and resident council grievances were handled by administrators. He stated when grievance was received administration staff would delegate it to the heads of department to work on a resolution and follow-up and communication will be provided to the residents. He stated at times there was not one solution, but multiple solutions and strategies presented to the residents. He stated resident council group grievances were addressed; however, prior to August 2025 he was not sure what happened to these grievances. He stated resident council group grievances would be separated by specific residents and addressed as an individual resident grievance. He stated he didn't have process or documentation system for group grievance and separation into individual grievance would be done. He stated he was not sure why the resident council group grievances for September and October 2025 could not be located. He stated with him coming on board recently he could not speak to the circumstances for not documenting resident council group grievances and providing response to the residents. He stated that it would change moving forward. He would work towards correcting this issue and ensure resident council group grievances were addressed, resolved, status communicated to the group, and stored appropriately moving forward.Review of document titled, Patient/Resident Council Meeting Minutes dated 9/30/2025, reflected: Resident Council communicated concerns with missing clothing, preferences for food separation, and facility van out of commission. There was no investigation conducted, no results or resolution reported to the resident council.Review of document titled, Patient/Resident Council Meeting Minutes dated 10/30/2025, reflected: Resident Council communicated concerns with bad salads and lunch being served late to 100 and 200 hallways. There was no investigation conducted, no results or resolution reported to the resident council.Review of document titled, Patient/Resident Council Meeting Minutes dated 11/20/2025, reflected: Resident Council communicated concerns with landlines in their rooms. There was no investigation conducted, no results or resolution reported to the resident council.Review of facility policy dated February 2021 and titled, Resident Rights reflected the following: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation:1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States;h. be supported by the facility in exercising his or her rights;u. voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal;v. have the facility respond to his or her grievances;2. Copies of our resident rights are posted throughout the facility, and a copy is provided to each employee, provider and contracted staff member. In addition, staff will have appropriate in -service training on resident rights prior to having direct-care responsibilities for residents.4. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights. Review of facility policy dated November 2017 and titled, Grievances reflected the following: Policy: The Patient or patient representative has a right to voice grievances to the facility or other entity that hears grievances without fear of discrimination or reprisal. Grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other patients, and other concerns regarding their LTC facility stay. Guidelines:1. The facility must make prompt efforts to resolve grievances and must make information on how to file a grievance or complaint available to the patient.3. When the facility is made aware of a problem or concern voiced by a Patient or on behalf of the Patient, the facility must make every effort for prompt resolution of all grievances regarding the residents' rights.c. The right to obtain a written decision regarding his or her grievance;6. As necessary, taking immediate action to prevent further potential violations of any Resident right while the alleged violation is being investigated.7. The Executive Director is the designated grievance official for the facility with the Director of Nursing as the designee who is responsible for overseeing:a. The grievance process to include initiation of resolution within 72 hours of receiving grievance.b. The receiving and tracking grievances to their conclusion.c. Leading any necessary investigations by the facility.9. All written grievance decisions shall include the date the grievance was received, a summary statement of the Resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the Resident's concern, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result. It of the grievance, and the date the written decision was issued.10. Maintain evidence demonstrating the results of all grievances for a period of no less than 3 years from the issuance of the grievance decision.

Based on interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 5 (Resident #2, #44, #54, #136, #310) of 24 residents reviewed for MDS accuracy and completion. Residents #2, #44, #54, #136, and #310 did not have discharge MDS's completed. This failure could result in MDS inaccuracies. The findings included: Record review of Resident #2's Electronic Health Record did not reveal a completed discharge MDS, at least 30 days after discharge. Record review of Resident #44's Electronic Health Record did not reveal a completed discharge MDS, at least 30 days after discharge. Record review of Resident #54's Electronic Health Record did not reveal a completed discharge MDS, at least 30 days after discharge.Record review of Resident #136's Electronic Health Record did not reveal a completed discharge MDS, at least 30 days after discharge.Record review of Resident #310's Electronic Health Record did not reveal a completed discharge MDS, at least 30 days after discharge. Record Review of the facility's policy titled, Electronic Transmission of the MDS, dated revised November 2019, reflected, All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records are completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data. Record review of the RAI Manual OBRA Assessment Summary, dated October 2019, revealed, Discharge refers to the date a resident leaves the facility or the date the resident ' s Medicare Part A stay ends but the resident remains in the facility. A day begins at 12:00 a.m. and ends at 11:59 p.m. Regardless of whether discharge occurs at 12:00 a.m. or 11:59 p.m., this date is considered the actual date of discharge. There are three types of discharges: two are OBRA required-return anticipated and return not anticipated; the third is Medicare required-Part A PPS Discharge. A Discharge assessment is required with all three types of discharges. Further review revealed Discharge Assessment refers to an assessment required on resident discharge from the facility, or when a resident ' s Medicare Part A stay ends, but the resident remains in the facility (unless it is an instance of an interrupted stay, as defined below). This assessment includes clinical items for quality monitoring as well as discharge tracking information. Continued review revealed OBRA Discharge assessments consist of discharge return anticipated and discharge return not anticipated. [ .] Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days).

Based on interviews and record reviews, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 3 residents (Resident #11) reviewed for dialysis services. The facility failed to complete Resident #11's post dialysis assessment on 8/4/2025, 8,6/20205, 8/8/2025, and 8/11/2025. This failure could place residents at risk for neglect by not being assessed and documenting the assessment. The findings included:A record review of Resident #1's admission record dated 8/22/2025 revealed an admission date of 5/21/2025 with diagnoses which included end stage renal disease with dialysis (kidney failure with a medical treatment that acts as artificial kidneys, removing waste products and excess fluid from the blood when the kidneys are unable to perform these functions.) A record review of Resident #11's quarterly MDS assessment dated [DATE] revealed Resident #11 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 14 out of a possible 15 which indicated no cognizant impairment. A record review of Resident #11's care plan dated 8/22/2025 revealed Resident #11 received recurring dialysis services three times a week on Monday, Wednesday, and Fridays, (Resident #11) needs hemodialysis related to end stage renal disease, dialysis Mondays Wednesdays and Fridays . monitor document report as needed the following signs and symptoms; edema, weight gain of over 2 pounds a day, neck vein distension, difficulty breathing, increased heart rate, elevated blood pressure, skin temperature, peripheral pulses, level of consciousness, monitor breath sounds for crackles . A record review of Resident #11's medical record from 5/21/2025 through 8/22/2025 revealed LVN assessed and documented Resident #11's pre dialysis assessments on 8/4/2025, 8/6/2025, 8/8/2025, and 8/11/2025. Further review revealed no post dialysis assessments for those dates. During an interview on 8/22/2025 at 10:36 AM with LVN I, he stated he was the Monday through Friday 6:00 AM through -2:00 PM nurse for Resident #11. LVN I stated Resident #11 was diagnosed with ESRD and was supported with offsite dialysis 3 times a week from 10:00 AM to 3:00 PM. LVN I stated prior to Resident #11's dialysis, he would initiate a dialysis communication record, assess Resident #11, and document the assessment. LVN I stated he would give report to the 2:00 PM to 10:00 PM nurse that Resident #11 was attending dialysis and had an open dialysis communication form which required a post dialysis assessment. LVN I stated Resident #11 would be assessed at the dialysis center by the dialysis nurse and would be sent back to the facility with a dialysis summary report. LVN I stated there was no dedicated 2:00 PM to 10:00 PM nurse and some of the 2:00 PM to 10:00 PM nurses were LVN A, LVN J, and LVN K. LVN I stated the policy and expectation for the post dialysis communication was for the 2:00 to 10:00 PM nurse to assess Resident #11 after the dialysis treatment, to document the assessment, and to include the data transcription from the dialysis summary form sent with the Resident from the dialysis center. During an interview on 08/22/2025 at 1:00 PM with ADON G, she stated she was the ADON for Resident #11 who was diagnosed with ESRD and was supported with dialysis services on Mondays, Wednesdays, and Fridays from mid-morning to midafternoon. ADON G stated the expectation for dialysis communication assessments was for the 6:00 AM to 2:00 PM nurse to assess residents prior to dialysis treatment and for the 2:00 PM to 10:00 PM nurse to assess residents post dialysis treatments which included the transcription of data from the post dialysis summary report sent by the dialysis center. ADON G stated every morning she would generate an audit report for incomplete assessments from the previous day and recognized that on 8/4/2025, 8/6/2025, 8/8/2025 and 8/11/2025, the post dialysis assessment was not completed. ADON G stated LVN A worked on 8/4/2025 and had failed to assess Resident #11 after dialysis and failed to document the assessment. ADON G stated she also recognized the dialysis center had failed to send the post dialysis documentations and had called the DON at the dialysis center to report the failures. During an interview on 8/22/2025 at 1:56 PM, LVN A stated he worked the 2:00 PM to 10:00 PM shift on 8/4/2025 and received Resident #11 back from dialysis therapy. LVN A stated Resident #11 was sent back from dialysis without any post dialysis report. LVN A stated he could not recall if he had assessed and documented Resident #11's post dialysis status. LVN A stated the expectation for the post dialysis nurse would be to transcribe the report into the residents' medical record. LVN A stated the post dialysis expectation was for nursing to assess post dialysis and to document the assessment. LVN A stated the assessment would include the condition of the dialysis port, vital signs, respirations, and swelling. LVN A stated the possible potential negative outcome for failing to document a post dialysis status for residents could be bleeding. During an interview on 8/22/2025 at 7:00 PM, the DON stated the expectation and policy for post dialysis assessments and documentation was for nurses to assess residents after they returned from dialysis therapy to include the transcription of the dialysis summary report to the residents' medical record. The DON stated if the dialysis center had not provided the summary report, the nurse was to assess the Resident and to document the assessment and the lack of a dialysis summary report. The DON stated the lack of assessment and documentation could potentially have a negative outcome for complications of dialysis therapy, cramps, nausea, and or headaches. A record review of the facility's Dialysis Protocol policy dated February 2024, revealed, POLICY: The Community will provide proper care of patients receiving dialysis. PROCEDURE The Director of Nursing Services will establish and maintain communication with the dialysis facilities to ensure continuity of care for all dialysis Patients. The charge nurse will monitor the patient's condition upon return from dialysis. The (Facility) DON, RODS and attending MD will review the dialysis recommendations, reports, labs and care plans as indicated. The Administrator and Dietary Services Manager will ensure that the Dietary Department follows the dialysis policies and procedures located in the Dietary Policy & Procedure Manual. The (Facility) DON or designee will periodically audit all charts for patients on dialysis. The facility DON, Medical Records or designee will contact the dialysis facility if a report has not been received.

Based on interview and record review, the facility failed to ensure that all licensed staff possessed the competency, and specific skill sets necessary to care for resident's needs for all nursing staff for 1 of 1 facility reviewed for competencies. The facility failed to ensure licensed nurses were appropriately updating Resident #12 for fall interventions when they were filling out the Nursing Fall Intervention Checklist. This failure could place residents at risk for harm due to staff who lack the appropriate skills, knowledge, and competencies to safely meet the residents' needs. Findings included: Record Review of Resident #12's admission record, dated 08/22/25, reflected Resident #12 was an [AGE] year-old, initially admitted [DATE] and re-admitted [DATE], with diagnoses to include restlessness and agitation, lack of coordination, muscle weakness, reduced mobility, and need for assistance with personal care. Record Review of Resident #12's MDS assessment for significant change in status, dated 08/01/25, reflected the resident had a BIMS of 08 out of 15, indicating moderate impaired cognition. Record Review of Resident #12's care plan, undated, reflected The resident is risk for falls r/t decreased mobility. 7/14/25 ACTUAL FALL UNWITNESSED8/7/25 actual fall unwitnessed [sic] no injury8/8/25 un-witnessed fall with no injury8/13/25 un-witnessed fall, initiated 08/08/25 and revised 08/14/25. With interventions to include Lateral Supports as appropriate, initiated 08/13/25, Provide Reclining W/C as appropriate, initiated 08/13/25, Tilt Wheelchair, initiated 08/13/24, Raised Toilet Seat, initiated 08/13/25. Record review of In-Service Training Report on 07/18/25 reflected the nursing department was educated on Post Fall Intervention Checklist to include Do not complete the fall interventions checklist Section B is completed by IDT. It further reflected 12 licensed nurses to not include nurses on the IDT signed that they received this training. Record review of staff roster, undated, reflected 35 licensed nurses to not include nurses on the IDT. Interview on 08/22/25 at 10:13 AM, LVN A revealed Resident #12 had interventions to include fall mats, bed in lowest position, and scoop mattress. He revealed the IDT were the ones to add appropriate fall interventions. Interview on 08/22/25 at 11:07 AM, LVN D and LVN A revealed after a fall occurred, they filled out the incident report for the fall, which triggered fall risk assessment and fall intervention checklist. They revealed they looked at Kardex, care plans, and fall intervention checklist for fall interventions for residents. LVN A revealed he followed the prompts to fill out the Nursing Fall Intervention Checklist. He was not aware if Intervention Checklist was for interventions in place or for suggested interventions. Interview on 08/22/25 at 11:15 AM, LVN D revealed for fall interventions he looked at a residents' care plan and Kardex. He revealed the nurse manager oversaw completing the fall intervention checklist and made sure the interventions on the care plan were added appropriately. He further revealed after a new fall, there would be new interventions like if resident already had a low bed and falls mats, the facility would add a new intervention. Interview on 08/22/25 at 12:17 PM, ADON F revealed the IDT discussed falls in the morning meetings and updated interventions in the care plans during the meeting. He revealed CNAs used the Kardex for fall interventions and the nurses used the care plans for fall interventions. He revealed the ADONs and DONs were able to oversee care plans to ensure they were updated, as needed. Interview on 08/22/25 at 12:31 PM, ADON G revealed witnessed and unwitnessed falls were documented in the incident reports. She revealed nurse managers (ADON, MDS, DON) and therapy discussed falls in the morning meetings. She revealed they added interventions for falls in the morning as they pertained to the circumstances that caused a fall. She revealed nursing staff were in-serviced on fall interventions after the IDT decided what interventions to add to residents' care plans. She revealed the MDS nurse oversaw updating care plans but the ADONs could also ensure the care plans were updated appropriately. She revealed the nurses looked at care plans for updated interventions and CNAs looked at the Kardex for updated interventions. She revealed she was not aware of the Nursing Fall Intervention Checklist entailed. Interview on 08/22/25 at 01:41 PM, the MDS nurse revealed Nursing Fall Intervention Checklist was a new assessment and she was not aware of what the fall intervention checklist was. She revealed falls were discussed the next day with the IDT team so they could review interventions. She revealed they would analyze what had been working and what not, and add interventions as needed. Interview and observation on 08/22/25 at 03:06 PM, CNA R and LVN Q revealed they did not know what a tilted wheelchair or lateral supports looked like. CNA R revealed Resident #12 did not have a raised toilet but would throw this raised toilet seat if she had it in her restroom, so it would not help the resident. CNA R revealed she did not tell anyone that this intervention was not working to take this intervention off Resident #12's care plan and Kardex. CNA R and LVN Q revealed they did not know Resident #12 needed a raised toilet seat, tilted wheelchair, or lateral supports. Interview on 08/22/25 at 03:51 PM, the MDS nurse revealed she was able to find out the Nursing Fall Intervention Checklist assessment revealed the interventions chosen to add to the residents' care plan. Interview on 08/22/25 at 04:10 PM, Regional Director of Clinical Services revealed the Nursing Fall Intervention Checklist assessment should not be able to be filled out by the licensed nurses, because the nurses were unknowingly adding inappropriate interventions to residents' care plans. She revealed the licensed nurses were supposed to be educated to not fill this assessment out. She revealed the IDT were supposed to fill out the Nursing Fall Intervention Checklist assessment, because the IDT were the ones responsible for reviewing falls and adding appropriate interventions to residents' care plan. She further revealed Resident #12's fall interventions that were not being implemented by the nursing staff were not added by the IDT and should not have been in Resident #12's care plan. Interview on 08/22/25 at 09:34 PM, the ADM and DON revealed they did not educate nurses on how to fill out the assessment Nursing Fall intervention checklist so the IDT had to review the falls and care plans to see if they needed to fix any care plan interventions that were inappropriately added. Record review of facility's policy Care Plans-Comprehensive, dated September 2010, reflected 6. Identifying problem areas and their cause and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation. The resident's physician (or primary healthcare provider) is integral to this process. Record review of facility's policy Fall Management Guidelines, dated November 2022, 3. Initiate Fall Risk Plan of Care for each Patient at risk for falls and update as needed. Include those interventions listed on the Intervention Check List as part of the Fall Risk Plan of Care. Policies for nurse training in general and nurse training regarding who can initiate care plan interventions were requested from the ADM on 08/22/25 at 10:10 PM. These were not provided.

Based on record review, interview and observation, the facility failed to ensure that residents (1 of 1 facility) had suitable, nourishing meals and snacks outside of scheduled meal service times. The facility failed to ensure residents were offered snacks at bedtimes. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and side effects from medication given without food, and diminished quality of life. The findings were:Record review of [NAME] PATIENT MEAL TIMES, revised 5/16, reflected Breakfast, Lunch, Dinner, and no snack time. Interview and observation on 08/21/25 at 07:10 PM, Confidential Resident #144 was observed to not have a snack and they revealed they did not receive a snack, but they would like one. They revealed they did not want the facility to know that they were asking for a snack. Interview and observation on 08/21/25 at 07:10 PM, Confidential Resident #145 was observed to not have a snack and they revealed they did not know if the facility was giving out snacks at night, but they would like to be offered one when they get hungry at night. They revealed they would like to not let the facility know it was them that mentioned having nighttime snacks. Interview on 08/21/25 at 7:34 PM, the ADM and ADON F revealed they gave snacks to all the diabetics and then gave leftover snacks to whoever asked for them. The ADM revealed they did not go to every resident's room to offer snacks. They revealed snacks get passed out by nursing staff around at about 8PM typically, when the kitchen is done cleaning up after dinner. Interview and observation on 08/21/25 at 07:36 PM, the Certified Dietary Manager (CDM) was pushing the snack cart and revealed they only made snacks that came from doctor's orders. She further revealed there were some extra snacks too. Record review of the facility's Order Listing Report, dated 08/22/25, reflected 39 residents (total census was 96 residents) were listed for an evening snack. Policy for snack was requested from the ADM on 08/22/25 at 10:11 PM.

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 8 residents (Resident #36) reviewed for resident rights. CNA M told Resident #36, just go in your brief and I'll come back to change you when Resident #36 asked to be taken to the restroom. This failure could place residents at risk for diminished quality of life, loss of dignity, and self-worth. The findings included: Record Review of Resident #36's admission Record, dated 08/22/2025, reflected a [AGE] year-old resident with an admission date of 08/08/2025 and diagnoses including: acute and chronic respiratory failure, type 2 diabetes, irritable bowel syndrome, and hyperlipidemia. Record Review of Resident #36's MDS Assessment, dated 08/12/2025, reflected that Resident #36 had, No impairment in her upper and lower extremities and used a walker as a mobility device. Further review reflected that Resident #36 required, Partial/Moderate assistance for the functional ability, Sit to stand. Section H, Bowel and Bladder, reflected that the resident was always incontinent of bowel and bladder. Resident #36's BIMS score was reflected to be a 9, indicating moderate cognitive impairment. Record review of Resident #36's Comprehensive Person-Centered Care Plan, dated 08/22/2025, reflected that Resident #36 had an ADL self-care performance deficit r/t unsteady gait, poor trunk control, with interventions including, Encourage the resident to participate to the fullest extent possible with each interaction. Observation on 08/21/2025 at 3:58 PM, Resident #36 was observed to be vocalizing in her room with her call light on. Staff member CNA M responded to the call light and Resident #36 asked to be taken to the restroom. CNA M told Resident #36 to, just go in your brief and I'll come back to change you. Interview on 08/21/2025 at 4:01 PM, CNA M stated she was uncertain if Resident #36 was a fall risk and was having a more difficult time ambulating, so she told the resident to use her brief yesterday and today. CNA M stated she felt that if someone asked to be taken to the restroom they should be taken to the restroom. In an interview on 08/21/2025 at 4:03 PM, the ADON stated that if a resident was able to transfer safely, they should be taken to the restroom. The ADON stated it was a dignity concern if residents were not taken to the restroom and just told to use their own brief, and that it was not acceptable to tell a resident to use their brief if they requested to be taken to the toilet. Interview on 08/22/2025 at 11:53 AM, the DON stated it was not acceptable to tell a resident to just use their brief and his expectation was that, if the resident was incontinent or not, to let them know they would be back and look at the resident's functional toileting ability and get help if necessary. Record review of the facility's policy, revised February 2021, reflected, Employees shall treat all residents with kindness, respect, and dignity.

Based on interview and record review, the facility failed to promote the resident's right to request, refuse, and/or discontinue treatment and to formulate an advance directive for 1 (Resident #25) of 22 residents reviewed for advance directives, in that:Resident #25's OOH-DNR was not signed twice by all parties and was therefore invalid.This deficient practice could result in the resident's wishes regarding end-of-life treatment being dishonored.The findings were:The findings were:Record review of Resident #25's face sheet, dated 08/22/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Paraplegia, Unspecified Cirrhosis of Liver, and Sepsis Unspecified Organism.Further review revealed, Advance Directive: DNR (Do Not Resuscitate).Record review of Resident #25's comprehensive MDS assessment, dated 08/08/2025, revealed a BIMS score of 14 which indicated intact cognition.Record review of Resident #25's care plan, initiated 04/14/2025, revealed [Resident #25] requests Code Status of: DNR.Record review of Resident #25's OOH-DNR, dated 06/23/2023, revealed the instructions for the last section of the document, All persons who have signed above must sign below, acknowledging that this document has been properly completed.Further review of Resident #25's OOH-DNR revealed the resident, two witnesses, and the resident's physician had signed above the last section, but only the physician's signature was present in the last section.During an interview with the Social Worker on 08/22/2025 at 10:20 a.m., the Social Worker confirmed that two signatures were required for all parties who signed an OOH-DNR form, the resident's signature and the witnesses' signatures were missing from the last section of Resident #25's OOH-DNR., and the missing signature rendered the form invalid. The Social Worker stated it was her responsibility to ensure OOH-DNR forms were correctly executed and the invalid form was an oversight.During an interview with the Administrator on 08/22/2025 at 3:00 p.m., the Administrator confirmed that she expected all OOH-DNR forms to be completed fully and accurately.Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated 03/25/2019, revealed, Frequently Asked Questions for DNR: What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly.Record review of the facility's policy, Advance Directives, dated March 2025, revealed, The Social Worker or designee must verify the Advance Directive report for accuracy.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 8 residents (Resident #79) reviewed for environment. Resident #79's recliner's footrest was broken and had a metal piece sticking out of it. This failure could place residents at risk of a diminished quality of life due to an exposure to an environment that is unpleasant, unsanitary, or unsafe. The findings included:Record review of Resident #79's admission Record, dated 08/21/2025, reflected an [AGE] year-old resident, initially admitted on [DATE], with diagnoses including muscle wasting and atrophy, chronic obstructive pulmonary disease, type 2 diabetes, and hypothyroidism. Record review of Resident #79's MDS Assessment, dated 08/06/2025, reflected that Resident #79 had a BIMS score of 15, indicating that the resident's cognition was intact. Record review of Resident #79's Comprehensive Person-Centered Care Plan, dated 08/21/2025, reflected that Resident #79, expresses desire for little or no activity involvement. Interview and observation on 08/20/2025 at 9:40 AM, reflected that Resident #79's foot rest for her recliner was broken and had a metal piece, which was typically part of the mechanical system that held up the foot rest sticking out. Resident #79 stated her foot rest had been broken since she was moved to this room [ROOM NUMBER] days prior. Resident #79 stated she had not told anyone about it, and that it had not hurt her as she was careful not to hit her leg against the metal piece. Record review of Resident #79's Census Report reflected Resident #79 had been moved into her room on 08/15/2025. Interview on 08/21/2025 at 1:00 PM, the Maintenance Director stated that Resident #79's recliner was replaced on 08/20/2025 after it was found to have been broken. The Maintenance Director stated he typically tried to fix things such as this as soon as he was made aware of them, which is what happened with Resident #79's recliner. Interview on 08/21/2025 at 1:30 PM, the Administrator stated they had replaced Resident #79's recliner as soon as they realized it had been broken. The Administrator stated no one noticed the recliner was broken until 08/20/2025, and it was immediately replaced to prevent any injury to the resident. The Administrator stated that her expectation was for staff to report any concerns with the resident environment to the Maintenance Director so that it is addressed accordingly. Record review of the facility's policy titled, Homelike Environment, dated revised 02/2021, reflected, The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .clean, sanitary, and orderly environment.

Number of residents sampled: Number of residents cited: Based on interview, observation, and record review, the facility failed to ensure 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 a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Residents #12) of 8 residents reviewed for care plans. The facility failed to implement fall interventions ( Lateral Supports as appropriate, initiated 08/13/25, Provide Reclining W/C as appropriate, initiated 08/13/25, Tilt Wheelchair, initiated 08/13/24, Raised Toilet Seat, initiated 08/13/25) from Resident #12's care plan. This failure could place residents at risk of not receiving care and services related to their identified needs to maintain or reach their highest practicable physical, mental, and psychosocial wellbeing. The findings included: Record Review of Resident #12's admission record, dated 08/22/25, reflected Resident #12 was an [AGE] year-old female, initially admitted [DATE] and re-admitted [DATE], with diagnosis to include restlessness and agitation, lack of coordination, muscle weakness, reduced mobility, and need for assistance with personal care. Record Review of Resident #12's MDS assessment for significant change in status, dated 08/01/25, reflected resident had a BIMS of 08 out of 15, indicating moderate impaired cognition. Record Review of Resident #12's care plan reflected The resident is risk for falls r/t decreased mobility. 7/14/25 ACTUAL FALL UNWITNESSED8/7/25 actual fall unwitnessed OOB no injury8/8/25 un-witnessed fall with no injury8/13/25 un-witnessed fall, initiated 08/08/25 and revised 08/14/25. With interventions to include Lateral Supports as appropriate, initiated 08/13/25, Provide Reclining W/C as appropriate, initiated 08/13/25, Tilt Wheelchair, initiated 08/13/24, Raised Toilet Seat, initiated 08/13/25. Observation on 08/19/25 at 03:24 PM revealed Resident #12 had her bed in lowest position, 2 quarter handrails, and a scoop mattress. Resident #12 appeared confused and was trying to get up on her own. Interview on 08/22/25 at 11:07 AM, LVN D and LVN A revealed after a fall occurred, they filled out the fall incident report, which triggered fall risk assessment and fall intervention checklist. They reflected they looked at Kardex, care plans, and fall intervention checklist for fall interventions for residents. LVN A revealed Resident #12 was non-compliant with her care plan interventions like she did not like her fall mats, but Resident #12 had good days and bad days and would cooperate on her good days. Interview on 08/22/25 at 11:13 AM, CNA B and CNA C revealed they did not work in Resident #12's hallway, but for fall interventions they used residents' Kardex to ensure residents' interventions were in place. They further revealed they also did the basics like made sure resident had water close to them, call light within reach, remove obstacles, and frequent monitoring. Interview on 08/22/25 at 12:17 PM, ADON F revealed the IDT discussed falls in the morning meetings and updated interventions in the care plans. He revealed CNAs used the Kardex to ensure they were implementing fall interventions, and the nurses used the care plans to ensure they were implementing fall interventions. Interview and observation on 08/22/25 at 02:56 PM, Hospice CNA P revealed Resident #12 did not have a raised toilet seat or tilted wheelchair. She revealed the facility was in charge of ensuring Resident #12 had their appropriate interventions implemented. Interview and observation on 08/22/25 at 03:06 PM, CNA R and LVN Q revealed they did not know what a tilted wheelchair or lateral supports looked like. CNA R revealed Resident #12 did not have a raised toilet but Resident #12 would throw the raised toilet seat so it would not help Resident #12. CNA R revealed she did not tell anyone that this intervention was not working, and to take it off Resident #12's care plan and Kardex. CNA R and LVN Q revealed they did not know Resident #12 needed a raised toilet seat, tilted wheelchair, or lateral supports. Interview on 08/22/25 at 04:45 PM, the ADM and Regional Director of Clinical Services stated they were aware that the care plans needed to be updated prior to the beginning of survey and were updating residents' care plans but had not gotten to every resident yet. They revealed CNAs looked at the Kardex and nurses looked at the care plan for resident care. The Regional Director of Clinical Services revealed the goal for Resident #12 was to prevent fall with injury because the resident was going to fall due to her current health condition. Interview on 08/22/25 at 05:08PM, the ADM, DON, and Regional Director of Clinical Services revealed interventions were in incident reports but not in care plans or Kardex and should have been. They revealed there was no concern that Resident #12 would injure herself because staff were able to tell them what fall interventions to do for Resident #12 and there was only a concern of updating the care plans. Record Review of the facility's policy Fall Management Guidelines, dated November 2022, reflected 3. Initiate Fall Risk Plan of Care for each Patient at risk for falls and update as needed. Include those interventions listed on the Intervention Check List as part of the Fall Risk Plan of Care. Record Review of the facility's policy Care Plans-Comprehensive, revised September 2010, reflected 3. Each resident's comprehensive care plan is designed to: f. Identify the professional services that are responsible for each element of care.

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 8 residents (Resident #79) reviewed for medication administration. The facility provided Resident #79 with the medication Hydralazine HCl outside of physician parameters. This failure could place residents at risk for not receiving the therapeutic effects of their prescribed medications. The findings included: Record review of Resident #79's admission Record, dated 04/04/2025, reflected an [AGE] year-old resident with diagnoses including muscle wasting and atrophy, chronic obstructive pulmonary disease, type 2 diabetes, and hypothyroidism . Record review of Resident #79's quarterly MDS assessment, dated 08/06/2025, reflected Resident #79 was assessed with a BIMS score of 15, indicating the resident was cognitively intact. Record review of Resident #79's Comprehensive Person-Centered Care Plan, dated 08/21/2025, reflected Resident #79 had hypertension with interventions including, Give all anti-hypertensive medications as ordered. Record review of Resident #79's Medication Administration Record , dated printed 08/20/2025, reflected an order for hydralazine HCl Oral Tablet 50 MG (Hydralazine HCl) Give 1 tablet by mouth at bedtime for Hold SBP <110 DBP <60 and HR 60 related to ESSENTIAL (PRIMARY) HYPERTENSION for 30 days, indicating the medication should not be provided to the resident if their systolic blood pressure (the top number, which measures the pressure in your arteries when your heart beats) was over 110, their diastolic blood pressure (bottom number) was over 60, or when the residents heart rate was under 60 beats per minute with a start date of 08/03/2025.Further review of Resident #79's Medication Administration Record for August 2025, dated 08/20/2025, reflected that Resident #72 could have been provided Hydralazine 15 times from 08/01/2025 through 08/20/2025 and was administered Hydralazine outside of parameters as follows: 1. On 08/06/2025, LVN N administered Hydralazine to Resident #79 while her DBP was 57.2. On 08/07/2025, LVN O administered Hydralazine to Resident #79 while her DBP was 53.3. On 08/15/2025, LVN N administered Hydralazine to Resident #79 while her DBP was 53.4. On 08/19/2025, LVN O administered Hydralazine to Resident #79 while her DBP was 56. Interview on 08/22/2025 at 11:53 AM, the DON stated that his expectation was for medications to be given within parameters and if parameters were not clear, to reach out to the physician. Record review of facility policy titled, Medication Administration,, undated, did not reflect information regarding medication parameters.

Based on observations, interviews and record reviews the facility failed to ensure all drugs and biologicals were stored and locked in compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 7 medication carts (800 hall medication cart) reviewed for safe and secure drug storage. The facility failed to ensure the 800-hall medication cart was secured and locked when LVN L utilized it and left it unlocked and unattended. This failure could place residents at risk for harm by accessing medications not prescribed for them, misappropriation, and not receiving the therapeutic effects of the medications as prescribed by their physicians. The finding included: During an observation on 8/19/2025 at 12:16 PM revealed the 800-hall medication cart was in the 800-hallway by a resident's room with a closed door. The medication cart was unattended and out of line of sight by the nurse who was assigned the cart. The drawers of the medication cart were able to be opened revealing many medications prescribed to residents of the 800-hall. A brief review reveled acetaminophen, aspirin, docusate, and vitamin c. During an observation and interview on 8/19/2025 at 12:22 PM LVN L exited resident room [ROOM NUMBER] and recognized the 800-hall medication cart was unattended and unlocked. LVN L stated the lock had malfunctioned and could not lock. LVN L stated she was assigned the medication cart at 6:00 AM and had not reported the malfunction and believed the facility had known of the malfunction. During an interview on 8/19/2025 at 12:28 PM ADON F stated he was not aware the 800-hall medication cart lock had malfunctioned. ADON F stated he would immediately address the issue and either correct the failed lock or replace the medication cart. During an interview on 8/22/2025 at 7:00 PM the DON stated the expectation for nursing staff who were assigned medication carts was for the cart to be locked whenever the nurse was away from the medication cart. The DON stated if a cart was to malfunction the nurse should immediately report the malfunction. The DON stated the potential risk to residents was the loss of security for their medications. A policy was requested of the Administrator via email on 8/22/2025 at 3:34 PM and, as of 8/25/2025, a policy had not been provided.

Based on observations, interviews, and record reviews the facility failed to ensure the establishment and maintenance of an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 [KA1] (Resident #139) residents reviewed for infection isolation protocols. HK S failed to wear a N95 FFR while providing housekeeping services for Resident #139. This failure could place residents and staff at risk for harm by contracting and spreading the Covid-19 virus. The findings included: A record review of Resident #139's admission record dated 8/22/2025, revealed an admission date of 8/15/2025 with diagnoses which included Covid-19 (a contagious disease caused by the coronavirus SARS-CoV-2.) A record review of Resident #139's admission MDS dated [DATE] revealed Resident #139 was an [AGE] year-old male admitted for covid-19 recovery. A record review of Resident #139's physician order dated 8/19/2025 revealed the physician prescribed for Resident #139 to be under isolation droplet protocol, order summary: Droplet precautions every shift for Covid . A record review of Resident #139's care plan dated 8/19/2025 revealed, The Resident has infection - COVID . During an interview on 8/19/2025 at 10:00 AM ADON F stated Resident #139 was under droplet precautions isolation due to his diagnosed Covid-19 infection. ADON F stated Resident #139 was admitted with Covid-19 and the physician had ordered Covid-19 isolation until the doctor would order the discontinuation of the isolation. During an observation on 8/20/2025 at 10:03 PM revealed Resident #139's room was designated to be under droplet precautions. The room presented with signage at the door prior to entry which read, STOP DROPLET PRECAUTIONS. During an observation and interview on 8/20/2025 at 3:09 PM revealed Resident #139's room door opened with HK S walking in and out of Resident #139's room to utilize the housekeeping cart stationed directly outside of Resident #139's room. HK S was observed to wear PPE which included a gown, gloves, face shield, and a surgical mask. Resident #139 was observed to be in his room and did not wear a respiratory mask. Resident #139 was observed to have a visitor who identified herself as a private care giver. The private care giver was observed to wear a surgical mask as her only PPE. The private care giver stated she was not trained on what PPE to wear while in Resident #139's room and wore the surgical mask as her own common sense. During an interview HK S stated she was providing housekeeping services for Resident #139 and wore her PPE which included her surgical mask as per the signage posted. HK S stated she used the PPE stored in the 2-drawer cabinet at Resident #139's doorway. An observation of the storage cabinet revealed no N95 FFR's. During an interview and observation on 8/20/2025 at 3:13 PM LVN T stated she was the charge nurse for Resident #139 and Resident #139 was under droplet precautions for a positive covid-19 infection. LVN T observed Resident #139's door opened with the housekeeping cart directly outside of the door and observed HK S to wear a surgical mask as a PPE FFR. LVN T stated HK S's PPE FFR should have been an N95 FFR. LVN T reviewed the PPE cabinet and stated there were no N95 FFR's within the cabinet. LVN T alerted ADON F and the DON. During an interview on 8/20/2025 at 3:29 PM ADON F stated Resident #139 was recovering from a Covid infection and all staff who entered his room should wear PPE to include a N95 FFR and not a surgical mask. ADON F stated the signage for the droplet precaution outside of Resident #139's room had not specified Covid-19 precautions which included the use of N95 FFR for the Prevention of Covid-19 cross-contamination. ADON F reviewed the PPE cabinet by Resident #139's room and stated the cabinet had no N95 FFR's within. During an interview on 8/22/2025 at 5:10 PM the DON stated Resident #139 was recovering from a Covid-19 infection on 8/20/2025 and was ordered by the physician to be under Covid-19 isolation precautions. The DON stated residents who were on Covid-19 precautions should have their door closed, should be encouraged to wear a surgical mask as source control measures, and all staff should wear Covid-19 isolation precautions PPE which included the use of a N95 FFR. The DON stated the potential risk for residents who received care from staff who had not worn Covid-19 PPE could be cross-contamination and spread of Covid-19. A record review of the Untied States of America's Centers for Disease Control and Prevention's website titled Covid-19; Infection Control Guidance: SARS-CoV-2 accessed 8/20/2025 https://www.cdc.gov/covid/hcp/infection-control/ revealed, Personal Protective Equipment; HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).

Based on interview and record review, the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for medical records. The facility failed to document all medications administered or withheld in the July 2025 MAR for Resident #1. This failure could place residents at risk of medication errors.Findings included: Record review of Resident #1's face sheet, dated 7/15/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included bipolar disorder (a mental health condition causing mood swings), type 2 diabetes mellitus (a condition resulting from the body's resistance to insulin), and hypertension (high blood pressure). Record review of the quarterly MDS submitted 5/6/2025 reflected a BIMS score of 14, which indicated intact cognition. Record review of Resident #1's July 2025 MAR, printed 7/15/2025, revealed the following: Amoxicillin-Potassium Clavulanate tablet 500-125mg, give one tablet by mouth one time a day for bacterial infection related to pneumonia for 7 days (start date 7/4/2025) 8 PM7/4/2025 8:00 PM: no entry/blankFamotidine oral tablet 40mg, give 1 tablet by mouth at bedtime related to gastroesophageal reflux disease (chronic heartburn)7/14/2025 8:00 PM: no entry/blankInvega oral tablet extended release 24 hour 3mg, give 4 tablets by mouth at bedtime related to bipolar disorder, give 4 tabs to = 12mg (start date 6/30/2025)7/4/2025 8:00 PM: no entry/blank7/14/2025 8:00 PM: no entry/blankLetrozole oral tablet 2.5mg, give 2.5mg by mouth at bedtime for hormone therapy (start date 6/11/2025)7/14/2025 8:00 PM: no entry/blankZetia oral tablet 10mg, give 1 tablet by mouth at bedtime related to hyperlipidemia (high cholesterol) (start date 5/22/2025)7/14/2025 7:00 PM: no entry/blankBenztropine Mesylate oral tablet 0.5mg, give 0.5mg by mouth two times a day for tremors7/14/2025 7:00 PM: no entry/blankCalcium oral tablet 600mg, give 600mg by mouth two times a day for supplement (start date 6/11/2025)7/14/2025 9:00 PM: no entry/blankColace capsule 100mg, give 1 capsule by mouth every 12 hours for constipation (start date 5/22/2025)7/14/2025 8:00 PM: no entry/blankMetoprolol tartrate oral tablet 50mg, give 1 tablet by mouth two times a day related to hypertensive chronic kidney disease (high blood pressure resulting from kidney disease) (start date 5/22/2025)7/5/2025 4:00 PM: no entry/blankOmega 3 oral capsule 1000mg, give 1 capsule by mouth two times a day for prophylaxis (start date 5/22/2025) 7/14/2025 8:00 PM: no entry/blankTegretol-XR tablet extended release 12 hour 400mg, give 1 tablet by mouth every 12 hours related to epilepsy (seizures) (start date 5/22/2025)7/14/2025 8:00 PM: no entry/blankDiclofenac sodium external gel 1%, apply to affected areas topically three times a day for pain related to pain in unspecified joint (start date 6/08/2025)7/4/2025 7:00 PM: no entry/blank7/14/2025 7:00 PM: no entry/blankGlucosamine capsule 500mg, give 1 capsule by mouth with meals related to pain unspecified joint (start date 5/22/2025)7/14/2025 5:30 PM: no entry/blankHydralazine HCl oral tablet 100mg, give 1 tablet by mouth three times a day related to hypertensive chronic kidney disease (start date 5/22/2025)7/5/2025 8:00 PM: no entry/blank7/14/2025: 8:0 PM: no entry/blankSevelamer HCl oral tablet 800mg, give 1 tablet by mouth with meals related to disorder of phosphorus metabolism (start date 5/22/2025)7/14/2025 5:00 PM: no entry/blankHumalog injection solution 100unit/mL, inject as per sliding scale four times a day for DM-2 (start date 5/30/2025)7/5/2025 5:00 PM: no entry/blank7/5/2025 9:00 PM: no entry/blank7/14/2025 5:00 PM: no entry/blank7/14/2025 9:00 PM: no entry/blankRecord review of the facility staffing schedule reflected the following staff members were responsible for administering Resident #1's medications on the following days/shifts:LVN C: 7/4/2025 2:00 PM to 10:00 PMLVN B: 7/5/2025 2:00 PM to 10:00 PMLVN A: 7/14/2025 2:00 PM to 10:00 PMRecord review of Resident #1's progress notes from 7/4/2025 to 7/15/2025 did not reveal documentation regarding missed dosages of medications or documentation regarding the resident being away from the facility during the above listed times. Resident #1 was interviewed on 7/16/2025 at 8:35 AM. She reported the only medication she had not been administered during July 2025 was an unknown antibiotic on the evening of 7/5/2025. She said she reported it to the nurse on duty, but the nurse disagreed with her and told her she received it. She reiterated that all other days in July 2025 she had received her ordered medications, to the best of her knowledge. She denied lingering symptoms of pneumonia, such as cough or shortness of breath, as a result from allegedly not receiving the dose of antibiotic. Resident #1 was unsure if she had been away from the facility in July 2025 during medication administration times. LVN A was interviewed on 7/16/2025 at 8:30 AM. He stated he was the nurse responsible for administering medications to Resident #1 from 2:00 PM to 10:00 PM on 7/14/2025. He stated Resident #1 received all of her medications, as ordered, except the insulin because her blood sugar level did not require administration. He was unsure why he did not document the administration of the medications in the MAR. He reported the potential harm to the resident of incomplete documentation was the possibility of Resident #1 receiving duplicate doses of medication. LVN B was interviewed on 7/16/2025 at 2:28 PM. She stated she was the nurse responsible for administering medications to Resident #1 from 2:00 PM to 10:00 PM on 7/5/2025. She was unable to recall administering medications to Resident #1 on that date, but she stated if her documentation reflected a medication was administered, which included the antibiotics, then she was certain Resident #1 received the antibiotics. LVN B was unsure why she did not document administration notes for the metoprolol, hydralazine, and insulin that were due to be administered during the shift. She speculated that perhaps Resident #1 was not at the facility during that time, and she should have documented accordingly by using a code to indicate the medications were not administered due to the resident being away from the facility. She stated the potential harm to the resident was that administrators would not be able to determine why a medication was not administered from the documentation. Attempted interview with LVN A on 7/17/2025 at 1:31 PM was unsuccessful. LVN A did not respond to request for interview made by voicemail. The DON was interviewed on 7/17/2025 at 8:55 AM. She stated the facility policy and her expectation of staff is the MAR would reflect all medication administrations, including medications not administered. She was not aware of a complaint from Resident #1 regarding a missed dosage of antibiotics. She reported the potential harm to residents from having incomplete documentation on the MAR was the possibility of residents receiving an additional dosage of medication. Record review of the facility's policy titled Medications (dated November 2017) did not reveal guidance related to the documentation of routine scheduled medications.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #6) reviewed for care plans 1. The facility failed to ensure CNA D and CNA E implemented Resident #6's care plan when they used a gait belt instead of a mechanical lift to transfer the resident. 2. The facility failed to ensure Resident #6 had her oxygen tubing on as care planned. These failures could place residents at risk of a decrease in independence and injury. The findings include Record review of Resident #6's admission Record, dated 07/15/2025, she was [AGE] year documented a female resident who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #6 had diagnoses which included acute respiratory failure with hypoxia (a condition where the body, or a region of the body, is deprived of adequate oxygen supply.), history of pneumonia, cognitive communication deficit, limitation of activates due to disability, dementia (a general term for a decline in mental ability severe enough to interfere with daily life), shortness of breath, muscle weakness, dependence on other enabling machines and devices.Record review of Resident #6's consolidated orders for July 2025 was documented Oxygen at 2-4 liters per nasal cannula, every shift related to acute respiratory failure with hypoxia, shortness of breath. Record review of Resident #6's Quarterly MDS dated [DATE], was documented she had a BIMS of 6/15 (severely cognitively impaired), she required a wheelchair to mobilize, he required partial/moderate assistance (does less than half the effort, helper lifts or holds trunk or limbs and provided more than half the effort) for chair/bed to chair transfer and was on oxygen therapy. Record review of Resident #6's care plan dated 5/26/2025 has altered acute respiratory status/difficulty breathing related to hypoxia also had obstructive sleep apnea-Interventions provide oxygen as ordered per MD orders. Resident [NAME] had an ADL self-care performance deficit related to decrease in mobility-Intervention was Transfer, the resident required a mechanical lift with 2 person staff assistance for transfers.A.Observation on 7/15/2025 at 12:21 PM with Resident #6, sitting on bed, CNA D and CNA E and observed a mechanical lift in the room. CNA D came back into Resident #6's room with CAN E and had a gait belt with him. Observation of a 2 person transfer with gait belt from Resident #6's bed to her wheelchair. No observations of harm during transfer.Interview on 7/16/2025 at 10:22 AM with CNA D stated he could not find a mechanical lift sling for Resident #6, so he was going use the gait belt. CAN D stated they did not have a lot of mechanical slings, and he had looked in the linen closet. CAN D stated Resident #6 usually is transferred with a mechanical lift. He had to leave because he was busy with resident. CNA D stated Resident #6 is stronger today and was able to pivot. Interview on 7/16/2025 at 10:42 AM with CNA E stated she did assist CNA D with Resident #6's transfer from bed to wheelchair. CNA E stated Resident #6 needs a mechanical lift transfer with a sling. CNA E stated she did report to her charge nurse. B. Observation on 7/15/25 at 1:17 PM in Resident #6's room revealed the oxygen concentrator was at 2 LPM (liters per minute) and the oxygen tubing was not on the resident nasal area. The oxygen was laying across her bed. Observation on 7/15/2025 at 1:35 PM with Resident #6 was sitting in her wheelchair, eating lunch and she was not wearing her oxygen tubing on her nasal area. Interview on 7/15/2025 at 1:36 PM with Resident #6 stated she wears her oxygen tubing on at night. Interview on 7/15/25 at 1:38 PM with ADON stated Resident #6 confirmed resident did not have the oxygen tubing in place as ordered with no response to risk. Interview on 7/16/2025 at 5:17 PM with ADM/DON stated they updated the care plan for Resident #6 and the risk would be resident could fall, and staff could fall with her. Interview with DON did not respond to risk of resident transfers. Interview with ADM/DON did not provide a policy for care plans. Interview with ADM stated the long-term care plan staff was not working any longer, as of last Friday. Record review of policy, Protocol for Oxygen Administration dated March 2019 was documented was documented, Patients with oxygen therapy will have their plan of care updated to reflect their oxygen use. When not in use, oxygen cannulas. will be stored in plastic bags attached to oxygen concentrator tank.

Based on observations, interviews, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 2 (#6) residents in the 500 hall in that: Resident #6 was not transferred with Mechanical lift (Hoyer) during a transfer as care planned. This could affect all residents with Hoyer transfers and could result in accidents/injury. The Failures included: Record review of Resident #6's admission Record, dated 07/15/2025, she was [AGE] year documented a female resident who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #6 had diagnoses which included acute respiratory failure with hypoxia (a condition where the body, or a region of the body, is deprived of adequate oxygen supply.), history of pneumonia, cognitive communication deficit, limitation of activates due to disability, dementia (a general term for a decline in mental ability severe enough to interfere with daily life), shortness of breath, muscle weakness, dependence on other enabling machines and devices. Record review of Resident #6's Quarterly MDS, dated [DATE] documented she had a BIMS of 6/15, which indicated the resident was severely cognitively impaired. Resident #6 required a wheelchair to mobilize, she required partial/moderate assistance (does less than half the effort, helper lifts or holds trunk or limbs and provided more than half the effort) for chair/bed to chair transfer and was on oxygen therapy. Record review of Resident #6's care plan, dated 5/26/2025. Documented the resident #6 had an ADL self-care performance deficit related to decrease in mobility-Intervention was Transfer, the resident required a mechanical lift with 2 person staff assistance for transfers. Observation on 7/15/2025 at 12:21 PM of Resident #6 revealed the resident was sitting on her bed, CNA D and CNA E observed a mechanical lift in the room. CNA D came back into Resident #6's room with CNA E and had a gait belt with him. Observation of a 2 person transfer with gait belt from Resident #6's bed to her wheelchair. No observations of harm during transfer. Interview on 7/16/2025 at 10:22 AM, CNA D stated he could not find a mechanical lift sling for Resident #6, so he was going use the gait belt. CNA D stated they did not have a lot of mechanical slings, and he looked in the linen closet. CNA D stated Resident #6 usually was transferred with a mechanical lift. He had to leave because he was busy with a resident. CNA D stated Resident #6 was stronger today and was able to pivot. Interview on 7/16/2025 at 10:42 AM, CNA E stated she assisted CNA D with Resident #6's transfer from bed to wheelchair. CNA E stated Resident #6 needed a mechanical lift transfer with a sling]. CNA E stated she did report to her charge nurse. Interview on 7/16/2025 at 2:21 PM Physical Therapist stated Resident #6 stated she could pivot and be transferred with 2 staff with gait belt. Interview with Physical Therapist stated it depended on Resident #6's transfer depended on her anxiety or if she is in pain. Interview with Physical Therapist was off services at this time. Interview on 7/16/2025 at 5:17 PM with ADM/DON stated they updated the care plan for Resident #6 and the risk would be resident could fall, and staff could fall with her. Interview on 7/17/2025 at 9:08 AM with ADM stated no policy.

Based on observations, interviews, and record reviews failed to ensure the facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 18 (#6) residents with oxygen orders in that: Resident #6 was not wearing her oxygen tubing as ordered. This could affect all resident with Oxygen and could result in residents as ordered. The findings included:Record review of Resident #6's admission Record, dated 07/15/2025, she was [AGE] year documented a female resident who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #6 had diagnoses which included acute respiratory failure with hypoxia (a condition where the body, or a region of the body, is deprived of adequate oxygen supply.), history of pneumonia, cognitive communication deficit, limitation of activates due to disability, dementia (a general term for a decline in mental ability severe enough to interfere with daily life), shortness of breath, muscle weakness, dependence on other enabling machines and devices.Record review of Resident #6's consolidated orders for July 2025 documented Oxygen at 2-4 liters per nasal cannula, every shift related to acute respiratory failure with hypoxia, shortness of breath. Record review of Resident #6's Quarterly MDS, dated [DATE] documented she had a BIMS of 6/15, which indicated the resident was severely cognitively impaired. Resident #6 required a wheelchair to mobilize, she required partial/moderate assistance (does less than half the effort, helper lifts or holds trunk or limbs and provided more than half the effort) for chair/bed to chair transfer and was on oxygen therapy. Record review of Resident #6's care plan, dated 5/26/2025. Documented resident #6 had altered acute respiratory status/difficulty breathing related to hypoxia and also had obstructive sleep apnea-Interventions provide oxygen as ordered per MD orders. Observation on 7/15/25 at 1:17 PM in Resident #6's room revealed the oxygen concentrator was at 2 LPM (liters per minute and the oxygen tubing was not on the resident nasal area. The oxygen was laying across her bed. Observation on 7/15/2025 at 1:35 PM revealed Resident #6 was sitting in her wheelchair, eating lunch and she was not wearing her oxygen tubing on her nasal area. Interview on 7/15/2025 at 1:36 PM, Resident #6 stated she wore her oxygen tubing on at night. Interview on 7/15/25 at 1:38 PM, the ADON stated Resident #6 did not have the oxygen tubing in place as ordered. she had not response to questions.Interview on 7/16/2025 at 5:17 PM with DON stated she updated care plan to say Resident #6 tries to take off oxygen tubing. Interview with DON stated the care plan staff for 500 hall was no longer working as of this last Friday. Interview with DON did not respond to the risk of residents that did not wear their oxygen tubing as ordered. Record review of the facility's policy, Protocol for Oxygen Administration, dated March 2019, documented, Patients with oxygen therapy will have their plan of care updated to reflect their oxygen use. When not in use, oxygen cannulas. will be stored in plastic bags attached to oxygen concentrator tank.

Based on observation, interview and record review the facility failed to provide special eating equipment and utensils for residents who needed them and appropriate assistance to ensure that the resident could use the assistance devices when consuming meals and snacks for 1 of 6 residents (Resident #7) reviewed for assistive devices. The facility failed to ensure Resident #7 had her 2 handed drinking cup as ordered. This failure could place residents at risk of a decrease in independence. The findings includeRecord review of Resident #7's [TF1] [RV2] admission record documented a female resident [AGE] years old, who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominate side (conditions affecting one side of the body. Hemiplegia is characterized by paralysis, while hemiparesis involves weakness, both impacting mobility and daily activities.), need for assistance with personal care, muscle weakness, low vision right eye, contracture of muscle on left hand, muscle wasting and atrophy (the wasting away or decrease in size of a body part, typically a muscle, organ, or tissue, due to cell degeneration, disease, or lack of use) on right and left hand, lack of coordination, cognitive communication deficit and age-related physical debility[TF3] [RV4] . Record review of Resident #7's admission MDS, dated [DATE], documented her BIMS was 12/15, which indicated moderate cognitive impairment. Resident #7 had no range of motion impairments and no mobility devices. Resident #17 ADLs where she required set-up and clean up assistance for eating, and she required partial/moderate assistance upper/lower body dressing. Record review of Resident #7's telephone order, dated 6/16/2025, documented Dietary Adaptive-Two handle plastic cup by LVN F. Record review of Resident #7's lunch ticket dated 7/15/2025, was documented 2 handle cup. Record review of Resident #7's care plan, dated 6/17/2025, documented the resident had an ADL self-care performance deficit and intervention was for Dressing-assist, the resident to choose simple comfortable clothes that enhances the resident ability to dress self and allow sufficient time for dressing and undressing. The resident requires assistance of 1 to 2 staff to dress, and this may fluctuate with weakness, fatigue, and weight bearing status. Resident #7 had potential nutritional problems interventions were OT, PT and ST to screen and provide adaptive equipment for feeding as needed. Observation on 7/15/2025 at 12:30 PM in the main dining room revealed Resident #7's lunch area did not include a 2-handle cup. Observation of Resident #7 had a regular plastic cup. Observation and interview on 7/15/2025 at 12:45 PM, Resident #7 stated her right hand was broken and her left hand was contracted from stroke. Resident #7 stated she could not pick up the plastic cup but could push the cup closer and could drink with a straw. Interview on 7/15/2025 at 12:40 PM, the DM stated the OT provided the 2-handle cup and she was not sure why Resident #7 did not have one at lunch. Attempted interview on 7/16/2025 at 9:37 AM with LVN F was unsuccessful. A voicemail was left. Interview on 7/16/25 at 11:16 AM, the OT stated he did not put the 2-handle cup order in Resident #7's consolidated orders. The OT stated any therapy discipline could address the need for adaptive equipment while eating. The OT stated Resident #7 was not on OT services at this time. The OT stated the risk for residents not having an order available was she would not be able to feed herself while in the dining room. The OT stated Resident #7 had tremors, lack of coordination and it could decrease her independence in feeding herself. Interview on 7/16/2025 at 1:42 PM, the DM stated she did not have the 2 handle cup, so she went to get five of the 2 handle cups from a sister facility. The DM stated she was not sure when the therapy department brought the order for a 2 handed cup. The DM stated the process was the therapy handed the dietary department the order for any equipment required for residents during meals. Record review of the facility's policy, admission protocol, dated January 20024, reflected To ensure the patient and family feel welcome and care is based on physician's admission orders instituted by all departments upon admission. under Dietary, upon admission of the patient, dietary will ensure the following are completed and in place: check diet orders and notify kitchen, proper diet/tray card. Record review of the facility's policy, Dining program, dated April 2025, reflected, 5. A diet rooster must be maintained and audited by the nutrition service director at least once monthly, utilizing the diet listing from the electronic medical record the meal ticket software. 8. A list of adaptive equipment for dining must be maintained and audited by the Nutrition Service Director at least once monthly, unitizing the diet listing form the electronic medical record and the meal ticket software. Record review of the facility policy, Adaptive equipment, dated November 3, 2004, reflected, The facility shall provide adaptive equipment as orders. Recommended by the therapist and/or physician. The ensure that all Residents receive the proper utensils/equipment for meals. 1. Residents are reviewed on admission, an as needed for need of adaptive devices. Referrals for need equipment may come for occupational or speech therapy, nursing physician or Dietician. 3. The Dietary Services Manager shall purchase and keep in inventory certain adaptive equipment. 4. Physician order is obtained for adaptive devices as per Therapist plan of care. 5. Adaptive devices in use are . provided for each meal by the Dietary Department. Adaptive devices are noted on each Resident Diet Card and medical record.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events and do not result 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 1 of 9 residents (Residents #6) reviewed for abuse and neglect, in that: 1. CNA D observed CNA G yank Resident #6 out of bed and overheard CNA G tell Resident #6 he was going to kill him in Spanish. CNA D did not report the allegation timely and did not report to the Administrator. 2. CNA M observed Resident #6 with wheelchair wheels tied together with plastic bags, restricting Resident #6's mobility, and CNA M did not report the incident to the DON or Administrator. 3. The DON was notified by LVN C that Resident #6 was observed with his wheelchair wheels tied together, restricting Resident #6's mobility and the DON did not report the allegation to the Administrator. 4. The UM was notified by LVN C that Resident #6 was observed with his wheelchair wheels tied together, restricting Resident #6's mobility and the UM did not report the allegation to the Administrator. This failure/deficient practice could place residents at risk for not having allegations of abuse or neglect reported to the State Agency to ensure that allegations are fully investigated. The findings were: 1. Record Review of Resident #6's undated face sheet revealed Resident #6 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included a Nontraumatic Intracerebral Hemorrhage (bleeding into the substance of the brain/stroke), Hemiplegia (paralysis on one side of the body), Hemiparesis (muscle weakness of one side of the body), Schizophrenia (a chronic mental illness characterized by delusions, hallucinations and disorganized thinking) and Epilepsy (a brain disorder that causes seizures). Record review of Resident #6's admission MDS assessment, dated 05/14/2025, revealed a BIMS score of 03, indicating severe cognitive impairment. Section GG- Functional Abilities revealed Resident #6 had impairment on both sides of his upper and lower extremities that interfered with daily functions or placed the resident at risk of injury in the prior 7 days of the assessment date. Section GG also revealed Resident #6 required substantial assistance with dressing, showers and sit to stand. Section J- Health Conditions revealed Resident #6 had one fall without injury since admission to the facility. Record review of Resident #6's comprehensive care plan care plan revealed a care plan, dated 05/08/2025 and revised 05/18/2025, Resident #6 required 1 person assistance from staff for transfers to move between surfaces. Resident #6 had a care plan for falls related to generalized weakness, dated 06/11/2025 and revised 06/12/2025, and revealed resident had a fall on 05/12/2025, 05/18/2025, 05/22/2025, 05/25/2025, 06/06/2025, 06/07/2025 and 06/11/2025. An intervention included to keep the resident in common areas for maximum observation opportunities, date initiated 05/30/2025. Record review of Resident #6's fall risk assessment, dated 06/10/2025, revealed Resident #6 was a high fall risk and had 3 or more falls in the past 3 months. The assessment revealed Resident #6 was chair bound. Record review of Resident #6's Occupational Therapy Treatment Encounter Note, dated 06/11/2025, revealed Resident #6 had poor standing balance and fair sitting balance. The note revealed complexities /barriers impacting the session included fall risk, reduced cognition, and LUE weakness. Record review of Resident #6's progress note, dated 06/17/2025 at 1:00 p.m. revealed Resident #6 was discharged to a rehabilitation center with all personal belongings and medications. Record review of a letter provided to the HHSC Investigator by a COTA, 06/18/2025 at 1:07 p.m., revealed On July 11, 2025, during 2pm to 10 pm shift, this incident occurred at [facility name] SNF in [city and state name]. [CNA G name] restrained [Resident #6 name] (patient) in one of the following ways: [CNA G name] tied patient arms to his hospital bed with trash bags. [CNA G name] tied patient arms to the wheelchair with trash bags. [CNA G] tied up patient w/c wheels so that patient could not move his w/c. [Resident #6 name] is cognitively impaired following a stroke and has hemiplegia. He is unable to recall information and events that have occurred. He can communicate basic wants and needs. [CNA G name] claims that [LVN G name] gave him permission to do so. Patient had been roaming the halls, opening med carts and taking items from the nurse's station. [LVN C name] witnessed [CNA G name] restraining patient and reported incident to Administrator. On another occasion, [CNA D name] overheard [CNA G name] tell the same patient that he was going to kill the patient. [CNA D name] reported this incident to [UM name]. [CNA G name] was suspended on July 12, 2025, pending investigation, however, he returned to work on July 15, 2025, during 2pm-10pm shift. During an interview with the COTA, 06/18/2025 at 1:10 p.m., the COTA stated the dates on her letter were for June 2025 and not July 2025 and stated she was informed by CNA D on 06/12/2025 that Resident #6 was restrained by CNA G on 06/11/2025. COTA stated LVN C witnessed the incident and reported it to the UM and CNA G was suspended but was allowed to return to work. The COTA stated she provided therapy services to Resident #6 on Friday 6/13/2025 and Resident #6 was not exhibiting any emotional distress. The COTA stated she did not witness the restraint but felt like it should have been reported to the state. The COTA stated she was not sure if any of the witnesses reported it, but she wanted to report it to the HHSC investigator. The COTA stated CNA D told her that CNA D witnessed CNA G tell Resident #6 that he was going to kill him and CNA D reported it to the UM. The COTA stated she should have reported it to the state when she became aware of the allegation so it could have been investigated at that time because the patients cannot advocate for themselves. The COTA stated she was not aware of any other residents being restrained or abused and stated she had been trained on abuse and neglect prior to being told about the allegations by CNA D. During an interview with CNA D, 06/18/2025 at 2:07 p.m., CNA D stated she had suspected another employee of abusing a resident and stated she reported the incident to the UM and DON. CNA D stated a few weeks ago CNA D was with CNA G around 7 p.m. in Resident #6's room and observed CNA G yank Resident #6 up off of the bed so hard I thought [CNA G] was going to break his back. CNA D said CNA G also said I am going to kill you in Spanish to Resident #6. CNA D stated she reported the incident to LVN E at the time of the incident, 2 days later reported the incident to the UM and then reported the incident to the DON one week later. CNA D stated the UM said he would send CNA G home. CNA D stated when she notified the DON the following week, the DON told CNA D that CNA D should have reported it to the DON at the time of the incident so she could have properly handled it. CNA D stated she did not know if anyone took her report seriously and stated she should have reported it to the Administrator but did not know who that was at the time and said, I did not know anyone's name or who to call. CNA D stated it was important to report abuse because CNA G could of literally hurt him and I left the room, so who knows what even happened after that. During an interview with the UM, 06/19/2025 at 2:00pm, the UM stated he was not notified of CNA G being rough with Resident #6 or telling Resident #6 that CNA G would kill him. The UM stated it that was reported to him he would have suspended CNA G and notified the DON and the Administrator. During an interview with LVN E, 06/20/2025 at 2:56 p.m., LVN E stated she was not notified of CNA G being rough with Resident #6 or telling Resident #6 that CNA G would kill him. LVN E stated CNA D reported to her that CNA G was not a team player but did not make any allegations of abuse toward CNA G. LVN E stated she had not received any reports of abuse or concerns regarding CNA G as the Charge Nurse. LVN E said she would have reported the incident to the DON if she was notified of an allegation of abuse and stated it was important to report abuse and neglect because the patients are our number one priority and we have to protect them from harm. During an interview with the DON, 06/20/2025 at 9:33 a.m., the DON stated CNA D did not report any allegations against CNA G regarding Resident #6 and had not received any other allegations of abuse or resident concerns regarding CNA G. The DON stated if CNA D reported any allegations of abuse to her, she would have notified the Administrator and suspended the employee. The DON stated employees received training on abuse and neglect when hired and throughout the year and the expectation was for employees to report abuse immediately to the Administrator. The DON stated allegations of abuse that were not investigated could cause psychological and physical harm to facility residents. Record review of facility document titled, Job Description Certified Nursing Assistant, revealed CNA D's signed the job description on 04/15/2025. The job description revealed an essential function as, has reviewed [company name] clinical policies and procedures for abuse prevention and knows the employee's responsibility to enforce it and responsible for assuring patient/resident safety. Record review revealed CNA D signed Senate [NAME] 9 of Nursing Home Policy on 04/15/2025 that included remember our policy that all patients/residents of this community are to be always treated with dignity and respect under all circumstances. Mistreatment or abuse of any nature will not be tolerated. Any employee guilty of abusing, neglecting or not disclosing such acts is subject to immediate discharge. Local authorities will be notified, and criminal charges may be filed. Record review revealed CNA D signed the facility Abuse Prohibition Protocol on 04/15/2025. 2. During an interview with CNA M, 06/19/2025 at 1:30 p.m., CMA M stated she arrived at work early on 06/11/2025 around 8 p.m. for her 10 p.m. - 6 a.m. shift. CNA M stated she was walking by the café day room and observed Resident #6 in the day room with his wheelchair wheels tied up with trash bags in all different directions in his wheels. CNA M stated Resident #6 was trying to move in the chair and could not move and appeared distressed. CNA M stated Resident #6 could not walk, and the trash bags were preventing Resident #6 from being about to move independently. CNA M stated she went to LVN E and told LVN E what she observed and LVN E said it was because he was going into other people's room and taking stuff. CNA M stated she told LVN E what she witnessed was abuse and LVN E did not respond. CNA M stated another nurse by Resident #6 and the nurse told her that she reported the incident, so CNA M did not report it. CNA M stated she felt like the incident was a restraint and abuse and stated she should have reported the incident to the Administrator and DON. CNA M stated she had received training on reporting abuse and neglect prior to witnessing the incident and knew that abuse should be reported immediately to the Abuse Coordinator who was the Administrator. During an interview with LVN E, 06/19/2025 at 2:56 p.m., LVN E stated no one reported observing Resident #6 with trash bags tied around his wheelchair wheels and stated she would have notified the DON and abuse prevention coordinator. LVN E stated she had been trained on restraints, restraints were not allowed at the facility and a resident who was improperly restrained could cause bruising, fractures, or aggression when the resident tried to get out of the restraint or cause the resident to fall and get injured. During an interview with the DON, 06/20/2025 at 9:33 a.m., the DON stated after this HHSC investigator entered the facility, the DON interviewed other employees at the facility on the night of 06/11/2025 and said, no one else admitted seeing it to me anyway, I don't know if they were scared of what, CNA G admitted to putting the trash bags on the chair though. 3. During an interview with LVN C, 06/18/2025 at 2:56 p.m., LVN C stated she had suspected another employee of abusing a resident and stated she reported the incident to the UM and DON. LVN C stated on July 11, 2025, around 8 p.m., LVN C was walking by the café day room close to the nurse's station and observed Resident #6 sitting in his wheelchair with trash bags wrapped around the wheelchair tires. LVN C stated Resident #6 was unable to move and was observed trying to move his chair, appeared distressed and agitated and was leaning out of his chair reaching toward the coffee bar. LVN C stated the trash bags were looped throughout the wheels and tied to the center bar in the back of the chair and some bags were tied together from one wheel to the other. LVN C said there were so many trash bags used, and the bags were woven together like a spider web. LVN C stated the bags were so thick that she had to hack at the trash bags with her scissors to cut the bags off. LVN C stated CNA G came over to Resident #6 while LVN C was trying to cut the bags off, and CNA G was laughing and told LVN C not to cut the bags off and told LVN C that LVN E knew about it and to talk to LVN E about it. LVN C stated she was not talking to LVN E about it, briefly assessed Resident #6 to see that he did not have any markings on him and said Resident #6 regained his mobility and got himself a cup of coffee. LVN C stated she immediately reported the incident to the DON and UM and was told her to send CNA G home. LVN C said she was under the impression an investigation would be conducted and CNA G would be terminated but CNA G was allowed to return to work. During an interview with LVN E, 06/19/2025 at 2:56 p.m., LVN E stated Resident #6 had a witnessed fall in his room at the beginning of LVN E's shift on 06/11/2025 at 2 p.m. LVN E stated Resident #6 was brought out of his room and placed in the café day room so he could be observed. LVN E stated Resident #6 was observed throughout the shift going in and out of other resident rooms, turning water faucets on and off and LVN E observed Resident #6 propelling himself around the unit during the shift. LVN E stated she was not aware that Resident #6 had trash bags tied to his wheelchair wheels on the night of 6/11/2025 until this HHSC Investigator asked her about it. LVN E stated she did not observe anything tied to Resident #6's chair, no one called her and notified her that Resident #6 had trash bags tied to his chair and no one had contacted her and asked her to suspend CNA G. LVN E stated she observed CNA G leaving the facility around 9 pm and said CNA G told her he was leaving and LVN E assumed he was being sent home because census was low. LVN E stated she spoke to the UM and DON about Resident #6 having a fall on the shift but was not questioned or notified about the observation of trash bags being tied to Resident #6's wheelchair wheels. LVN E stated she was not asked to complete a head-to-toe assessment after the incident. LVN E stated she did not instruct CNA G to restrain Resident #6 and LVN E stated tying trash bags on the wheels of a resident wheelchair was a restraint and abuse and LVN E stated she would have notified the DON and abuse prevention coordinator. During an interview with CNA G, 06/19/2025 at 4:22 p.m. CNA G stated Resident #6 was roaming around in different patient rooms on the evening of 06/11/2025 so CNA G redirected him to the café day room so we could keep a better eye on him. CNA G stated he put trash bags in the resident wheelchair wheels gently and stated he did it so we would be able to see him if he tried to leave again so we could see him and help him. CNA G said he placed the trash bags in the wheels to do something like slow the resident down. CNA G stated he had received training on restraints prior to this incident and stated the definition of a restraint was when a patient cannot move or get up or do anything on their own. CNA G stated he was not told to add the trash bags by anyone else and did not tell anyone else that he did it because he did not feel like it was a restriction. CNA G stated he had never placed trash bags in any other resident wheelchair wheels and had never restrained another resident. CNA G stated he was notified by LVN C that he restrained a resident and was being suspended. CNA G stated he met with the UM on 06/12/2025 and received training on abuse, neglect, and restraints. CNA G stated a resident who was improperly restrained could harm themselves mentally or physically. CNA G stated he never threatened to kill Resident #6 and denied ever handling Resident #6 roughly during a transfer. CNA G stated he used a gait belt any time he transferred Resident #6. During an interview with the DON, 06/20/2025 at 9:33 a.m., the DON stated, staff received training on abuse/neglect, behavior management and restraints upon hire and throughout the year. The DON stated staff had received training on reporting abuse to the abuse coordinator and any allegations of abuse should have been reported immediately. The DON stated the facility was restraint free and described a physical restraint as any type of device used in contact with the body that limits the movement of the resident. The DON stated it would be considered a restraint if a resident's primary mode of mobility was his wheelchair and the resident was unable to move in the chair due to the wheelchair wheels being compromised by a staff member. The DON stated Resident #6 was a fall risk, had several falls at the facility, was able to propel himself in his wheelchair and was not able to ambulate safely. The DON stated LVN C sent the DON and UM a text on 06/11/2025 around 8:15 p.m. and said, someone needs to deal with [CNA G], he restrained a patient and he put trash bags on [Resident #6]'s wheelchair and it is not okay to tie him down and he cannot move. The DON said, I responded and said this is not acceptable behavior and please send him home and [UM] responded and said, yes send him home. The DON said LVN C informed her that she was not CNA G's nurse so the DON stated she called LVN E and asked LVN E to send him home and LVN E said she could see Resident #6 and he was moving around freely but I didn't think about the fact that LVN C had already cut the trash bags off so when I heard LVN E say he could move freely I thought it was with the trash bags on. The DON stated she did not notify the Administrator of the allegation and did not report the allegation to HHSC. The DON reviewed an in-service conducted by the Regional Nurse Manager regarding reporting abuse and neglect, dated 06/16/2025, and said, the in-service was because I did not report it and this was her telling me and [UM name] we should have reported this to the ED and said oh that must be a mistake because they didn't know about it until after you got here regarding the in service date. The DON stated In lieu of the concerns and the UM telling me the concerns of what happened we went ahead and reported it to HHS on 06/19/2025 regarding [CNA G] restraining the resident and I called the HHSC Liaison, and she said it definitely needed to be reported and should have been reported within the 2-hour window. She asked me if I thought I should have reported it and I said yes. The DON stated an emergency QAPI was held on 6/19/2025 with the physician, behavior management education was initiated and [psychiatric company name] was conducting an in service for the staff at 2:00 p.m. on 06/20/2025. 4. During an interview with the UM, 06/19/2025 at 2:00 p.m., the UM stated LVN C called the UM and DON on 06/11/2025 around 8 p.m. and reported observing CNA G place trash bags around Resident #6's wheelchair and stated LVN C was instructed to send CNA G home. The UM stated he met with CNA G on 06/12/2025 and CNA G explained the situation to me and I suspended him and notified the DON of what he said. The UM stated CNA G said Resident #6 had increased behaviors during the shift and was going in other resident rooms and being disruptive so he attempted to slow him down from going into other rooms by getting some trash bags and wrapped them around the wheelchair wheels to slow him down from being able to move in the wheelchair. The UM stated the wheelchair was Resident #6's primarily mode for mobility and Resident #6 was not able to ambulate safely. The UM stated he was not sure if the Administrator was notified and stated the DON conducted the investigation, staff received in servicing on abuse and restraints and CNA G was placed on a final disciplinary warning. The UM stated he did not notify the Administrator of the allegation of abuse and stated the Administrator was the Abuse Prevention Coordinator and all allegations should be reported to the Administrator immediately. The UM stated he was responsible for reporting abuse and neglect to the Administrator when I am notified and if the staff cannot get ahold of the Administrator. The UM stated, when allegations of abuse and neglect or restraints are not reported and investigated properly, the issues could continue to happen, and the employee could place other residents in danger. Record review of a facility incident report for Resident #6, dated 06/12/2025 at 2:00 p.m. and completed by the UM, categorized the incident as alleged abuse and described the incident as charge nurse reported that employee had wrapped trash bag around pt wheelchair wheel as a restraint to keep patient from moving in w/c. Immediate action taken revealed, employee was send home and suspended during investigation, head to toe assessment was performed on patient and patient was interviewed. The report revealed the physician and DON were notified on 06/13/2025 at 1:11 p.m. Record review of an undated statement signed by CNA G revealed, on 6/11 [Resident #6] was having increased behaviors throughout the shift and going to other patient rooms and been inappropriate/disruptive, with guest and patients. [Resident #6] was redirected numerous times and taken out of patient's rooms and he kept going back to the rooms. In an attempt to help other patient and keep close watch on [Resident #6], I put him in café where he likes to drink coffee. I tried to slow him down by putting trash bags at the bottom of the wheelchair, but he was never restrained and could get up and move freely if he wanted to. Record review of a statement dated 06/19/2025, and signed by LVN C revealed, On 06/11/2025 @ 8:00 pm I was walking down 700 hall to the Nurse's station when I passed the café and saw patient [Resident #6 last name] with 2 CNAs [CNA G and CNA H]. I heard [CNA G and CNA H] laughing in which case I came over and then had [CNA G] point out to me that he had tied up the patient's wheelchairs together with trash bags. The trash bags were tied to each of the wheels and then tied to the center piece of the wheelchair limiting the patients ROM. Patient appeared aggravated while attempting to reach for the coffee cups and was seen attempting to scoot himself off his wheelchair in order to reach the coffee. I demanded that [CNA G] remove the trash bags, [CNA G] refused. I attempted to tear the trash bags with my hands and was unable to because of how many trash bags were used. I then proceeded to grab a pair of scissors, when [CNA G] attempted to stop me telling me 'ASK [LVN E first two letters of name]! ASK [LVN E first two letters of name]! ASK [LVN E first two letters of name]! BEFORE YOU CUT THEM OFF!' I told [CNA G] that I was not going to ask [LVN E first two letters of name] anything and if she did not want me to cut off the trash bags she can come over and discuss it with me. I then proceeded to cut off and remove the trash bags, and quickly looked over patient, no apparent injury was noted right after incident. I reported to DON and UM on 06/11/2025 at 8:15 p.m. Record review of in-service roster, presented by the Regional Corporate Nurse on 06/16/2025, revealed the topic was abuse and neglect reporting, incident and accidents, restraints and was signed by the DON and UM. Record review of a facility document titled, [facility name] Emergency QAPI Plan Reporting of Abuse and Neglect, dated 06/19/2025, revealed, Problem: Facility not reporting abuse/neglect allegations as required and are unsure of the policy and procedures associated. The document also revealed, Education: On 06/19/2025 the Director of Nursing and Unit Manager of in serviced by the Regional Director of Clinical services on the Abuse Prevention Protocol, Reporting of Abuse allegations, to include a questionnaire and statement ensuring understanding and knowing who the abuse coordinator is along with the contact information. Being on 6/19/25 - All staff were re-in serviced by the Director of Nursing Services and/or Nurse Manager on the following: *Abuse Prevention Protocol and reporting of abuse allegations to include a questionnaire and statement ensuring understanding and knowing who the abuse coordinator is along with their contact information. *Dealing with patients with behaviors to include a post test for understanding. The document was signed by 6 employees including the Medical Director, Director of Nursing, Regional [NAME] President, Regional Director of Clinical Services, Assistant Director of Nursing and Unit Manager. Record review of a facility document titled, [company name] Abuse Prohibition Protocol (Company Name Protocol 3-B August 2024), revealed, The patient has the right to be free from abuse, neglect, mistreatment of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required in treating the Patient's symptoms. The protocol revealed, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. Instances of abuse of all patient/resident, irrespective of any physical or mental condition, cause physical harm, pain, or mental anguish. 'Willful' as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflect injury or harm. Mistreatment means inappropriate treatment or exploitation of a patient. Record review of a facility document, [Company name] Reportable Incident Protocol, revealed, External Reportable Incidents: In response to allegations of abuse, neglect, exploitation, or mistreatment the facility must: 1. Ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of patient property, are reported immediately, but no later than 2 hours after allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Executive Director of the facility to other officials (including State Survey Agency and adult protective services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. 2. Have evidence that all alleged violations are thoroughly investigated. 3. Prevent further potential abuse, neglect, exploitation, or mistreatment while investigation is in progress. 4. Report the results of all investigations to the ED or his or her designee and to other officials in accordance with State law, including the State Survey Agency within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Based on interview and record review the facility failed to ensure the residents had a right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of convenience, and not required to treat the resident's medical symptoms and to use the least restrictive alternate for the least amount of time and document ongoing re-evaluation of the need for restraints for 1 of 9 residents (Resident #6) whose care was reviewed in that: CNA G restrained Resident #6 by tying trash bags around Resident #6's wheelchair wheels to reduce Resident #6's independent mobility in the facility. This deficit practice could potentially affect residents who required wheelchairs for mobility evidenced by restricting movement, a decline in ADL function and psychological distress. The findings were: Record Review of Resident #6's undated face sheet revealed Resident #6 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included a Nontraumatic Intracerebral Hemorrhage (bleeding into the substance of the brain/stroke), Hemiplegia (paralysis on one side of the body), Hemiparesis (muscle weakness of one side of the body), Schizophrenia (a chronic mental illness characterized by delusions, hallucinations and disorganized thinking) and Epilepsy (a brain disorder that causes seizures). Record review of Resident #6's admission MDS assessment, dated 05/14/2025, revealed a BIMS score of 03, indicating severe cognitive impairment. Section GG- Functional Abilities revealed Resident #6 had impairment on both sides of his upper and lower extremities that interfered with daily functions or placed the resident at risk of injury in the prior 7 days of the assessment date. Section GG also revealed Resident #6 required substantial assistance with dressing, showers and sit to stand. Section J- Health Conditions revealed Resident #6 had one fall without injury since admission to the facility. Record review of Resident #6's comprehensive care plan care plan revealed a care plan, dated 05/08/2025 and revised 05/18/2025, Resident #6 required 1 person assistance from staff for transfers to move between surfaces. Resident #6 had a care plan for falls related to generalized weakness, dated 06/11/2025 and revised 06/12/2025, and revealed resident had a fall on 05/12/2025, 05/18/2025, 05/22/2025, 05/25/2025, 06/06/2025, 06/07/2025 and 06/11/2025. An intervention included to keep the resident in common areas for maximum observation opportunities, date initiated 05/30/2025. Record review of Resident #6's fall risk assessment, dated 06/10/2025, revealed Resident #6 was a high fall risk and had 3 or more falls in the past 3 months. The assessment revealed Resident #6 was chair bound. Record review of Resident #6's Occupational Therapy Treatment Encounter Note, dated 06/11/2025, revealed Resident #6 had poor standing balance and fair sitting balance. The note revealed complexities /barriers impacting the session included fall risk, reduced cognition, and LUE weakness. Record review of Resident #6's progress note, dated 06/17/2025 at 1:00 p.m. revealed Resident #6 was discharged to a rehabilitation center with all personal belongings and medications. Record review of a letter provided to the HHSC Investigator by a COTA, 06/18/2025 at 1:07 p.m., revealed On July 11, 2025, during 2 pm to 10 pm shift, this incident occurred at [facility] SNF in [city and state]. [CNA G] restrained [Resident #6 name] (patient) in one of the following ways: [CNA G name] tied patient arms to his hospital bed with trash bags. [CNA G name] tied patient arms to the wheelchair with trash bags. [CNA G] tied up patient w/c wheels so that patient could not move his w/c. [Resident #6 name] is cognitively impaired following a stroke and has hemiplegia. He is unable to recall information and events that have occurred. He can communicate basic wants and needs. [CNA G name] claims that [LVN G name] gave him permission to do so. Patient had been roaming the halls, opening med carts and taking items from the nurse's station. [LVN C name] witnessed [CNA G name] restraining patient and reported incident to Administrator. On another occasion, [CNA D name] overheard [CNA G name] tell the same patient that he was going to kill the patient. [CNA D name] reported this incident to [UM name]. [CNA G name] was suspended on July 12, 2025, pending investigation, however, he returned to work on July 15, 2025, during 2pm-10pm shift. During an interview with the COTA, 06/18/2025 at 1:10 p.m., the COTA stated the dates on her letter were for June 2025 and not July 2025 and stated she was informed by CNA D on 06/12/2025 that Resident #6 was restrained by CNA G on 06/11/2025. COTA stated LVN C witnessed the incident and reported it to the UM and CNA G was suspended but was allowed to return to work. The COTA stated she provided therapy services to Resident #6 on Friday 6/13/2025 and Resident #6 was not exhibiting any emotional distress. The COTA stated she did not witness the restraint but felt like it should have been reported to the state. The COTA stated she was not sure if any of the witnesses reported it, but she wanted to report it today. The COTA stated CNA D told her that CNA D witnessed CNA G tell Resident #6 that he was going to kill him and CNA D reported it to the UM. The COTA stated she should have reported it to the state when she became aware of the allegation so it could have been investigated at that time because the patients cannot advocate for themselves. The COTA stated she was not aware of any other residents being restrained or abused and stated she had been trained on abuse and neglect. During an interview with LVN C, 06/18/2025 at 2:56 p.m., LVN C stated she had suspected another employee of abusing a resident and stated she reported the incident to the UM and DON. LVN C stated on July 11, 2025, around 8 p.m., LVN C was walking by the café day room close to the nurse's station and observed Resident #6 sitting in his wheelchair with trash bags wrapped around the wheelchair tires. LVN C stated Resident #6 was unable to move and was observed trying to move his chair, appeared distressed and agitated and was leaning out of his chair reaching toward the coffee bar. LVN C stated the trash bags were looped throughout the wheels and tied to the center bar in the back of the chair and some bags were tied together from one wheel to the other. LVN C said there were so many trash bags used, and the bags were woven together like a spider web. LVN C stated the bags were so thick that she had to hack at the trash bags with her scissors to cut the bags off. LVN C stated CNA G came over to Resident #6 while LVN C was trying to cut the bags off, and CNA G was laughing and told LVN C not to cut the bags off and told LVN C that LVN E knew about it and to talk to LVN E about it. LVN C stated she was not talking to LVN E about it, briefly assessed Resident #6 to see that he did not have any markings on him and said Resident #6 regained his mobility and got himself a cup of coffee. LVN C stated she immediately reported the incident to the DON and UM and was told to send CNA G home. LVN C said she was under the impression an investigation would be conducted, and CNA G would be terminated but CNA G was allowed to return to work. During an interview with LVN C, 06/19/2025 at 11:43 a.m., LVN C stated CNA G stated he tied the trash bags to Resident #6's wheelchair because Resident #6 was going in and out of other resident rooms. LVN C stated Resident #6's primary mode of mobility was his wheelchair and Resident #6 was not ambulatory and was a fall risk. During an interview with CNA M, 06/19/2025 at 1:30 p.m., CMA M stated she arrived at work early on 06/11/2025 around 8 p.m. for her 10 p.m. - 6 a.m. shift. CNA M stated she was walking by the café day room and observed Resident #6 in the day room with his wheelchair wheels tied up with trash bags in all different directions in his wheels. CNA M stated Resident #6 was trying to move in the chair and could not move and appeared distressed. CNA M stated Resident #6 could not walk, and the trash bags were preventing Resident #6 from being about to move independently. CNA M stated she went to LVN E and told LVN E what she observed and LVN E said it was because he was going into other people's room and taking stuff. CNA M stated she told LVN E that was abuse and LVN E did not respond. CNA M stated another nurse was by Resident #6 and the nurse told CNA M that she reported the incident, so CNA M did not report it. CNA M stated she felt like the incident was a restraint and abuse and stated she should have reported the incident to the Administrator and DON. CNA M stated she had received training on reporting abuse and neglect prior to witnessing the incident and knew that abuse should be reported immediately to the Abuse Coordinator who was the Administrator. During an interview with the UM, 06/19/2025 at 2:00 p.m., the UM said the definition of a physical restraint was impeding a patient from being able to move freely and stated facility staff received training on abuse and neglect upon hire and anytime there was an investigation. The UM stated LVN C called the UM and DON on 06/11/2025 around 8 p.m. and reported observing CNA G place trash bags around Resident #6's wheelchair wheels and stated LVN C was instructed to send CNA G home. The UM stated he met with CNA G on 06/12/2025 and CNA G explained the situation to me and I suspended him and notified the DON of what he said. The UM stated CNA G said Resident #6 had increased behaviors during the shift and was going in other resident rooms and being disruptive so he attempted to slow him down from going into other rooms by getting some trash bags and wrapped them around the wheelchair wheels to slow him down from being able to move in the wheelchair. The UM stated the wheelchair was Resident #6's primarily mode for mobility and Resident #6 was not able to ambulate safely. The UM stated he was not sure if the Administrator was notified and stated the DON conducted the investigation, staff received in servicing on abuse and restraints and CNA G was placed on a final disciplinary warning. The UM stated CNA D did not report an allegation of CNA G being rough with Resident #6 or telling Resident #6 that CNA G would kill him. The UM stated if that was reported to him, he would have suspended CNA G and notified the DON and the Administrator. The UM stated he was not aware of any other restraints methods being used and stated a resident who was improperly restrained could fall, get a fracture, or skin tear while trying to get out of the restraint depending on the type of restraint used. During an interview with LVN E, 06/19/2025 at 2:56 p.m., LVN E stated Resident #6 had a witnessed fall in his room at the beginning of LVN E's shift on 06/11/2025 at 2 p.m. LVN E stated Resident #6 was brought out of his room and placed in the café day room so he could be observed. LVN E stated Resident #6 was observed throughout the shift going in and out of other resident rooms, turning water faucets on and off and LVN E observed Resident #6 propelling himself around the unit during the shift. LVN E stated she was not aware that Resident #6 had trash bags tied to his wheelchair wheels on the night of 6/11/2025 until this HHSC Investigator asked her about it. LVN E stated she did not observe anything tied to Resident #6's chair, no one called her and notified her that Resident #6 had trash bags tied to his chair and no one had contacted her and asked her to suspend CNA G. LVN E stated she observed CNA G leaving the facility around 9 pm and said CNA G told her he was leaving and LVN E assumed he was being sent home because census was low. LVN E stated she spoke to the UM and DON about Resident #6 having a fall on the shift but was not questioned or notified about the observation of trash bags being tied to Resident #6's wheelchair wheels. LVN E stated she was not asked to complete a head-to-toe assessment after the incident. LVN E stated she did not instruct CNA G to restrain Resident #6 and LVN E stated tying trash bags on the wheels of a resident wheelchair was a restraint and abuse and LVN E stated she would have notified the DON and abuse prevention coordinator. LVN E stated no other staff members had reported any allegations of abuse regarding CNA G and Resident #6 to her and she was not aware of any other restraint methods ever used in the facility. LVN E stated she had been trained on restraints, restraints were not allowed at the facility and a resident who was improperly restrained could cause bruising, fractures, or aggression when the resident tried to get out of the restraint or cause the resident to fall and get injured. During an interview with CNA G, 06/19/2025 at 4:22 p.m. CNA G stated Resident #6 was roaming around in different patient rooms on the evening of 06/11/2025 so CNA G redirected him to the café day room so we could keep a better eye on him. CNA G stated he put trash bags in the resident wheelchair wheels gently and stated he did it so we would be able to see him if he tried to leave again so we could see him and help him. CNA G said he placed the trash bags in the wheels to do something like slow the resident down. CNA G stated he had received training on restraints prior to this incident and stated the definition of a restraint was when a patient cannot move or get up or do anything on their own. CNA G stated he was not told to add the trash bags by anyone else and did not tell anyone else that he did it because he did not feel like it was a restriction. CNA G stated he had never tied Resident #6's arms to his bed or wheelchair, never placed trash bags in any other resident wheelchair wheels and had never restrained another resident. CNA G stated he was notified by LVN C that he restrained a resident and was being suspended. CNA G stated he met with the UM on 06/12/2025 and received training on abuse, neglect, and restraints. CNA G stated a resident who was improperly restrained could harm themselves mentally or physically. During an interview with the UM, 06/20/2025 at 3:11 p.m., UM stated he conducted a psychosocial wellbeing assessment for Resident #6 on 06/12/2025 as part of the investigation policy whenever there is an allegation or a concern. UM stated no one asked him to complete the assessment and stated it was usually completed by the Social Worker, but the Social Worker was not available. UM stated he completed patient safe survey questionnaires and employee abuse investigation questionnaires for a few employees on 06/12/2025 as part of the investigative protocols and turned the forms into the DON. UM stated Resident #6 did not recall the incident and was not exhibiting any emotional or psychosocial distress and no additional allegations were identified during the questionnaires. During an interview with the DON, 06/20/2025 at 9:33 a.m., the DON stated, staff received training on abuse/neglect, behavior management and restraints upon hire and throughout the year. The DON stated staff had received training on reporting abuse to the abuse coordinator and any allegations of abuse should have been reported immediately. The DON stated the facility was restraint free and described a physical restraint as any type of device used in contact with the body that limits the movement of the resident. The DON stated it would be considered a restraint if a resident's primary mode of mobility was his wheelchair and the resident was unable to move in the chair due to the wheelchair wheels being compromised by a staff member. The DON stated Resident #6 was a fall risk, had several falls at the facility, was able to propel himself in his wheelchair and was not able to ambulate safely. The DON stated LVN C sent the DON and UM a text on 06/11/2025 around 8:15 p.m. and said, someone needs to deal with [CNA G], he restrained a patient and he put trash bags on [Resident #6]'s wheelchair and it is not okay to tie him down and he cannot move. The DON said, I responded and said this is not acceptable behavior and please send him home and [UM] responded and said, yes send him home. The DON said LVN C informed her that she was not CNA G's nurse so the DON stated she called LVN E and asked LVN E to send him home and LVN E said she could see Resident #6 and he was moving around freely but I didn't think about the fact that LVN C had already cut the trash bags off so when I heard LVN E say he could move freely I thought it was with the trash bags on. The DON stated she did not notify the Administrator of the allegation and did not report the allegation to HHSC. The DON stated CNA G received a write up on 06/12/2025 by the UM and the DON met with CNA G when he returned to work on 6/16/25 after a 3-day suspension and in serviced him on customer service and what LVN C observed. The DON stated CNA G apologized and stated he was just trying to slow Resident #6 down. The DON said she did not instruct anyone to complete a head-to-toe assessment, psychosocial assessment after the incident but in servicing was started on 06/12/2025 on abuse and neglect and did not cover restraints. The DON said the Administrator became aware of the allegation after LVN C met with this HHSC investigator on 06/18/2025 and the DON stated they had CNA G come in and demonstrate how he placed the trash bags in the wheels and CNA G was suspended again on 06/18/2025. The DON stated the staff began receiving education on restraints after this HHSC investigator entered the facility. The DON stated [psychiatric company name] visited Resident #6 on 06/13/2025 on a routine visit and it was not related to the incident on 06/11/2025. The DON stated LVN E signed a head-to-toe assessment on 6/11/2025 that was completed by a CNA after a shower earlier in the day and the head-to-toe assessment in the investigation summary was not completed after the incident by LVN E. The DON stated an emergency QAPI was held on 6/19/2025 with the physician, behavior management education was initiated and [psychiatric company name] was conducting an in-service for the staff at 2:00 p.m. on 06/20/2025. The DON stated a question about restraints was added to the employee abuse questionnaire. The DON stated safe surveys were initiated for all interviewable patients on 06/19/2025 on 2 p.m.- 10 p.m. shift and non interviewable residents received head to toe assessments to ensure there were no further allegations. The DON said the allegation regarding the restraint was reported to HHSC on the evening of 06/19/2025. The DON stated she was never notified of any other allegation of abuse from any other employees and had not received any other reports of restraints. The DON stated physical injury or psychosocial injury could occur for residents who are improperly restrained. During an interview with the Administrator, 06/20/2025 at 12:23 p.m., the Administrator stated she is the Regional [NAME] President and became the acting Administrator on 5/23/2025 when the previous Administrator left the position and would remain in the position until the new Administrator started on 06/23/2025. The Administrator stated staff had received training on abuse and neglect, restraints and reporting abuse and neglect upon hire and throughout the year. The Administrator stated the expectation was for all allegations to be reported directly to the Administrator, who was the Abuse Prevention Coordinator and stated the facility was restraint free. The Administrator stated she was notified by the Regional Corporate Nurse on 06/18/2025 that a nurse had reported we had restrained a patient. The Administrator stated she spoke to the DON who told her a trash bag was used in a resident's wheelchair tires and the DON thought it was a customer service issue and did not report it. The Administrator stated, when I got here yesterday, my understanding is that they initiated an investigation and that there was a head to toe that night and that psych services saw him the next day to make sure there was no emotional distress. The Administrator stated she should have been notified on 06/11/2025 and she would have reported the incident to HHSC and completed an investigation. The Administrator stated she was not sure what harm could come to a resident who was improperly restrained because her understanding was that Resident #6 was able to propel himself in the wheelchair with the trash bags in place, but the investigation was ongoing. Record review of a facility incident report for Resident #6, dated 06/12/2025 at 2:00 p.m. and completed by the UM, categorized the incident as alleged abuse and described the incident as charge nurse reported that employee had wrapped trash bag around pt wheelchair wheel as a restraint to keep patient from moving in w/c. Immediate action taken revealed, employee was send home and suspended during investigation, head to toe assessment was performed on patient and patient was interviewed. The report revealed the physician and DON were notified on 06/13/2025 at 1:11 p.m. Record review of a facility document titled Employee Coaching and Counseling revealed CNA G placed a resident in small dining room then placed trash bags on wheelchair wheels to attempt to keep patient from going into other patient rooms. Action taken revealed employee was suspended x 3 days, in serviced regarding abuse and restraints and placed on final warning. The form was signed by the UM on 06/12/2025 and signed by CNA G, undated. Record review revealed CNA G signed a facility document titled, [Company name] Acknowledgement of Abuse Policy and Reporting Requirements, on 06/12/2025. Record review revealed CNA G completed a Restraint Quiz on 06/16/2025 that included the question, 2. It's okay to prevent a patient from roaming freely within the facility? A. true B. False. CNA G marked the question as B. False. Record review of an undated statement signed by CNA G revealed, on 6/11 [Resident #6] was having increased behaviors throughout the shift and going to other patient rooms and been inappropriate/disruptive, with guest and patients. [Resident #6] was redirected numerous times and taken out of patient's rooms and he kept going back to the rooms. In an attempt to help other patient and keep close watch on [Resident #6], I put him in café where he likes to drink coffee. I tried to slow him down by putting trash bags at the bottom of the wheelchair, but he was never restrained and could get up and move freely if he wanted to. Record review of an undated statement signed by LVN E revealed, on 06/11/25 I was the nurse for [Resident #6 name] on the 2-10 shift. The patient had an unwitnessed fall at the beginning of the shift. After doing a thorough head to toe assessment on the resident, the aide and I place him in his w/c and placed him in the café next to the nurse's station so I could monitor him closely. The measure did not disable the patient's movement or restrict him from using his limbs. He was still doing things like turning the water on in the sink, getting up out of the wheelchair to fetch coffee, opening p the creams & sugars & pouring them on al the tables, and able to stand briefly. I witnessed this throughout the remainder for the shift. At no point was the resident's limbs compromised or he was confined to the café. I check on him frequently throughout the shift due to his fall risk until it was time for him to be put to bed. Record review of a statement dated 06/19/2025, and signed by LVN C revealed, On 06/11/2025 @ 8:00 pm I was walking down 700 hall to the Nurse's station when I passed the café and saw patient [Resident #6 last name] with 2 CNAs [CNA G and CNA H]. I hard [CNA G and CNA H] laughing in which case I came over and then had point [CNA G] point out to me that he had tied up the patient's wheelchairs together with trash bags. The trash bags were tied to each of the wheels and then tied to the center piece of the wheelchair limiting the patients ROM. Patient appeared aggravated while attempting to reach for the coffee cups and was seen attempting to scoot himself off his wheelchair in order to reach the coffee. I demanded that [CNA G] remove the trash bags, [CNA G] refused. I attempted to tear the trash bags with my hands and was unable to because of how many trash bags were used. I then proceeded to grab a pair of scissors, when [CNA G] attempted to stop me telling me 'ASK [LVN E first two letters of name]! ASK [LVN E first two letters of name]! ASK [LVN E first two letters of name]! BEFORE YOU CUT THEM OFF!' I told [CNA G] that I was not going to ask [LVN E first two letters of name] anything and if she did not want me to cut off the trash bags she can come over and discuss it with me. I then proceeded to cut off and remove the trash bags, and quickly looked over patient, no apparent injury was noted right after incident. I reported to DON and UM on 06/11/2025 at 8:15 p.m. Record review of a statement dated 06/12/2025 and signed by the UM revealed, This nurse conducted an interview with [Resident #6], patient stated that he is satisfied with all the services been provided by employees. Patient was asked if he feels safe as a patient here at the facility and he said yes, pt was asked if he ever has been mistreated, pt responded that it has never happened. [Resident #6] was asked if he has ever been restricted of kept from moving freely throughout the facility, and he responded no. that he can move around in his w/c at all times and that he transfers self from w/c to bed but has been told not to do that on his own because he can fall. Record review of a facility document titles, Psychosocial Well-Being, revealed the UM completed the assessment for Resident on 06/12/2025 and revealed Resident #6 had no change in his psychosocial well-being. Record review revealed 6 facility residents were administered a patient abuse questionnaire on 06/12/2025, completed by UM and included Resident #6. The questionnaires revealed no additional allegations. Record review of an employee abuse questionnaire revealed 39 employees completed the questionnaires dated 06/12/2025. Record review of an in-service roster, presented by the DON and dated 06/12/2025, revealed the topic was abuse and neglect, reporting abuse and neglect and the use of restraints and revealed 43 names. Record review of an in-service roster, presented by the DON on 6/12/25, revealed the topic was incident/accidents and revealed 27 names. Record review of facility document titled, Job Description Certified Nursing Assistant, revealed CNA G's signed the job description on 10/23/2024. The job description revealed the essential function of the role included promote and support the greatest possible degree of independence for patients and responsible for assuring patient/resident safety. Record review revealed CNA G completed a Restraint Competency Quiz on 10/15/2024. Record review revealed CNA G signed Senate [NAME] 9 of Nursing Home Policy on 10/14/2024 that included remember our policy that all patients/residents of this community are to be always treated with dignity and respect under all circumstances. Mistreatment or abuse of any nature will not be tolerated. Any employee guilty of abusing, neglecting or not disclosing such acts is subject to immediate discharge. Local authorities will be notified, and criminal charges may be filed. Record review of the facility's policy titled, [company name] Abuse Prohibition Protocol dated August 2024, revealed, The patient has the right to be free from abuse, neglect, mistreatment of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required in treating the Patient's symptoms. The protocol revealed, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. Instances of abuse of all patient/resident, irrespective of any physical or mental condition, cause physical harm, pain, or mental anguish. 'Willful' as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflect injury or harm. Mistreatment means inappropriate treatment or exploitation of a patient. Record review of the facility's policy titled, [company name] Physical Restraints dated November 2016, revealed, 1. The facility promotes and adheres to restraint free care for the patient's overall well-being. 2. The patient must be free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the patient's medical symptoms .