Every finding on record at St. Giles Nursing and Rehabilitation Center

Based on interview, observation, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 5 residents (Resident #3) reviewed for accidents hazards and supervision. -The facility failed on 06/28/2026 to prevent Resident #3 from falling due to CNA C leaving Resident #3 on her right side while attempting to change the draw sheets. This resulted in Resident #3 experiencing severe pain, being transported to the hospital and developing bruising to her left forehead, left eye, and left shoulder.These deficient practices could affect residents by injuring them during transferring and repositioning care.Findings included: Record review of Resident #3's admission sheet dated 07/07/2026 revealed a [AGE] year-old female with an initial admission date of 02/26/2026 and a readmission date 06/29/2026. Record review of Resident #3's Quarterly MDS dated [DATE] revealed the resident had a BIMS of 12 indicating the resident had moderate cognitive impairment. Under section GG - functional abilities, mobility, the resident was coded as not applicable for rolling left to right with the significance being not attempted and the resident did not perform this activity prior to the current illness. The resident was coded as requiring partial to moderate assistance (helper does less than half the effort) for sit to lying and lying to sitting on side of bed. The resident was coded as requiring substantial to maximal assistance(helper does more than half the effort) for sit to stand and chair/bed to chair transfer. Under section H - bladder and bowel the resident was coded for having an ostomy (an opening in the abdominal wall to redirect waste out of the body). Under section I - Active Diagnoses the resident was diagnosed with muscle wasting and atrophy (conditions where the muscle tissue shrinks and weakens), muscle weakness (reduced capacity to exert force with your muscles), age-related osteoporosis without current pathological fracture (progressive bone density loss in older adults). Under section J - health conditions the resident was coded for not having a fall since admission/entry into the facility. Record review of Resident #3's comprehensive care plan dated 05/08/2026 revealed no focus or interventions for assisting the resident with ADLs, transfer, and repositioning. Record review of Resident #3's physical and history dated 02/27/2026 revealed the resident was diagnosed with end-stage renal disease (the final stage of a chronic kidney disease, when kidney function drops to less than 15% of normal capacity), age related physical debility (progressive functional decline, muscle weakness, slow gait, and severe fatigue), and pleural effusion (an abnormal buildup of excess fluid in pleural space between the lungs and chest wall). Record review of CNA C's written statement undated, read in part after Spanish to English translation, I was changing [Resident #3]. She was sitting on the bed and I told her that we would lower the back of the bed so it would be easier and more comfortable for her. The bed still had the bedspread (draw sheet) on and I was taking it off. I stood on the right side of the bed and I turned her to the left side to start removing the bedspread (draw sheet), I adjusted her catheter and tucked it into the sheet. I went to turn [Resident #3] back over toward me on her right side, but she said she was crushing the catheter and I told her to wait for me a bit. I went to the left side, leaving [Resident #3] turned towards the right side. I think she made a small movement and fell to the floor. Immediately I spoke to the nurse. Record review of LVN H's fall risk assessment for Resident #3 dated 06/28/2026 at 9:36 p.m. revealed Resident #3 was scored at a 9 with the significance being moderate fall risk. Record review of LVN H's progress note for Resident #3 dated 06/28/2026 at 9:38 p.m. read in part, CNA called this nurse into resident room. Resident was lying on the floor noted 2 hematomas (localized collection of clotted or pooled blood) left forehead/eye. Complaints of pain 9 out of 10 (with 10 being the worst) to her head and hearing loss to right ear, assessed vital stats (blood pressure) 184/85 (pulse) 85 (oxygen saturation) 93 at 2 liters per minute, range of motion intact to upper and lower extremities. Physician on call, DON, supervisor and family member notified. 911 was called at 9:05 p.m. ambulance arrived at 9:23 p.m. and resident was taken via stretcher to hospital 9:35 p.m. Appears and/or stated to be in pain. Describes the pain as: intermittent, locations of pain: head, pain relieving interventions used at this time: p.m. medication. Record review of RN K's progress note for Resident #3 dated 06/29/2026 at 2:02 a.m. read in part, resident returned from hospital, diagnosis status post fall, pleural effusion. Resident continue on 2 liters per minute nasal cannula oxygen. Cough was noted during admission. As per report head computed tomography scan was completed with negative results. No new orders sent with paperwork. Physician on call was notified of readmission Record review of Resident #3's hospital discharge date d 06/29/2026 read in part, arrival time 06/28/2026 at 9:45 p.m. Patient diagnosis: fall; pleural effusion; scalp contusion (soft tissue injury caused by blunt impact). Discharge location: follow up with primary care provider within 3-5 days.computed tomography to spine cervical without contrast completed. Order details: discharge to home resume normal activity. Record review of Resident #3's Therapy Screen completed by DOT on 06/30/2026 read in part, the resident exhibited a change in one area under falls. The recommendations implemented were, no skilled therapy intervention indicated, will continue to monitor patient. Record review LVN L's weekly skin assessment of Resident #3 dated 07/03/2026 at 6:26 a.m. read in part, skin color: normal, temperature skin: warm, bruise present: Yes, Location, measurements of bruising: left aspect facial/periorbital region (around the eye to include eyelids, eyebrows, and the bony socket), 7.5CM x 8.5. left upper shoulder 7CM x 5CM status post recent fall skin tear present: no, abrasion present: no, laceration present: no. rash present: no, moisture associated skin damage present: no. other skin findings present: no. In an interview and observation on 07/06/2026 at 9:39 a.m., Resident #3 was observed sitting upright in bed eating breakfast with visible purple/green bruise to her left eye, left side of forehead, and left shoulder. She stated that 9 days prior (06/28/2026), she was in bed at night when a CNA entered the room to change the draw sheet underneath her that was used for repositioning. She stated usually staff would transfer her to her wheelchair to provide these services but did not do so this time. She stated the CNA rolled her to her right side where her ostomy bag was located and she vocalized fear of squishing it or tugging on it. She stated at that point the CNA had stepped towards the foot of her bed and left the resident on her right side near the edge of the bed. She stated that she was unable to prevent herself from falling due to strength limitations and subsequently fell to the floor. She stated that the nurse came in and evaluated her and eventually the ambulance showed up to transfer her to the hospital. She stated while at the hospital she received x-rays and a CT scan that came back negative for fractures and serious injuries and was discharged to go home after about 4 hours. She stated at the time of the fall her pain was a 9 out of 10 but was currently managing the pain well with reports of it being tender and sore. She stated that the nurse provided pain medication when she requested it in the form of Tylenol (dosage unknown) and added it was sufficient to manage pain/discomfort. She stated that she did not know the name of the CNA who provided the care but was able to recall it was a female (CNA C was later identified as the CNA involved). She denied feeling fear for her wellbeing or safety with the care provided upon her readmission. She stated if she felt abused, neglected or feared for her safety she would tell the nurse. In an observation on 07/07/2026 at 2:22 PM, CNA I and J were observed replacing the draw sheet for Resident #5 while the resident was in bed. The CNAs entered the room and introduced themselves to Resident #5 and explained they were going to change the draw sheet. CNAs proceeded to wash their hands and apply gloves promptly after. CNAs drew the privacy curtains and lowered the resident's bed to a flat position and placed the bed at waist height. CNAs coordinated with each other and Resident #5 to place resident on her left side and roll the draw sheet under the resident and line up the new draw sheet next to the resident. CNAs explained to Resident #5 the next steps of their procedure before beginning and asked if there was any pain or discomfort thus far. CNAs proceeded to roll Resident #5 to her back then to her right side in a controlled manner and finished removing the old draw sheet and adjusting the new draw sheet. The procedure ended and the CNAs returned the resident back to her previous position and asked Resident #5 if there was anything further they could provide. CNAs proceeded to place call light within reach, opened privacy curtains, discarded gloves, and washed hands prior to exiting. Resident #5 tolerated the procedure well with no signs or vocalizations of distress and pain In an interview on 07/06/2026 at 1:35 p.m., LVN D stated if the resident provided minimal assistance during transfers and repositioning, he would get them out of bed to change the drawsheet. He stated that it was not appropriate for residents to be left on their side if they were maximum assistance and for staff to step away. He stated if staff stepped away from the resident who was on their side they could fall. He stated that all staff were responsible for preventing resident falls and the specific staff member providing the procedure was directly responsible. He stated staff should never leave a resident on their side when stepping away and always return the resident to their back if they had to step away during the procedure. He stated the last in service for abuse and neglect, transfers, and fall prevention/management was within the past 2 weeks. He stated he was not present for Resident #3's fall. In an interview on 07/06/2026 at 11:13 p.m., CNA E explained the process for changing the draw sheet was to pull the resident to one side, roll and tuck the old draw sheet underneath the resident, and place the new one next to the old draw sheet being replaced. She stated at this point she would return the resident to their back, remove the old draw sheet entirely once cleared, and roll the resident to the opposing side to adjust the new draw sheet. She stated at no point would she step away from the resident who was left on their side without returning them to their back. She stated that the resident who was side lying near the edge needed to be placed on their back to prevent a fall. She stated that this was knowledge from competent practice and previous schooling. She stated she was not aware of any falls recently due to a practice of leaving residents on their side during sheet change. She stated the staff who were handling the sheet exchange were responsible for ensuring the residents were not left in a compromised position. She stated that the resident could suffer a fracture, scrapes, bruising, bleeding, pain, hospitalization, permanent disfigurement and/or death from a fall from their bed. She stated the last in service for repositioning was on 06/09/2026. She stated the last in service for abuse and neglect was on 06/23/2026. She stated she was not present when Resident #3 had fallen on 06/28/2026. In an interview on 07/07/2026 at 1:11 p.m., CNA G stated that the sheets can be changed with 1 or 2 staff members present. She stated the process was to roll the resident to one side, stay by them, and roll the dirty draw sheet as close to the resident was possible and place the new draw sheet near the old one. She stated she returned the resident to her back and would proceed to roll the resident to the other side. She stated she would fully remove the old draw sheet and adjust the new one while the resident was on their side. She stated staff should not step away from the resident at any point while the resident was on their side. She stated this procedure needed to be adhered to avoid the resident from falling to the floor. She stated whichever staff member was providing the services was responsible for ensuring the resident did not fall and was repositioned to their back if they needed to step away from the resident. She stated the last in service for fall management/prevention, abuse, and neglect was in June 2026. She stated that if staff left the resident on their side and stepped away the resident could suffer a fall. She stated that the resident falling could result in pain, bruises, bone fractures, and hospitalizations. In an over-the-phone interview on 07/07/2026 at 2:01 p.m., LVN H stated she was the responding nurse to Resident #3's fall on 06/28/2026. She stated that at approximately 10 p.m., CNA C called out for her from Resident #3's room. She stated that upon arrival Resident #3 was on the floor seated on her bottom with hematoma to her left eye, forehead, and shoulder with the bed in the lowest position. She stated CNA C had told her she was providing incontinent care when Resident #3 fell. She stated CNA C had told her that Resident #3 was on her lying on her right side facing towards the room entrance, when CNA C had walked around the foot rest to the opposite side of the bed near the window to try and adjust Resident #3. She stated CNA C had explained to her that she moved to get to the other side to assist with adjusting Resident #3 but had left Resident #3 lying on her right side. She stated that CNA C did provide a written statement. LVN H stated she needed to end the phone call as she was busy. At approximately 3:20 p.m. LVN H arrived at the facility to resume an in person interview. She stated that Resident #3 had a nephrostomy tube (a catheter inserted through the skin of the lower back directly into your kidney to drain urine) to the lower right hand side of Resident #3's back. She stated Resident #3 had told her and CNA C that she did not want to be on top or pinch the nephrostomy tube and attempted to pull it out from under her while she was on her right side. She stated she assessed Resident #3 for head to toe injuries, range of motion, skin tears, vitals, and immediately initiated 911. She stated Resident #3 was complaining of difficulty hearing post fall. She stated Resident #3 reported the pain was a 9 out of 10. She stated that RN K collected a statement from CNA C. She stated that she had doubted that Resident #3 would be capable of rolling from back over her right side and off the bed based on her condition. She stated the last in service for abuse, neglect, fall management and prevention was last week. She stated the abuse coordinator was the Administrator who needed to be notified immediately about any allegations of abuse or neglect. She stated it was not acceptable to leave Resident #3 on her side with her conditions. In an interview on 07/07/2026 at 2:56 p.m., CNA C stated she worked as a CNA for 2 years and had complete 9 months at the facility. She stated her responsibilities as a CNA were to assist residents with bathing, dressing, transferring, repositioning, deliver meal trays, assisting with feeding, provide incontinent changes, coming hair. She stated the incident with Resident #3 occurred when she was changing the draw sheet. She stated Resident #3 was able to roll side to side on her own. She stated she was on the side of the bed near the center of the room with Resident #3 on her right side. She stated during the procedure Resident #3 was cautions of the bag (nephrostomy) and was concerned about rolling on top of it. She stated she placed Resident #3 on her back and began walking to the opposite side of the bed near the window to assist with adjusting the bag before proceeding with the draw sheet change. She stated while she was walking to the other side, Resident #3 rolled out of the bed from back lying position over her right shoulder onto the floor before she was able to react. She stated that she did not leave Resident #3 unattended on her side at any point. She stated when Resident #3 fell from the bed it was approximately 3 feet from the ground. She stated she still worked with Resident #3 with the last time being on 07/04/2026. She stated that she and Resident #3 still get along. She stated Resident #3 went to the hospital and had a bruise on her eye, shoulder and part of her forehead. She stated she was not suspended following the incident and was interviewed by ADON A. She stated she did not receive training or in-service for fall management/prevention, or transfers following the incident with Resident #3. She stated that the only in-service provided after the incident was on abuse and neglect. In an interview on 07/07/2026 at 4:09 p.m., ADON A stated the DON was notified about the incident involving Resident #3 and CNA C and had collected the statement from CNA C. She stated that CNA C told her that she was changing the resident and the resident was concerned for her nephrostomy tube, was guarding it, and subsequently fell. She stated it was not okay for staff to step away from the resident while they were positioned on their side. She stated that the resident needed to be put on her back to ensure safe measures were taken to prevent the resident from falling. She stated a resident could get bruises, fractures and hematoma from a fall. She stated that the staff member providing care would be responsible for placing the resident back in a safe position prior to moving away from the resident. She stated she does not think CNA C was suspended. She stated she does not know if there was an investigation conducted. She stated that Resident #3 said she was feeling better post fall and hospital visit on 06/29/2026. She stated Resident #3's injuries were bruises to the left eye/eyebrow area. She stated the resident did not suffer a fracture or internal bleeding. She stated the in-services created following this incident were on fall management/prevention, abuse, and neglect. In an over-the-phone interview on 07/07/2026 at 4:27 p.m., DOT stated that he completed an assessment for Resident #3 approximately a week ago. He stated Resident #3 required partial to moderate assistance and in the form of an outreached hand to go from back to side. He stated that it was possible for Resident #3 to roll from her back over her right side but added it would be a clear struggle. He stated Resident #3 would take some time which would be ample enough for staff to be able to react if they were near. He stated Resident #3 was not strong enough to do it in the blink of an eye and would take approximately 15-20 seconds to complete the rolling task. He stated the last transfer training he provided to direct care staff was 4-6 weeks ago. He stated it was never appropriate to leave a resident on their side and step away. He stated that he would never leave Resident #3 on her side and step away based on her conditions and abilities. He stated Resident #3 did not have enough reaction to stop a fall if she was placed on her side and left unattended. In an interview on 07/07/2026 at 5:33 p.m., the Administrator stated she could not interview Resident #3 or CNA C because she did not have enough knowledge in Spanish. She stated that it was reported to her via translation from ADON A that, CNA C was providing incontinent care to Resident #3 and had gone to the other side of the bed, but Resident #3 was trying to get off the bed. She stated it was reported to her that Resident #3 had placed herself on her side while CNA C walked to the other side of the bed. She stated that based on CNA C's written statement abuse, neglect, and quality of care concerns were ruled out because it was the assumption Resident #3 was attempting to self-transfer. She stated she did not interview Resident #3 that ADON A was tasked with this. She stated that Resident #3 had recall difficulty with flight of ideas. She stated that Resident #3 had the strength to reposition herself but not to roll from her back over her right shoulder and ultimately fall to the floor. She stated it would not be safe to leave Resident #3 on their side and move away. She stated the direct care staff providing the services would be responsible for placing residents in a safe position before moving away. She stated if the residents were to be left unattended, they should be placed back in a safe position. She stated that if a resident was left in a compromised position, then there was a possibility for the resident to be injured. She stated that Resident #3 suffered minor injuries to her eyebrow and scalp but could not recall orientation of them. She stated Resident #3 was sent to the hospital immediately following the fall and it was determined there were no major injuries. She stated Resident #3 was discharged from the emergency room within 2-3 hours from leaving the facility. She stated there was a facility wide in-service on abuse and neglect provided following the incident. She stated CNA C was not suspended and did not receive further training on transfers and repositioning. Record review of the facility's policy titled, Preventative Strategies to Reduce Fall Risk dated 10/15/2016 read in part: (Policy) The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. (Procedures) (2) The comprehensive MDS assessment will assist in identifying those residents as risk for falls. (3) Residents at risk will be care planned for fall prevention. (4) After risk is assessed, individualized nursing care plans will be implemented to prevent falls.(7 Rehabilitation Strategies) (a) low intensity leg strengthening and weight bearing exercise (b) gait, balance, and transfer training, (c) exercise programs. (8) Restorative programs may be offered by nursing staff. The programs will be a simple program that nurses or nurse assistant can easily perform on their own to help maintain resident mobility. (10, Incident Reporting) reported falls will be thoroughly investigated to assess fall risk factors and determine contributing factors in order to provide a safe environment for the resident(s). Record review of the facility's in-service titled Abuse, neglect, and exploitation and falls dated 06/28/2026 does not reflect CNA C received in-service training following Resident #3's fall.

Based on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated and report the results of all investigations to the State Survey Agency within 5 working days of the incident for 3 of 3 residents (Residents #1, #2, #3) reviewed for records. -The facility failed on 05/28/2026 to thoroughly investigate a self-reported incident with an allegation of neglect for Resident #1 who was alleged to have been exploited for $2,000 by a family member.-The facility failed on 07/03/2026 to thoroughly investigate a self-reported incident within 5 working days of it being reported to the stated on 06/27/2026-The facility failed on 07/06/2026 to thoroughly investigate a fall that occurred on 06/28/2026 while CNA C was providing care to Resident #3. These deficient practices could affect residents by failing to prevent further neglect and taking appropriate corrective action based on investigation findings.Findings included: Resident #1 Record review of Resident #1's admission sheet dated 07/07/2026 revealed a [AGE] year-old male with an initial admission date on 02/05/2026. Record review of Resident #1's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 6 indicating the resident had severe cognitive impairment. Under Section I, active diagnoses, the resident was diagnosed with unspecified dementia, unspecified severity, with other behavioral disturbances (undeniable cognitive decline and behavioral complications without the exact cause being determined) and senile degeneration of brain, not elsewhere classified (progressive age-related cognitive decline or brain tissue shrinkage that occurs without distinct neurological disorders). Record review of Resident #1's care plan dated 07/01/2026 revealed the resident had a focus area for impaired cognitive function/dementia or impaired thought processes with an intervention to communicate with the resident regarding resident's capabilities and needs. Record review of Resident #1's physical and history dated 02/07/2026 reflected he was diagnosed of unspecified dementia, unspecified severity, with other behavioral disturbances (undeniable cognitive decline and behavioral complications without the exact cause being determined) and senile degeneration of brain, not elsewhere classified (progressive age-related cognitive decline or brain tissue shrinkage that occurs without distinct neurological disorders), anxiety disorder (mental health conditions involving excessive fear and worry that interferes with daily life), and required redirection as needed. Under neurological assessment the resident was alert and oriented to self and able to follow simple commands. Resident #2 Record review of Resident #2's admission sheet dated 07/03/2026 revealed a [AGE] year-old female with an initial admission date on 05/04/2026 and readmission date on 06/29/2026. Record review of Resident #2's admission MDS dated [DATE] revealed the resident had a BIMS score of 0 indicating the resident had severe cognitive impairment. Under section GG functional abilities, self-care, revealed the resident was dependent on staff for toileting, bathing, and dressing. Under the mobility portion, the resident was coded for requiring partial to moderate assistance for rolling left to right, sitting to lying, chair to bed and bed to chair transfers. Record review of Resident #2's care plan dated 05/05/2026 revealed the resident had a focus area for impaired cognitive function/dementia or impaired thought processes with an intervention to communicate with the resident regarding resident's capabilities and needs. The resident had a focus area to address the risk for falls related to confusion, gait/balance problems, and unaware of safety. Record review of Resident #2's physical and health dated 05/04/2026 revealed the resident was diagnosed with dementia (a decline in mental ability that interferes with cognitive abilities and to function independently), previously suffered from a fall at home resulting in hospitalization, and physical deconditioning (decline of physiological and functional abilities). Record review of Resident #2's progress notes dated 06/21/2026 by ADON B read in part, Resident had a fall. Location: Resident room. Fall information: unwitnessed, from low bed, discovered on floor, next to bed. Resident found on top of floor mat crawling. Head to toe assessment performed.resident is not receptive to redirection or use of call light.no pain. Resident #2's progress notes reflected neuro assessments were completed 11 times on 06/21/2026 and ongoing monitoring for change of condition, pain, and 1 weekly skin assessment with no findings. Resident #2's progress notes revealed the resident was transferred to the hospital on [DATE] at 12:35 a.m. due to significant findings in the form of a right tibia and fibula (leg bones below the knee and about the ankle) fracture. Record review of the residents x-ray results dated 06/26/2026 at 10:50 p.m. revealed the resident had acute-appearing fractured to the lower portion of her right tibia and fibula along with bone demineralization (signs that the bones are losing their strength and becoming fragile) Resident #3 Record review of Resident #3's admission sheet dated 07/07/2026 revealed a [AGE] year-old female with an initial admission date of 02/26/2026 and a readmission date 06/29/2026. Record review of Resident #3's Quarterly MDS dated [DATE] revealed the resident had a BIMS of 12 indicating the resident had moderate cognitive impairment. Under section GG - functional abilities, mobility, the resident was coded as not applicable for rolling left to right with the significance being not attempted and the resident did not perform this activity prior to the current illness. The resident was coded as requiring partial to moderate assistance for sit to lying and lying to sitting on side of bed. The resident was coded as requiring substantial to maximal assistance for sit to stand and chair/bed to chair transfer. Under section H - bladder and bowel the resident was coded for having an ostomy (an opening in the abdominal wall to redirect waste out of the body). Under section I - Active Diagnoses the resident was diagnosed with muscle wasting and atrophy (conditions where the muscle tissue shrinks and weakens), muscle weakness (reduced capacity to exert force with your muscles), age-related osteoporosis without current pathological fracture (progressive bone density loss in older adults). Record review of Resident #3's comprehensive care plan dated 05/08/2026 revealed no focus or interventions for assisting the resident with ADLs, transfer, and repositioning. Record review of Resident #3's physical and history dated 02/27/2026 revealed the resident was diagnosed with end-stage renal disease (the final stage of a chronic kidney disease, when kidney function drops to less than 15% of normal capacity), age related physical debility (progressive functional decline, muscle weakness, slow gait, and severe fatigue), and pleural effusion (an abnormal buildup of excess fluid in pleural space between the lungs and chest wall). Record review of a facility incident, undated, for Resident #3's fall did not include detailed information such as interviews with key personnel, Resident #3, corrective actions taken against CNA C, what documentation was reviewed, and what steps were taken to assess the scope of effected residents. Record review of LVN H's fall risk assessment for Resident #3 dated 06/28/2026 at 9:36 p.m. revealed Resident #3 was scored at a 9 with the significance being moderate fall risk. Record review of LVN H's progress note for Resident #3 dated 06/28/2026 at 9:38 p.m. read in part, CNA called this nurse into resident room. Resident was lying on the floor noted 2 hematomas (localized collection of clotted or pooled blood) left forehead/eye. Complaints of pain 9 out of 10 (with 10 being the worst) to her head and hearing loss to right ear, assessed vital stats (blood pressure) 184/85 (pulse) 85 (oxygen saturation) 93 at 2 liters per minute, range of motion intact to upper and lower extremities. Physician on call, DON, supervisor and family member notified. 911 was called at 9:05 p.m. ambulance arrived at 9:23 p.m. and resident was taken via stretcher to hospital 9:35 p.m. Appears and/or stated to be in pain. Describes the pain as: intermittent, locations of pain: head, pain relieving interventions used at this time: p.m. medication. Record review of RN K's progress note for Resident #3 dated 06/29/2026 at 2:02 a.m. read in part, resident returned from hospital, diagnosis status post fall, pleural effusion. Resident continue on 2 liters per minute nasal cannula oxygen. Cough was noted during admission. As per report head computed tomography scan was completed with negative results. No new orders sent with paperwork. Physician on call was notified of readmission Record review of Resident #3's hospital discharge date d 06/29/2026 read in part, arrival time 06/28/2026 at 9:45 p.m. Patient diagnosis: fall; pleural effusion; scalp contusion (soft tissue injury caused by blunt impact). Discharge location: follow up with primary care provider within 3-5 days.computed tomography to spine cervical without contrast completed. Order details: discharge to home resume normal activity. Record review of Resident #3's Therapy Screen completed by DOT on 06/30/2026 read in part, the resident exhibited a change in one area under falls. The recommendations implemented were, no skilled therapy intervention indicated, will continue to monitor patient. Record review LVN L's weekly skin assessment of Resident #3 dated 07/03/2026 at 6:26 a.m. read in part, skin color: normal, temperature skin: warm, bruise present: Yes, Location, measurements of bruising: left aspect facial/periorbital region (around the eye to include eyelids, eyebrows, and the bony socket), 7.5CM x 8.5. left upper shoulder 7CM x 5CM status post recent fall skin tear present: no, abrasion present: no, laceration present: no. rash present: no, moisture associated skin damage present: no. other skin findings present: no. Record review of the Provider Investigation Report for incident intakes did not include detailed information such as interviews conducted with key personnel, what documentation was reviewed, and what interventions the facility took to correct or prevent further incidents. This included the following separate intakes involving Resident #1 and #2. In an interview on 07/07/2026 at 9:55 a.m., the Administrator stated Resident #1 was speaking to Hospice Social Worker and her about a time he had left the facility and went to the bank to withdraw $2,000 while he was in the middle of a pending Medicaid application due to lack of reported income. She stated Resident #1 had told her the money was for his family member. She stated the facility was unsuccessful in contacting family members to provide documents for Resident #1's finances so the Hospice Social Worker assisted. She stated she created an APS report and self-report to the state on concerns for exploitation and neglect based on Resident #1 reporting he gave $2,000 to a family member. She stated she did not see the family member visit Resident #1 for one week after creating the report. She stated Resident #1 had a previous exploitation case confirmed by APS upon his admission into the facility. She stated that the facility contacted the Ombudsman to speak to Resident #1and family due to possibility of discharge for nonpayment. She stated during the investigation the facility tried to minimize Resident #1 from leaving the facility with the alleged family member but was unsuccessful. She stated that she notified the alleged family member the facility would not be doing anything further on the family's behalf until she obtained a POA. She stated she referred the alleged family member to attorney services offered by the facility's corporate partners. She stated the resident had his Medicaid application approved following the involvement of APS who assisted family member in obtaining POA for Resident #1. She stated she did not complete any interviews with staff or residents for the investigation. She stated she let APS take over the investigation and contacted a foster home advisory service (a third-party business who assisted residents and families with finding a foster home in their area) for her portions of the investigation. She stated she did not complete a 3613-A form (provider investigation report for self-reported incidents) and only uploaded the digital Provider Investigation Report to TULIP. She stated she only completed one interview with Resident #1 and utilized the Hospice Social Worker as a translator. She stated She stated the 3613-A form was used to provide status on investigations, assist in resolving allegations, document the interventions put in place, and what the investigation findings were. She identified herself as the individual responsible for completing the 3613-A form and thoroughly investigating all allegations and incidents. She stated that the 3613-A form would have had to been completed within 5 days of the investigation along with the initial findings. She stated that the 3613-A form needed to be emailed, faxed, uploaded to TULIP, and stored in the facility's physical investigation copy. In a follow-up interview on 07/07/2026 at 5:33 p.m. regarding Resident #2, the Administrator stated she was notified on 06/22/2026 about Resident #2's fall on 06/21/2026. She stated that she was notified on 06/27/2026 about Resident #2's hospital transfer following significant findings from an x-ray on 06/26/2026. She stated because Resident #2's fracture was not determined on the initial fall date the facility self-reported under the allegation of neglect. She stated the interventions included speaking with Resident #2's family member about interventions in the form of a bolster (concave) mattress, continue with incontinent briefs, address Resident #2's fixation on restroom breaks, change to hourly monitoring, start antibiotic regimen for urinary tract infection, and placed the resident's bed against the wall. She stated for her investigation she interviewed only LVN M who was the nurse who assessed Resident #2 on 06/26/2026 and ordered x-rays. She stated she did not document her interview, collect a statement, conduct safety surveys, or interview Resident #2. She stated Resident #2 could engage in simple conversations and sharing needs and pain but had difficulty with recalling events and elaboration. She stated that she would be responsible for compiling the information collected during the investigation and delegating the tasks to nursing supervisors to complete on her behalf. She stated it needed to be done because it ensured the residents' safety as priority and to prevent future incidents. She stated that her investigation was not thorough as to the adherence of the facility's abuse and neglect policy. She stated that the investigation would determine if there were interventions to prevent or mitigate the injuries. She stated that the investigation would be provided to Texas HHSC for further review. She stated that this was a requirement per CMS and with her license to thoroughly investigate self-reported incidents. In a follow-up interview on 07/07/2026 at 5:45 p.m. regarding Resident #3, the Administrator stated she could not interview Resident #3 or CNA C because she did not have enough knowledge in Spanish. She stated that it was reported to her via translation from her ADON A that, CNA C was providing incontinent care to Resident #3 and had gone to the other side of the bed, but Resident #3 was trying to get off the bed. She stated it was reported to her that Resident #3 had placed herself on her side while CNA C walked to the other side of the bed. She stated that based on CNA C's written statement abuse, neglect, and quality of care concerns were ruled out because it was the assumption Resident #3 was attempting to self-transfer She stated she did not interview Resident #3 that ADON A was tasked with this. She stated that she was notified by ADON A that Resident #3 was trying to maneuver herself to get out of bed. She stated that Resident #3 suffered minor injuries to her eyebrow and scalp but could not recall orientation. She stated Resident #3 was sent to the hospital immediately following the fall and it was determined there were no major injuries. She stated Resident #3 was discharged from the emergency room within 2-3 hours from leaving the facility She stated CNA C was not suspended and did not receive further training on transfers and repositioning. She stated she was unable to understand CNA C's written statement because it was in Spanish and relied on translation for understanding. In an interview on 07/07/2026 at 4:09 p.m., ADON A stated she did not participate in the investigation involving Resident #1. She stated she was not notified about Resident #2's fall until 06/22/2026 when she was reading progress notes entered. She stated monitored for pain, change in condition, and followed Physicians orders. She stated when she saw Resident #2 she would assess for pain. She stated Resident #2 did not display any variation from her baseline. She stated she did not participate in the investigation involving Resident #2. She stated the DON was notified on 06/28/2026 about Resident #3's fall but not her directly. She stated she was not present during Resident #3's fall and she did not participate in any portion of the investigation. She stated the DON had collected the statements for the fall with Resident #3. She stated she does not think CNA C was suspended. She stated she does not know if there was a facility investigation conducted. She stated that Resident #3 said she was feeling better post fall and hospital visit on 06/29/2026. She stated Resident #3's injuries were bruises to the left eye/eyebrow area. She stated the resident did not suffer a fracture or internal bleeding. In an interview on 07/07/2026 at approximately 12:05 a.m., the DON notified the surveyor she would not be attending work during the day on 07/07/2026. An interview with the DON was not obtained prior to surveyor exit on 07/07/2026 at 6:30 p.m. Record review of the facility's policy titled, Abuse/Neglect dated 03/29/2018 read in part: .Residents should not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, reports, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situation that may constitute abuse or neglect to any resident in the facility. (Procedures, F - Investigation) Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. (1) The administrator in consultation with Risk Management Department will be responsible for investigating and reporting cases to the HHSC. (6) the Abuse preventionist and/or administrator will conduct a thorough investigation of incident(s). A copy of the written report will accompany any personnel action deemed necessary.(G - Protection) The facility will take necessary measures to protect resident and employees from harm during and following an abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property investigation. Record review of the Texas Health and Human Services Commission document, Long-Term Care Regulation Provider Letter, undated, read in part under 2.0 Policy Details & Provider Responsibilities: A provider must: ensure a thorough investigation is conducted and documented in the PIR .

Based on observation, interview and record review the facility failed to maintain evidence demonstrating the result of all grievances for a period no less than 3 years from the issuance of the grievance decision for 1 of 1 grievance binders reviewed.The facility failed to maintain evidence demonstrating the results of grievances from 04/14/26-05/08/26.This failure could place residents at risk of not having their grievances properly resolved, tracked, and documented for future review.Findings include:During an observation and record review on 05/07/2026 at approximately 1:30 PM, revealed that the grievance binder provided did not have any documentation of grievances from 04/14/26-05/08/26. During an interview on 5/8/269 at 111:38 am, the DON stated that any verbal concerns or complaints were reported to the Administrator in accordance with the facility grievance process. The DON stated that she investigated concerns related to the nursing department and reported findings to the Administrator. The DON stated that the Administrator was responsible for overseeing, tracking, and maintaining grievance records. The DON stated that failure to maintain grievance documentation could prevent the facility from demonstrating that concerns had been addressed. During an interview on 5/8/26 at 12:27 pm, The Administrator stated that, based on the facility grievance policy, she was responsible for maintaining grievance records. The Administrator stated the grievance tracking system was missing. The Administrator stated she maintained personal notes regarding concerns; however, she stated she did not maintain the grievance forms necessary to demonstrate how complaints were addressed and tracked. The Administrator stated the SW typically completed grievance tracking; however, due to the absence of an SW, she had been overseeing the process and stated the lack of tracking was an oversight. The Administrator stated a new SW had been hired and stated she waited for the individual to complete a two-week notice period prior to starting employment. Risks identified included the facility's inability to demonstrate complaints were appropriately addressed and tracked due to the absence of a grievance tracking system. Record review of the facility policy titled Grievances dated 11/2/2016 read in part, The grievance official will: Receive and track grievances to their conclusion Maintain the confidentiality of all information associated with grievances.

Based on interviews and record reviews, the facility failed to follow requirements of their written agreement with hospice agency indicating the facility would immediately notify the hospice about a significant change in the resident's physical, mental, social, or emotional status for 1 resident (Resident #2) of 1 reviewed for hospice care. The facility did not notify the local hospice agency of an as needed care plan meeting for Resident #2's significant change of condition in which Resident #2 was admitted to Hospice on [DATE]. The facility failed to implement a coordinated comprehensive person-centered care plan for Resident #2 when she was admitted to hospice on [DATE] for a significant change in condition. This failure could cause a decline in health for residents in hospice if the hospice agency is not notified of changes to their care plan.Findings included:Record review of Resident #2's Face Sheet dated [DATE], revealed, a [AGE] year-old female who was admitted on [DATE] and re-admitted on [DATE] to the facility. Diagnoses included Type 2 diabetes, Vascular Dementia (decline in thinking, memory, and behavior caused by conditions that block or reduce blood flow to the brain, depriving it of oxygen and nutrients), Unspecified Dementia (a diagnosis used when a patient shows clear signs of cognitive decline (memory loss, reasoning issues) that impair daily life, but tests cannot pinpoint a specific cause, such as Alzheimer's or vascular dementia), Mood Disorder due to known physiological condition with mixed features (describes a mental health state where symptoms of both mania/hypomania and depression occur concurrently, directly caused by a medical condition (e.g., stroke, hormonal disorder) or medication), anxiety disorder, and insomnia. Record review of Resident #2's significant change MDS dated [DATE], revealed, Resident #2's has severely impaired cognition with a BIMS score of 3 and unable to recall or make daily decisions. Resident #2 was coded for disorganized thinking. Record review of Resident #2's care plan dated [DATE], revealed, Resident #2 had a terminal prognosis and/or was receiving hospice services under local hospice. Assess Resident #2's coping strategies and respect Resident #2s wishes. Consult with physician and Social Services to have hospice care for Resident #2 in the facility. If receiving hospice services, work cooperatively with hospice team to ensure the Resident #2's spiritual, emotional, intellectual, physical and social needs are met. Record review of Resident #2's physician order(s) dated [DATE], revealed, admitted under local hospice related to diagnosed heart failure. Order date [DATE], revealed, DNR/Hospice. Interview with Resident #2 was not conducted as resident had already expired. During an interview on [DATE] at 10:11 a.m., with the Hospice Nurse, she stated when Resident #2 was admitted to hospice on [DATE], that she was not asked to attend nor did she attend a care plan meeting regarding Resident #2's significant change. The Hospice Nurse stated it would have benefited if hospice was part of the care plan because they (hospice & the facility) would have known what was going on and know what care was being provided. During an interview on [DATE] at 11:53 a.m., the ADON she stated hospices were involved in care plans. The ADON stated the facility should have had a care plan meeting with the local hospice for Resident #2's significant change in condition on [DATE]. The ADON stated the Receptionist was responsible for calling the local hospice for care plan meetings. The ADON stated she was not sure who was responsible for ensuring that the Receptionist was actually calling the local hospice for the care plan meetings. The ADON stated the negative outcome of not calling the local hospice and/or the local hospice not attending would be that they would not know what would be happening with the resident. During an interview on [DATE] at 1:28 p.m., with the Hospice DON, he stated the local hospice did not have any care plan meetings with the facility for Resident #2 who was admitted into hospice on [DATE]. The Hospice DON stated they were not invited to any care meetings with the facility for Resident #2. The Hospice DON stated it would have benefited Resident 2 because hospice and the facility could have calibrated and talk about how Resident #2 was declining. During an interview on [DATE] at 2:13 p.m., the MDS Nurse stated care plan meetings were done quarterly, on request, and as needed. The MDS Nurse stated Resident #2 had a care plan meeting regarding being admitted to hospice on [DATE]. The MDS Nurse stated Resident #2 was on hospice and the focus area of hospice care was updated on her care plan on [DATE]. The MDS Nurse stated the Receptionist was responsible for calling the local hospice. The MDS Nurse stated she was not sure the receptionist actually called the local hospice for the care plan meetings. The MDS Nurse stated the local hospice for Resident #2 had not been attending the care plan meeting(s). The MDS Nurse stated the facility needed the local hospice at the care plan meeting so everyone would be on the same page and know what was going on with Resident #2. The MDS Nurse stated she did not think there would be a negative outcome if the local hospice did not attend the care plan meeting. The MDS Nurse stated as per the facility policy the local hospice needed to be invited so that they may attend the residents care plan meeting.During an interview on [DATE] at 2:42 p.m., the Receptionist stated the MDS Nurse would provide her with a list of residents who she needed to call from hospice for care plan meetings. The Receptionist stated that she would notify the MDS staff via Outlook in real time to inform them of who was going to attend or not. The Receptionist stated she was not able to confirm if she had or had not notified the local hospice for Resident #2 as it did not save in the system. During an interview on [DATE] at 2:55 p.m., with the DON, she stated the purpose of a care plan was to see the residents plan of care and medications and special interventions. The DON stated that local hospice was called to be apart of the care plan meeting. The DON stated it was the responsibility of the Receptionist to call and schedule the care plan meetings with hospice. The DON stated she would not know if it was the SW or MDS who were responsible for overseeing that the local hospice was invited to the care plan meeting. The DON stated the risk would be the local hospice missing out on something that the resident might need The DON stated the local hospice not attending the care plan meeting would not be a coordinated offered to provide the needed services for the resident During an interview on [DATE] at 3:15 p.m., the Administrator stated she would receive an e-mail with resident names and who would be having a care plan meeting from the Receptionist. The Administrator stated the Receptionist calls the local hospice for care plan meetings so they may attend and coordinate with them. The Administrator stated that MDS was ensured the Receptionist was making the calls to the local hospice. The Administrator stated that the list was sent in the system in real time and was not saved. The Administrator stated the local hospice should be included in the care plan meetings since the residents were under their services. The Administrator stated the negative impact of not inviting the local hospice was that they would not be aware of the interventions in place for the residents.Record review of the facilities Hospice Services policy not dated, revealed, Procedures - 3. The delineation of the role(s) of the hospice and the nursing facility in the admission process, recipient and family assessment, and the interdisciplinary team case conferences. 12. The nursing facility and hospice provider must ensure that a coordinated plan of care reflects the participation of the hospice.Record review of the facilities Hospice Care Services Agreement dated [DATE], revealed, Agreement - Definitions: Plan of Care - The plan of care must reflect the Hospice patient and family goals and interventions based on the problems identified in the Hospice Patient Assessment. The Plan of Care should reflect the participation of the hospice which include implementing and coordinating the plan of care. Exhibit A - Section I Services: 4. Plan of Care - 4.1. The Plan of Care shall include those services to be provided by the facility and coordinated by the hospice. 4.4. The Plan of Care shall be developed in full consultation of both Hospice and Facility. The parties agree that each shall maintain its portion of the Plan of Care, in accordance with applicable laws and regulations governing each party. Furthermore the parties will collaborate in jointly coordinating the implementation, evaluation and modification, as needed, of the Plan of Care on an ongoing basis.

Based on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 4 (Resident #2, Resident #46, Resident #62 and Resident #79) of 12 residents observed for oxygen management. The facility failed to properly bag and store an oxygen nebulizer for Resident #2, and Resident #46 The facility failed to clean the oxygen concentrator air filter for Resident #62 and Resident #79 while the oxygen was in use.Findings included: Resident #2: Record review of Resident #2's face sheet dated 04/02/2026 revealed a [AGE] year-old male with an admission date of 03/30/2026. Record review of Resident #2's history and physical dated 04/02/2026 revealed that the resident had diagnoses including acute and chronic respiratory failure with hypoxia (a condition where the lungs cannot provide enough oxygen to the body), dyspnea (shortness of breath), and dependence on supplemental oxygen (requiring oxygen support to maintain adequate breathing). The record revealed that the resident required oxygen therapy to support respiratory function. Record review of Resident #2's admission assessment MDS dated [DATE] revealed under Section GG (Functional Abilities and Goals) that the resident required assistance with ADLs. The MDS revealed under section I – Active Diagnoses; the resident had debility, cardiorespiratory conditions, and respiratory failure. The MDS revealed under section O – Special Treatments, Procedures and Programs; the resident required oxygen therapy. The MDS revealed under section J – Health Conditions, Resident #2 had shortness of breath with trouble breathing with exertion (walking, bathing, transferring). Record review of Resident #2's care plan dated 03/30/2026 revealed the resident had oxygen therapy related to ineffective gas exchange (inability of the lungs to properly exchange oxygen and carbon dioxide). The care plan included interventions for staff to monitor signs and symptoms of respiratory distress, including changes in respirations, oxygen levels, confusion, and increased heart rate. The care plan revealed staff were to provide interventions to provide assistance with oxygen equipment, including ensuring proper positioning, use of oxygen delivery devices, and monitoring effectiveness of treatments. During an observation and interview on 04/12/2026 at 1:34 p.m. with Resident #2, he stated that he needed his nebulizer to breathe better, and he used it especially when he turned sides on his bed and he needed help breathing. Resident #2 stated he had taken off his nebulizer in the morning and had left it on his nightstand to use it later. Resident #2 stated that staff had been going to check on him through the day, but that no one had cleaned or stored his nebulizer. Resident #2's nebulizer was observed next to him on his night stand; it was not bagged and out in the open. During an interview on 04/13/2026 at 2:16 p.m., CNA A stated that nebulizer equipment should have been properly sanitized after each use, then placed in a bag and stored appropriately to prevent exposure to environmental contaminants. CNA A stated that failure to properly store the nebulizer created a risk of contamination from dust, lint, or other airborne particles, which could enter the equipment and be inhaled by the resident. CNA A stated that such contamination had the potential to negatively impact the resident's respiratory system or lungs, increasing the risk of illness or infection. CNA A stated that all staff providing care to residents were responsible for ensuring nebulizers were cleaned, sanitized, and stored according to facility expectations. During an interview on 04/13/2026 at 2:43 PM, LVN B stated that all staff working directly with residents were responsible for ensuring nebulizer equipment was properly sanitized and stored when not in use. LVN B stated it was not appropriate to leave Resident #2's nebulizer exposed on the nightstand, as this increased the likelihood of contamination. LVN B stated that improper sanitation and storage of nebulizer equipment created a significant risk of infection, which could worsen the resident's respiratory condition if contaminated equipment was used. LVN B stated there was a safety concern related to improperly stored tubing, noting it could become tangled or create a tripping hazard, potentially resulting in a fall and injury to the resident or any visitors who went into Resident #2's room. During an interview on 04/14/2026 at 1:33 p.m., with the DON, she stated nasal cannulas and nebulizer masks were to be stored in the plastic bag when not in use to prevent any cross contamination. She stated that all staff was responsible for ensuring that oxygen materials were stored properly. She stated the risk to the resident could be residents getting sick from using a contaminated nebulizer mask or nasal canula. During an interview on 04/14/2026 at 1:53 p.m. with the Administrator, she stated that staff working in the facility and provided direct care to the residents, were responsible for sanitizing, bagging, and properly storing nebulizer equipment when not in use. The Administrator stated that failure to follow proper infection control practices could result in the nebulizer becoming contaminated, placing Resident #2 at risk for infection if the equipment was used without being properly cleaned. The Administrator stated there was a risk of cross-contamination, which could lead to illness affecting the resident's mouth, lungs, or nasal passages, particularly given the direct route of administration through respiratory equipment. Record review of the Nursing Policy and Procedure Manual, titled Oxygen Administration, not dated, revealed in part: Oxygen therapy includes the administration of oxygen (O2) in liters/minute (L/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse. The nasal cannula delivers 22-40 % oxygen and is the most common, inexpensive, and easiest device to use. Common oxygen sources for long-term administration include cylinder (portable or stationary) or wall system near the resident's bed or concentrator. Goals 1. The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen. 2. The resident will maintain an effective breathing pattern with administration of oxygen. 3. The resident will be free from infection. Procedure 11. Change the tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated. Resident # 46 Record review of Resident # 46's admission record dated 04/14/2026 revealed a [AGE] year-old female with an original admission date of 12/28/2023 and a readmission date of 04/27/2024. Record review of Resident # 46's history and physical dated 12/01/2025 revealed a diagnosis of mild persistent asthma with acute exacerbation (worsening of chronic, asthma symptoms that requires increased medication). Record review of Resident # 46's quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognitive function. Record review of Resident #46's clinical physician orders revealed an active order dated 08/15/2025 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol), 1 application inhale orally one time a day for shortness of breath. Record review of Resident # 46's care plan revised 02/25/2026 revealed Resident # 46 had altered respiratory status/ difficulty breathing/ shortness of breath interventions did not mention anything about applying nebulizer treatment. An observation on 04/12/2026 at 10:20 a.m., revealed a nebulizer mask not in use, laying on top of the nebulizer machine uncovered, the Resident was not in the room. Resident #62 Record review of Resident #62's admission record dated 04/14/2026 revealed a [AGE] year-old female with an original admission date of 03/28/2024 and a readmission of 05/29/2025. Record review of Resident # 62's acute episodic visit note dated 02/27/2026 revealed a diagnosis of heart failure. Record review of Resident #62's comprehensive MDS asessment dated 03/27/2026 revealed a BIMS score of 03 indicating severe cognitive impairment. Section O- special treatments, procedures and programs revealed the use if oxygen therapy. Record review of Resident # 62's clinical physician orders revealed an active order dated 03/13/2026 for oxygen at 2 liters per minute via nasal canula for shortness of breath. Record review of Resident # 62's care plan revised on 03/24/2026 revealed Resident # 62 had oxygen therapy related to heart failure. Interventions included administering oxygen at 2 liters per minute via the nasal canula. An observation on 04/12/2026 at 10:43am in Resident # 62's room revealed an oxygen concentrator machine with a dirty oxygen filter while in use. Resident # 62 was asleep in bed. Resident #79 Record review of Resident #79's admission record dated 04/14/2026 revealed a [AGE] year-old female with an admission date of 08/28/2024 and a readmission date of 09/13/2024. Record review of resident # 79's history and physical dated 11/17/2025 revealed a diagnosis of chronic respiratory failure with hypoxia (long term condition where the lungs can not adequately transfer oxygen into the blood stream). Record review of Resident # 79's quarterly MDS assessment dated [DATE] revealed a BIMs of 08 indicating moderate cognitive impairment. Section O- special treatments, procedures and programs revealed the use of oxygen therapy. Record review of Resident # 79's clinical physician orders revealed an active order dated 08/18/2025 for oxygen at 2 liters per minute via nasal canula for shortness of breath. Record review of Resident # 79's care plan revealed Resident # 62 had oxygen therapy related to altered cardiovascular status. Interventions included administering oxygen as ordered. An observation on 04/12/2026 at 10:54am in Resident # 79's room revealed an oxygen concentrator machine with a dirty oxygen filter while in use. Resident # 79 was asleep in bed

Based on observation, interview, and record review, the facility failed to provide safe and secure storage of medications for 3 of 4 medication carts (Halls E, B and C). 1. -The facility failed to ensure Blood Glucose Strips bottle was dated when opened according to manufacturer's specifications in two of two nurses' medication carts. 2. -The facility failed to ensure opened bottles of Liquid Protein Supplement was dated when opened according to manufacturer's specifications in two of two Med Aide's medication carts. 3. -The facility failed to ensure medication cart drawers were clean. 4. -The facility failed to ensure medication bottles stored in medication carts were free of dried dripping; staff were not storing personal care items removed from residents' rooms, discontinued medications and money in the medication carts.5. -The facility failed on 04/12/2026 by leaving a dixie cup at bedside of Resident #66 with leftover medications and a tongue depressor in it, exposed and within reach of other residents.These failures could affect residents that received diabetes medications and nutritional supplement from the facility. Findings included:During an observation and interview on 4/13/26 at 10:56 a.m. with LVN F assigned to the 200 Hall revealed: -There were two bottles of Blood Glucose Strips that were not dated when opened. The label on the bottle documented to use within 6 months after first opening or before expiration date 08/13/2027. LVN F said they had been trained to date the bottles and boxes when opened. -There was a bottle of Milk of Magnesia stored in the drawer with dried drippings on the side of the bottle. LVN F said they had been trained to clean the liquid medication bottles after each use. -There were dried drippings on the bottom of the drawer where medication bottles were stored. LVN F said all of the nurses were responsible for keeping the medication carts clean. Medication Cart 300 Hall: During a observation and interview on 4/13/26 at 11:09 a.m. with LVN D revealed: -There were air pods, dollar bills, multiple coins, upper denture stored in a plastic glove and a coin purse stored in one of the drawers in the medication cart. -There were 5 bottles of eye drops stored together in a small plastic container. LVN D, said, When we remove the bottles from the boxes, we just store them all together in the plastic container. How should they be stored? -There was a bottle of Iron Supplement Liquid, a bottle of Geri-Tussin, and a bottle of Milk of Magnesia stored in a drawer that had dried drippings on the sides of the bottles. -There was an open large plastic bag stored in the bottom drawer of the medication cart that contained a can of air freshener, a box that contained a perfume bottle, chap stick, deodorant bottle and other personal care products. There was another bag that contained over the counter medications. LVN said, All of those things stored in those two plastic bags are items that we removed from the residents' rooms that they are not allowed to have, and this is where we stored them. -There was an opened bottle of Nystatin Topical Powder stored in one of the drawers in the medication cart without a cap that had white residual on the top of the sides of the bottle. -There were two large, opened bags of Lollipops stored in one of the bottom drawers in the medication cart. LVN D, We give Lollipops to some of the residents, so that is why they are stored in the medication cart. Medication Cart used by the Med Aides for the 200/300 Hall revealed: During an observation and interview on 04/13/26 11:23 a.m. with Med Aide G revealed: -There were two small plastic containers with pudding that were not dated. Med Aide G said he used them to mix crushed medications to administer to some of the residents. He said, I got those pudding containers this morning from the refrigerator where snacks are stored for the residents. He said that he did not know that the containers needed to be dated. -There was an opened bottle of Active Liquid Protein that was not dated when opened. The label on the bottle documented, Do Not Refrigerate. Shelf stable. 3-month shelf life from date opened. Date Opened: left blank. Med Aide G stated, I did not know that. -11:27 a.m. There was a bottle of Valproic Acid Solution and a bottle of Lactulose stored in a drawer. The bottles had dried, dripping on the sides of the bottles. -11:27 There was a bottle that contained Metformin 500 mg, and two bottles that contained Galantamine ER stored in a drawer. The drawer was dusty and had particles on the bottom of the drawer. Med Aide G said, Those are discontinued medications that are stored in the medication cart. -11:29 a.m. There was a medication box that contained Fluticasone Propionate Nasal Spray that had part of the pharmacy label torn off. During an interview on 4/13/26 12:00 p.m. with the facility's Compliance Nurse said the nurses had been trained to date nutritional supplement bottles according to manufacturer's specification; trained to date Blood Glucose Strip bottles when opened according to manufacturer's specification. She said the nurses and Med Aides had been trained to immediately remove discontinued medications from the medication carts and not to store resident personal items in the medication carts. The state surveyor requested facility's policy and procedure on storage of medications and was not provided befor exit. Findings included: Record review of Resident #66's face sheet dated 04/14/2026 revealed a [AGE] year-old female with an original admission date of 08/17/2018. Record review of Resident #66's history and physical dated 07/26/2024 revealed that the resident had diagnoses including unspecified dementia (decline in memory and thinking abilities), muscle weakness (reduced strength), abnormal gait (difficulty walking safely), and cognitive communication deficit (difficulty understanding or expressing thoughts). Record review of Resident #66's annual MDS assessment dated [DATE] revealed she had a BIMS of 0 indicating she was severely cognitively impaired. The MDS revealed under Section GG (Functional Abilities and Goals) that the resident required assistance with ADLs. The MDS revealed that the resident demonstrated cognitive impairment and required supervision and assistance with daily care tasks. Record review of Resident #66's care plan dated 04/01/2026 revealed the resident had diagnoses including dementia and cognitive communication deficit, requiring ongoing monitoring and assistance. The care plan included interventions for staff to administer medications as ordered and monitor effectiveness and side effects. During an observation and interview on 04/12/2026 at 10:02 a.m. with Resident #66, she was asked if she knew which medication she was supervised with that was left inside the dixie cup. Resident #66 was confused and could not provide an answer to the surveyor. Resident #66 mumbled under her breath, and the attempt to interview concluded. During an interview on 04/13/2026 at 2:24 PM with CNA A, she stated that it was likely the contents remaining in the dixie cup were medication for Resident #66. CNA A stated that the staff member responsible for supervising the medication administration process was also responsible for properly disposing of any remaining medication by placing the cup in the designated biohazard waste bin located on the medication carts. CNA A stated that leaving the cup unattended in the resident's room posed a risk to infection control practices. She stated that if another resident accessed the medication and ingested it, it could result in gastrointestinal illness or other adverse health effects. During an interview on 04/13/2026 at 2:39 PM, LVN B stated that the cup most likely contained residual medication and stated that it was not appropriate to leave it unattended in the resident's room after administration. LVN B stated that the nurse or staff member who administered the medication was responsible for ensuring proper disposal of any remaining medication by discarding it in the designated trash bin within the medication cart. LVN B stated that leaving medication unattended created a safety risk, particularly for residents with cognitive impairments such as dementia, who could wander into the room and ingest the medication. LVN B stated this could result in illness or potentially trigger an allergic reaction depending on the resident's sensitivities. During an interview on 04/14/2026 at 2:45 p.m. with the Corporate Nurse, she stated that it was not acceptable practice to leave leftover medications in a resident's room following administration. The Corporate Nurse stated that medications left unattended created a significant safety risk, as another resident could enter the room and inadvertently ingest the medication, potentially resulting in illness or triggering an adverse or allergic reaction depending on the resident's medical history and sensitivities. The Corporate Nurse stated that improper disposal of leftover medications also presented an infection control concern. She stated that exposed medications could become contaminated through environmental exposure, increasing the risk of cross-contamination if handled or ingested. The Corporate Nurse stated that failure to properly dispose of medications in accordance with facility expectations could compromise resident safety, leading to preventable health complications, including gastrointestinal distress, medication-related adverse events, or the spread of contaminants within the resident care environment. Record review of the facility policy, not dated, titled Medication Administration, revealed the facility did not have a policy specifically outlining procedures for the disposal of leftover medications or clear guidance on how staff were to properly discard residual medications following administration. The Corporate Nurse stated at 3:14 PM that the facility did not have a specific policy addressing procedures of disposal for leftover medications.

Based on observations, interviews, and record reviews, the facility failed to store food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage.-The facility failed to keep food containers stored in the dry storage room free of food particles.- The facility failed to ensure food stored in the dry storage room was properly stored, labeled, and dated.-The facility failed to keep liquid bottles stored in the dry storage room and refrigerator free of dried drippings and grease build-up.-The facility failed to keep the ice machine free of white calcium build-up.These failures could place residents who received meals and/or snacks from the kitchen at risk of foodborne illnesses. Findings included:Dry Storage Room:During an observation and interview on 4/12/26 at 9:31 a.m. with [NAME] E revealed: -9:32 a.m. Four small clear plastic containers that contained breakfast cereal were covered with plastic wrap and were not dated. It was observed that there were food particles and several pieces of breakfast cereal on the bottom of the plastic containers where the breakfast cereal bowls were stored.-9:33 a.m. There was a disposable food plate that contained two sunny side eggs, beans, bacon and bread covered with a paper napkin stored on the metal shelf on top of metal food cans; Seashell pasta was stored in a plastic bag tied in a knot, that was not dated. -9:34 a.m. Multiple food plastic containers stored on metal shelves had grease build-up and had food particles; one of the squared plastic food containers where the pasta bags were stored had food particles and pieces of spaghetti on the bottom of the container.-9:35 a.m. food cans stored on the metal shelves had food particles on top of the cans. A large plastic container that contained macaroni noodles had a cracked plastic lid. The plastic lid was greasy and had food particles.-9:37 a.m. food plastic and glass bottles stored on a meal tray on one of the shelves had multiple bottles with dried drippings on the tops and sides of bottles, were greasy and some of them had food particles on the sides of the bottles. The bottom of the meal tray where the bottles were stored had dried food stains, had grease build up and had food particles.-9:40 a.m. opened bag of corn chips dated as opened on 4/02/26 was not sealed was stored on the metal shelve.-9:41 a.m. opened bag of cinnamon sticks was opened, was not sealed or dated when opened was stored in a plastic food container. The lid was greasy and had food particles.-9:42 a.m. opened bags of Cinnamon Sugar, Roasted Chicken Gravy, were stored in food plastic containers. It was observed that the bags were opened, were not sealed, and/or dated when opened. The lids to the plastic containers were greasy and had food particles. Multiple small bags of crushed corn stored in plastic containers covered with food particles. -9:47 a.m. an opened bag of Flavored Gray that was partially closed with a metal binder clip. The bag was not dated when it opened.9:51 a.m. A large container of Chocolate Fudge Frosting opened 01/09/26 had a cracked lid.-9:54 a.m. Large plastic oil container had oil dripping on the side of the bottle.Refrigerator:-10:10 a.m. There was a plastic bottle of chocolate syrup dated as opened 3/12/26 dried drippings on the side of the bottle.-10:11 a.m. A plastic bottle that contains tomato pasted dried drippings on the side of the bottle.-plastic syrup dispenser dated 3/05/26 that contained chocolate syrup had dried dripping on the lid and below the handle on the bottle.-A large plastic container of cottage cheese dated 2/02/26 stored on the shelf had a cracked lid.Ice Machine:During an observation and interview with Dietary Supervisor on 4/12/26 at 10:13 a.m. revealed the ice machine had white calcium build-up on the front directly below the ice maker and around the edges of the Bin Door and white calcium build-up and white particles. The Dietary Supervisor said that they had attempted to remove the white calcium build-up and were not able to remove it.Review of the Cleaning Schedules dated April 2026 provided by the Dietary Supervisor revealed did not list the ice machine.In an interview at 04/13/26 at 12:15 p.m. with the director of Food and Nutrition said the thermometers were checked daily and was not aware that some of the Digital Type Pocket Thermometer was not working and said that he had not used the digital thermometer for a while.During an interview on 04/14/26 at 2:10 p.m. with facility's Consultant Dietitian revealed that she conducted weekly visits and did not leave any notes regarding her findings and/or recommendations. She said she had not noted any concerns related to food storage and cleanliness. She said that she did not conduct deep observations of the kitchen.Review of facility's Food Storage and Supplies policy dated 2012 provided by director of Food and Nutrition revealed:All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure. The storage area is very clean, organized, dry and protected from vermin, and Insects. Procedures: Dry monk foods such as flour, sugar are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. Containers are clean regularly. Open packages of food are stored in closed containers with covers or sealed bags and dated as to when opened.

Based on observation and interview the facility failed to post in a form and manner accessible and understandable to residents and resident representatives a list of names, addresses (mailing and email, and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit for 1 of 1 buildings reviewed for postings. The facility failed to ensure the number to HHS Long Term Care Regulatory (state survey and certification agency) number for filing grievances, or complaints or suspected violations of state or Federal violations was posted in an area where it was accessible to all residents and family members. This failure could place residents at risk of lack of knowledge of who to contact should they require advocacy, investigation, and not knowing their rights, how to exercise their rights, or investigations into violations of their rights. Findings include: In observation on 04/12/2026 at 2:00 pm revealed postings to include HHSC compliant number and statement that resident may file a compliant with State Survey Agency were on the wall on the 300 hall. There were no postings on the 100, 200 and 400 hall. In a confidential group interview on 04/14/2026 at 10:00 am with 9 residents revealed 7 of them did not know how to file and contact the State Survey Agency if they had complaints. They stated that the only number that they were aware of was the administrators number as it was posted in all hallways, but that they would like to be aware of how to file a complaint directly with the State Survey Agency. One resident stated that she had noticed the State Survey Agency number was posted in the 300 hallway, but that she rarely went to that hallway unless she was going to the activities room. An interview on 04/14/2026 at 2:46 pm with the administrator revealed that the number to the State Survey Agency was posted on the wall of the 300 hallway. She stated that it was the only location where that information was posted, but that her contact information as the abuse coordinator was posted throughout the building and if family member or residents wanted that information, the residents could ask any staff member and they would provide that information to the family or resident. She stated that there was a possibility that residents would not know how to report their concerns directly to the State Survey Agency and that it was something that all residents and family members should have easy access to so that if incase there were any concerns, they knew how to file a report. She stated that there was not a policy regarding required postings.

Based on interview and record review , the facility did not ensure prompt efforts were made to document a resident grievance for 1 (Resident #65) of 9 residents reviewed for grievance resolutions. The facility failed to promptly document grievances regarding a complaint regarding customer service voiced by Resident #65 and Responsible Party. This failure placed resident at risk of not having their grievances resolved. Findings included: Resident # 65 Record review of Resident # 65's admission record dated 04/14/2026 revealed an [AGE] year-old female with an original admission date 0f 08/15/2025. Record review of Resident # 65's diagnosis list dated 04/14/2026 revealed a diagnosis of dementia (progressive decline in mental ability specifically in memory, thinking and behavior) Record review of Resident # 65's quarterly MDS assessment dated [DATE] revealed a BIMs score of 10 indicating mild cognitive impairment. Record review of resident # 65's care plan revealed Resident # 65 had impaired cognitive function/ dementia or impaired through process. Interventions included discussing concerns about confusion, disease process, nursing home placement with resident /family/caregivers. In an interview on 04/13/2026 at 2:43 pm with Resident # 65's responsible party, revealed that on 03/30/2026, Resident # 65 called him to tell him that she had been asking one of the medication aides for help to be laid down back in bed. She had stated to him that she had asked her multiple times and that she had told her that she was too busy and walked away. He stated that he came to the facility and he verbally notified the DON of this incident the day it had happened on 3/30/2026. He stated that he was not told to file a grievance, he was told that the DON would take care of it and the facility never followed back up with him regarding this concern. In an interview on 04/14/2026 at 1:33 pm with the DON, she stated that on 03/30/2026 Resident # 65's responsible party came to the facility to tell her that Resident #65 had called him to tell him that she felt that medication aide had been rude to her. She stated that she might have had a conversation with him about removing the medication aide from Resident #65's care but she could not recall. She stated that this was not documented. She stated that she thought it was resolved. She stated that the purpose of the grievance form awas to ensure that any complaints were followed up on. She stated that she would have had to complete a grievance form to ensure that it was addressed and that there was supporting documentation to ensure residents needs were met. She stated that the risk of not completing a grievance form was that there would be lack of communication between the facility and the family or resident and the concern would not be resolved. In an interview on 04/14/2026 at 2:46pm with the administrator revealed that she was made aware of this situation by corporate as Resident # 65's responsible party reported it to the company complaint hotline. She stated that she received an email from the corporate office on 04/07/2026 regarding the medication aide refusing to provide care to the resident. She stated she was the grievance officer. She stated that the facility followed up on this, but there was no supporting documentation. She stated that the DON should have filed a grievance as soon as she was informed of the concern. She stated that the risk of not filing a grievance would be lack of communication and the whole team would not be aware of the situation. She stated that the resident would feel like the concerns weren't taken seriously. Review of facility policy titled Grievances revised 11/2/1016 read in part . The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. The grievance official will oversee grievance process, receive and track grievances to their conclusion, issue written grievance decisions to the resident.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 resident (Resident #46) of 9 residents reviewed for care plans. The facility failed to ensure comprehensive person-centered care plan for Resident #46 addressed the use of the nebulizer under interventions. This failure could affect residents and put them at risk for not receiving care and services to meet their needs. Findings Included: Record review of Resident #46's admission record revealed a [AGE] year-old female with an original admission date of 12/28/2023 and a readmission date of 04/27/2024. Record review of Resident #46's history and physical dated 12/01/2025 revealed a diagnosis of mild persistent asthma with acute exacerbation (chronic respiratory condition with regular symptoms that occasionally worsen suddenly, requiring prompt management). Record review of Resident #46's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating intact cognitive function. Record review of Resident # 46's clinical physician orders revealed an active order dated 08/15/2025 for ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml to be inhaled orally 1 application as needed. Record review of Resident # 46's care plan revised 02/25/2026 revealed Resident # 46 had altered respiratory status/difficulty breathing/shortness of breath. Interventions did not address the use of the nebulizer treatment, rather it stated to provide oxygen as ordered. In an interview on 04/14/2026 at 1:08 pm with the MDS nurse, revealed care plans were to detail the care of the resident and that it was patient centered. She stated that the care plan should mention the nebulizer treatment as it was one of the interventions being provided to the resident. She stated that one risk might have been that the resident would not received the treatment as ordered. She stated that it was the responsibility of the MDS nurse and nursing to ensure care plans were updated correctly. In an interview on 04/14/2026 at 1:33 pm with the DON revealed the purpose of the care plan was to ensure residents needs were being met and that the care required was being followed. She stated that the care plan should have been updated to reflect the intervention of the nebulizer treatment as it was a treatment that was being administered. She stated that it was the responsibility of nursing, nursing administration( DON and ADONs) and MDS nurses to ensure it was updated correctly. She stated that there was no risk to the resident if nebulizer treatment was not included in the care plan as there was an order for it. In an interview on 04/14/2026 at 2:46 pm with the Administrator revealed the purpose of the care plan was to know how to care for the resident. She stated that care plans were updated as needed and quarterly. She stated that the use of a nebulizer treatment needed to be addressed in the care plan to ensure all staff knew about the use of the nebulizer for resident's care. She stated that a risk to the resident would be the treatment not being administered. She stated that the MDS nurse, and floor nurses were responsible to ensure that it was updated correctly. Review of facility policy titled Comprehensive Care Planning not dated read in part The comprehensive care plan will describe the following- The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being .

Based on observation, interview, and record review the facility failed to provide proper treatment and care to maintain mobility and good foot health in accordance with professional standards of practice, including to prevent complications from the resident's medical conditions and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments for 3 (Residents #29, #57 and #93) of 18 residents reviewed for foot care.The facility failed to ensure Resident #29, Resident #57, and Resident #93 who required assistance with ADLs, did not have long and dirty fingernails.The facility failed to ensure Resident # 93 who required assistance with ADL's did not have long toenails.This deficient practice placed residents at risk of poor foot hygiene and decline in residents' physical condition.Findings include: Resident #29. Record review of Resident #29's face sheet dated 04/13/2026 revealed an [AGE] year-old male with an admission date of 11/27/2023.Record review of Resident #29's history and physical dated 01/13/2026 revealed that the resident was an [AGE] year-old male with a history of cerebrovascular accident (stroke affecting brain function), left-sided hemiplegia (paralysis on one side of the body), contractures (permanent tightening of muscles limiting movement), and muscle wasting (loss of muscle mass). The record revealed the resident was wheelchair bound with reduced strength on the left side and contractures to the upper extremity, requiring assistance with mobility and ADLs. Physical examination revealed limited range of motion, weakness, and continued need for assistance due to functional decline. Record review of Resident #29's annual MDS dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. The MDS under Section GG (Functional Abilities and Goals) revealed that the resident required assistance with ADLs. The MDS revealed the resident required substantial/maximal assistance (resident performs part of the activity, staff provide more than half the effort) with tasks such as dressing (putting on and removing clothing) and hygiene (personal cleanliness such as bathing and grooming). The MDS revealed the resident required assistance with mobility due to weakness and contractures, impacting his ability to safely perform daily tasks independently.Record review of Resident #29's care plan dated 04/01/2026 revealed the resident had conditions including hemiplegia and contractures which required assistance with ADLs. The care plan included interventions for staff to assist the resident with ADLs and repositioning every two hours. The record revealed that due to the resident's limited mobility and contractures, staff assistance was required to maintain proper hygiene and prevent complications. The care plan further indicated that staff were responsible for monitoring the resident's condition and providing necessary assistance with personal care needs, which would include hygiene-related tasks such as nail care (trimming fingernails to prevent injury and infection).Record review of #57's admission record dated 04/13/2026 revealed an [AGE] year-old female with an original admission date of 12/12/2024 and a readmission date of 08/01/2025.Record review Resident #57's history and physical dated 02/06/2026 revealed a diagnosis of unspecified osteoarthritis (joint cartilage degeneration, pain and stiffness).Record review of Resident # 57's quarterly MDS dated [DATE] revealed section gg functional abilities coded Resident # 57 as 09 for personal hygiene meaning the activity was not attempted prior to the current illness, exacerbation or injury.Record review of Resident #57's care plan revealed Resident #57 has an ADL self care performance deficit related to Alzheimer's, history of falls and limited mobility. Interventions included checking nail length and trim and clean on bath day and as necessary.An observation on 04/12/2026 at 11:26 am revealed Resident #57 with fingernails about one centimeter in length on bilateral hands. Resident was unable to voice if she wanted fingernails trimmed or not.Resident # 93Record review of Resident #93's admission record dated 04/14/2026 revealed a [AGE] year old female with an admission date of 09/16/2025.Record review of Resident #93's history and physical dated 02/06/2026 revealed a diagnosis of a cerebrovascular accident with residual left sided weakness (neurological impairment caused by damage to the right hemisphere of the brain, resulting in lasting weakness).Record review of Resident # 93's quarterly MDS assessment dated [DATE] revealed a BIMs score of 12. Section gg coded Resident #93 as 09 for personal hygiene meaning the activity was not attempted prior to the current illness, exacerbation or injury.Record review of Resident # 93's care plan revealed Resident #93 had an ADL self care performance deficit related to a history of cerebral infarction with left hemiparesis/ hemiplegia, contractures, lack of coordination. Interventions revealed the resident required one staff participation with personal hygiene and oral care.An observation and interview on 04/12/2026 at 11:13 AM revealed Resident # 29's fingernails on both hands were about one and a half centimeters long with dark and yellow debris under his fingernails. Resident # 29's left hand was contracted, and his fingernails were touching his palm. Resident #29 stated he did not like his fingernails long and he had requested the facility's staff to trim them but he had not been assisted as of 04/12/2026. An observation and interview on 04/12/2026 at 11:17 am revealed Resident # 93's fingernails on right hand were about a centimeter long with dark debris under and on the nails. Toes nails on bilateral feet were observed to be about 1.5 centimeters long. Resident #93 stated that she would like her nails trimmed and that she had not mentioned this to the facility, but no one had asked her if she would have liked them trimmed.During an interview on 04/13/2026 at 2:05 PM with CNA A, she stated that it was the responsibility of CNAs to ensure fingernails were maintained appropriately. CNA A emphasized that failure to trim Resident #29's fingernails could have resulted in the resident scratching himself, leading to cuts and potential infection. She stated that due to Resident #29's contractures, untrimmed nails could have dug into the skin, increasing the likelihood of injury, skin tears, bleeding, and infection.During an interview on 04/13/2026 at 2:50 PM with LVN B, she stated that all direct care staff were responsible for routinely assessing and maintaining residents' fingernails. She stated it was not acceptable for Resident #29 to have long fingernails, especially considering his contractures, as this could have caused the nails to press into his skin, resulting in bleeding, skin tears, and possible infection. During an interview on 04/13/2026 at 3:16 PM with CNA C, she stated that CNAs were responsible for checking residents' fingernails during routine care, including showers, and ensuring they were properly trimmed. She stated that failure to trim Resident #29's fingernails could have resulted in skin tears, bleeding, and infection. During an interview on 04/14/2026 at 11:43 AM with the PTA, she stated that maintaining trimmed and clean fingernails was essential in preventing injuries, particularly for residents with contractures such as Resident #29. She stated that long fingernails were not acceptable, as they could have dug into the resident's hand, leading to lacerations, bleeding, and potential infection. During an interview on 04/14/2026 at 12:47 PM with LVN D, he stated that both finger nails and toe nails were trimmed as needed. He stated that podiatrist visited the facility every 3 months. He stated that it was the responsibility of both nurses and CNAs to ensure residents fingernails were clean and trimmed. He stated that CNAs and nurses can cut finger nails. CNAs were able to cut toe nails and fingernails if they were not diabetic. He stated residents with long fingernails and toe nails could potentially hurt themselves by scratching themselves or breaking the skin. During an interview on 04/14/2026 at 1:33 PM with the DON, she stated nails were trimmed as needed. She stataed podiatrist came to facility quarterly. She stated that if needed the nurses and CNAs were able to cut the nails. She stated that if residents were not diabetic the CNAS were able to cut fingernails. She stated that a possible risk would be residents scratching themselves causing skin tears and bacteria to enter the wound, long toe nails could get caught in socks and hurt the resident. She stated that it was everyone's responsibility to ensure residents nails were clean and trimmed. During an interview on 04/14/2026 at 1:46 PM with the Administrator, she stated that both the charge nurse and CNAs were responsible for ensuring residents' fingernails were monitored and maintained. She stated that failure to do so could have resulted in skin tears, bleeding, and infection. The Administrator stated that all members of the IDT, including activities staff, were expected to observe and communicate any concerns or assist in ensuring residents' needs were met. Record review of the Nursing Policy and Procedure Manual, titled Nail Care, not dated, revealed in part: Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle are and is usually done during the bath. Nails can become thinner and more brittle in the elderly and thicker if peripheral circulation is impaired. Nails are also important in assessment, as changes occur with certain medical conditions, such as clubbing with chronic obstructive pulmonary disease or cardiac disease. Color changes with circulatory or lymphatic impairment and certain drug therapy is common. Ingrown toenails are also common in the elderly. Fungal infections of the toenails, dry, brittle ridges and thickening of the nails all occur in the elderly with some frequency.Goals:Nail care will be performed regularly and safely.The resident will be free from abnormal nail conditions.The resident will be free from infection.

Based on observations, interviews, and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 3 of 4 medication carts reviewed for medication storage. -The facility failed to ensure LVN F signed off on the Individual Control Record when she administered Morphine on 4/13/26 at 10:00 a.m. This failure could place residents at risk of drug diversion of controlled substances.Finding included:Medication Cart 200 Hall:During an observation and interview on 4/13/26 at 10:49 P.M. with LVN F revealed, during a random check of Narcotic Counts revealed that she had administered Morphine 10 mg/0.2 ml oral syringe at 10:00 a.m. and I forgot to sign the medication as given on the Individual Control Record. She said they had been trained to immediately sign out for controlled substance when removed from the medication cart. During an interview on 4/13/26 at 12:00 p.m. with facility's Compliance Nurse revealed that the licensed staff were just retrained on signing out for controlled substances when a controlled medication is administered, by the licensed nurse administering the medication. Review of the facility's policy undated policy on Medication Administration dated provided by the facility's Nurse revealed: Policy:Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal and state laws and regulations. Procedure:The Director of Nursing, when applicable, the consultant pharmacist maintains the facility's compliance with federal and state laws and regulations and the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications. When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: Date and time of administration, Amount administered, and signature of the nurse administering the dose, completed after the medication is actually administered.

Based on interview, and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported to the State Survey Agency, for two Residents (Resident #1 and #2) of six residents reviewed for abuse/neglect.The facility failed to report Resident #1's allegation of being double briefed on 03/09/26 to HHSC.The facility failed to report Resident #2's allegation of an unnamed nurse stating she did not speak Spanish to Resident #2 and left without meeting her needs or sending other staff to assist when made aware 02/11/26.This failure could place the 92 residents who reside in the facility at risk of abuse and neglect.Findings included:Record review of Resident #1's face-sheet dated 03/30/26 revealed an [AGE] year-old female with initial admission date 12/12/24, and re-admission date 08/01/25.Record review of Resident #1's Health and Physical dated 02/16/26, revealed a medical history of: Alzheimer's disease (a form of Dementia, a loss of brain function), Diabetes Mellitus II (a chronic condition causing high levels of sugar in the blood), and a history of falls.Record review of Resident #1's Quarterly MDS dated [DATE], revealed the BIMS was not completed as Resident #1 was noted to be rarely/never understood.Record review of Resident #1's progress note dated 03/11/25 by the Social Worker, revealed a Care Plan meeting was held with Resident #1's family member, IDT, SW, and the Treatment Nurse. It read: RP (Responsible Party) showed a picture of [Resident #1] being double briefed. RP mentioned that bed is soiled. Picture showed feces and urine . Treatment Nurse reported no redness, breakdown, peri area [groin area] was good. RP educated that [Resident #1] was a 'heavy wetter.' Nursing team will have in-services regarding no double briefing . Retraining was an intervention. SW asked RP regarding resident safety. RP stated that [Resident #1] does feel safe .Record review of Resident #2's face-sheet dated 04/01/26, revealed an [AGE] year-old female with initial admission date 08/15/25 and re-admission date 03/23/26.Record review of Resident #2's Health and Physical dated 03/18/26 revealed medical history of Acute Kidney Injury (when the kidney suddenly cannot filter the wastes from the blood), and Diabetes Mellitus.Record review of Resident #2's Discharge MDS dated [DATE] revealed no BIMS score.Record review of the facility's Grievances revealed a grievance dated 02/11/2026 regarding an allegation made by Resident #2's family member. The grievance noted Resident #2 alleged an unnamed nurse went into her room the night before to answer Resident #2's call light but allegedly stated no [NAME] (No Spanish), when spoken to by Resident #2, and left without providing assistance or sending another staff to assist.Record review of the facility's In-Service Training: Double Briefing of residents is never allowed, dated 03/09/26, with all staff signatures noted under Attendees. In-service training provided by DON and ADONs.In an interview on 03/31/26 at 9:27 AM with Resident #1's family member, he stated he was present on Saturday 03/07/26 in the morning when he smelled a strong odor of urine and feces from Resident #1. He stated he requested assistance from the nursing staff, and he waited outside while Resident #1 had her brief changed. He stated after some minutes, nursing staff left and the family member went back into Resident #1's room and it still smelled like urine and feces. He stated he requested the nurse on the floor to assist, and it was found that Resident #1 had two briefs on, one brief was soiled with urine and feces. He stated he was unable to recall the staff names but stated there was a meeting with the Social Worker, the Treatment Nurse, and the Administrator, regarding the allegation. He stated it was acknowledged Resident #1 was double briefed in the meeting by the nursing staff and stated it was done because Resident #1 was a heavy wetter. He stated the facility staff provided the solution to have CNA A does not provide Resident #1 care, which he agreed to.In an interview on 03/31/26 at 1:58 PM with CNA B, she stated residents having two briefs on at once was not an acceptable practice. She stated the potential risk to residents for double briefing included skin breakdown. CNA B stated double briefing was a form of Abuse and would be reported to the floor nurse right away if observed on the floor.In an interview on 03/31/26 at 2:35 PM with the Treatment Nurse, he stated leaving a resident unattended or leaving the resident and not meeting their needs was Neglect. He stated he recalled the incident with Resident #1 and he was notified of the family member's allegation that Monday 03/09/26 which the Treatment Nurse completed a skin assessment with no findings or changes of Resident #1's skin status. He stated double briefing was not an acceptable practice because it included the risk of infection or illness, including UTIs or skin breakdown. He stated Resident #1 was unable to communicate what happened, and Resident #1's family member was present and witnessed the incident and made the allegation. In an interview on 03/31/26 at 3:00 PM with CNA C, she stated nursing staff was responsible for changing the residents' briefs per policy, including CNAs. She stated having residents with two briefs on at once was negligence and was to be reported to the nurse on the floor, or the DON, immediately if observed. She stated the risk of residents using two briefs at once was an infection control issue which could cause the residents to become sick.In an interview on 03/31/26 at 4:02 PM with LVN D, she stated staff not answering the call light or not meeting residents' needs and turning off the call light anyway was a form of Abuse and Neglect. She stated that all allegations of abuse and neglect were to be reported to the DON and the Administrator, so an investigation could be conducted. She stated double briefing was not acceptable and was a form of neglect. She stated the risks to residents that had two briefs on at once included potential for skin infections or UTI's.Phone interview attempts were made on 04/01/26 at 2:20 PM, 3:34 PM, and 3:56 PM to CNA A, with no answer or call back to the State Investigator before exit. In an interview on 04/01/26 at 11:06 AM with RN E, he stated not changing residents' briefs was abuse. She stated placing two briefs on a resident at the same time was not acceptable and was a dignity issue. She stated double briefing placed residents at risk for skin impairment issues, and it was to be reported to the DON right away.In an interview on 04/01/26 at 02:05 PM with the DON, she stated she was out on personal leave during the allegation of Resident #2. She stated the facility staff were expected to report all allegations of Abuse and Neglect to the Administrator immediately. She stated that allegations made by Resident #1's and Resident #2's family members were allegations of Abuse or Neglect, and they warranted for an internal investigation. She stated there was no written documentation of investigations being conducted for either resident's allegations. She stated the purpose of investigating allegations of Abuse or Neglect was for the safety of the residents and to prevent harm to them. She stated herself as the DON, and the Administrator, were responsible for investigating allegations of abuse and neglect. She stated double briefing was not an acceptable practice and was a form of abuse and neglect. The DON stated the risk of double briefing was skin breakdown from excessive moisture and placed a dignity issue. She stated she was informed by the ADON of Resident #1's family member's allegation and knew CNA A was in-serviced for double briefing. She stated CNA A was not suspended for the allegation regarding Resident #1. The DON stated there was no suspension of any staff for Resident #2's grievance. She stated the Administrator was responsible for reporting all allegations of Abuse, Neglect, and Exploitation, to the State HHSC.In a phone interview on 04/01/26 at 2:30 PM with RN F, she stated she was familiar with Resident #2 but not able to recall any details about her shift on 02/11/26. She denied being aware or being reported concerns regarding Resident #2's allegation. She stated call lights were to be turned off when needs were met.In an interview on 04/01/26 at 2:43 PM with the Administrator, she stated double briefing was not acceptable and there was no rationale for the practice. She stated she recalled the meeting with Resident #1's family member and other staff present, regarding the double brief allegation. The Administrator stated that a skin assessment was completed by the Treatment Nurse on 03/09/26 and there were no changes or concerns identified in Resident #1's skin. She stated CNA A was in-serviced regarding the allegation but was not suspended. The Administrator stated there was an internal investigation conducted but did not have it documented to provide to this investigator. She stated that the ADONs, DON, and the Treatment Nurse monitor nursing staff every shift. She stated the risks of double briefing included for residents to experience skin breakdown, infection including UTIs. The Administrator stated Resident #2's grievance was investigated internally but did not have it documented to provide. She stated she spoke with assigned staff during Resident #2's family member allegations, but the staff denied the allegations. She stated no staff was suspended. The Administrator stated the purpose of investigating allegations were to find out accurate information that occurred and verify facts of what happened and the timeline. She stated suspension was done with the purpose of residents feeling safe in the nursing facility and validated with their concerns being addressed. She stated it was done for residents' safety. The Administrator stated she did not believe these allegations were forms of Abuse or Neglect and did not believe they needed to be reported to HHSC.In an interview on 04/01//26 at 3:31 PM with the ADON, she stated she was notified by nursing staff of Resident #1 being double briefed. She stated she worked as the floor nurse over the weekend, but she did not see Resident #1's brief in that incident. The ADON stated she interviewed CNA A, which CNA A admitted to double briefing Resident #1 and apologized. She stated that CNA A was not suspended, and the allegation was not investigated.Record review of the facility's policy Abuse/Neglect with revision date 03/29/2018, read in part: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . It continued to read: The Facility will provide and ensure the promotion and protection of resident rights. Under E. Reporting, 3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of provider Letter 19-17 dated 07/10/19. it also stated if the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.Record review of the Long-Term Care Regulation Provider Letter, provided by the Adminstrator, with revision date 01/22/26, read in part: 2.1 Incidents that Providers Must Report to HHSC: Abuse, Neglect . with the time frame being reporting to HHSC was noted as immediately but not later than 24 hours after the incident or allegation occurs. It also read: Definitions and Examples of ANE and other Reportable Incidents- Neglect: HHSC rules define neglect as, 'the failure to provide for oneself the goods or services, including medical services, that are necessary to avoid physical or emotional harm, pain, or the failure of a caregiver to provide such goods or services.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents (Resident #3) reviewed for incontinent care in that; -CNA B failed to change her gloves after they became contaminated during incontinent care while assisting Resident #3. The failure could place resident's risk for cross contamination and the spread of infection.The findings include:Record review of Resident #3's face-sheet dated 04/01/26 revealed a [AGE] year-old female with admission date 09/28/23.Record review of Resident #3's Quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating Resident #3 was cognitively intact.Record review of Resident #3's Health and Physical dated 10/09/25 revealed a medical history of Muscle wasting and atrophy (loss of muscle mass and strength).Record review of Resident #3's care plan with revision date 01/24/2025, revealed Resident #3 was dependent on ADLs and required toileting/brief change x1 person assist.In an observation on 03/31/26 at 1:40 PM with CNA B revealed she was providing perineal care by using a clean wipe each time cleaning the groin area for Resident #3, and disposing the dirty wipes into the trash can located next to Resident #3's bed. CNA B was observed instructing Resident #3 to assist with rolling to her right side so she could clean Resident #3's buttocks. CNA B was observed wiping buttocks with clean wipes and disposing dirty wipes and soiled brief into the trash can. CNA B was observed using the wipes to clean or wipe her gloved hands and proceeded to throw the wipe into trash can. With the same gloves, CNA B put on Resident #3's new brief and covered Resident #3 with her sheets and blanket. CNA B disposed her dirty gloves into the trash and lowered Resident #3's bed.In an interview on 03/31/26 at 02:10 PM with CNA B, she stated all nursing staff were responsible for performing hand hygiene while providing perineal care during brief changes. She stated it was protocol for staff to wash their hands after they disposed of the dirty brief and wipes, and after disposal of the dirty gloves. She stated hand hygiene was done before putting on new gloves and touching the clean supplies such as the new brief. She stated it was an infection control issue and placed residents at risk of illness. She stated she did not change her gloves after disposing the dirty wipes and the soiled brief. She stated she used a clean wipe to clean her gloves after disposing all the dirty wipes and brief. She stated it was not protocol but she did it because Resident #3 was not that dirty. She stated the Resident #3's clean areas were at risk for being contaminated with her dirty gloves when putting on her new brief.In an interview on 03/31/26 at 04:07 PM with LVN D, she stated nursing staff including the CNAs, were responsible for their perineal care provided to residents. She stated nursing staff was expected to perform hand hygiene after disposing all the dirty supplies and gloves. She stated not washing hands or changing gloves during perineal care placed residents at risk for contamination and illness. She stated nurses were responsible for monitoring CNAs and it was done as needed.In an interview on 04/01/26 at 11:09 AM with RN E, she stated nursing staff were responsible for providing proper perineal care including hand hygiene after disposing of the dirty gloves and before putting on new gloves. She stated it was an infection control issue and not washing hands or changing gloves left an opportunity for contamination and illness. RN E also stated residents would also be at risk for infections such as a UTI.In an interview on 04/01/26 at 2:25 PM with the DON, she stated nursing staff was responsible for performing perineal care per facility protocol, including hand hygiene and changing of gloves. The DON stated it was an infection control issue and not doing hand hygiene protocols included risk to residents of illness or being exposed to bacteria. She stated ADONs and herself as the DON, perform Skill Checkoffs, meaning skills were physically evaluated for protocol compliance. Record review of facility's Infection Control Plan: Overview, with no date, read in part: The facility will establish and maintain an infection control program designed to provide a safe sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. It continued to read, Intent- The intent of this policy is to assure that the facility develops, implements, and maintains an infection Prevention and Control Program in order to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. The program will: Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infection.Record review of the facility's policy Perineal Care Female, with no date, read in part: Procedural Guidelines- H. Gently wash perineal [referring to the genital and anal area] area . H.c. Continue to wash the rest of the perineal area . H.d. change gloves. H.g. Pat dry the perineal area . H.h. Change gloves. and read, J. Closing steps- J.a. If gloved, remove and discard gloves, wash hands.

Based on interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Residents #1) of one resident who was provided incontinence care by CNA A observed.CNA A failed to dispose Resident #1's soiled brief after a brief change request and double briefed Resident #1 on 03/07/2026.These failures could affect the residents with incontinence by placing them at risk for the development or worsening of UTIs. The findings include:Record review of Resident #1's face-sheet dated 03/30/26 revealed an [AGE] year-old female with initial admission date 12/12/24, and re-admission date 08/01/25.Record review of Resident #1's Health and Physical dated 02/16/26, revealed a medical history of: Alzheimer's disease (a form of Dementia, a loss of brain function), Diabetes Mellitus II (a chronic condition causing high levels of sugar in the blood), and a history of falls.Record review of Resident #1's Quarterly MDS dated [DATE], revealed BIMS was not completed as Resident #1 was noted to be rarely/never understood.Record review of Resident #1's progress note dated 03/11/25 by the Social Worker, revealed a Care Plan meeting was held with Resident #1's family member, IDT, SW, and the Treatment Nurse. It read: RP (Responsible Party) showed a picture of [Resident #1] being double briefed. RP mentioned that bed is soiled. Picture showed feces and urine . Treatment Nurse reported no redness, breakdown, peri area [groin area] was good. RP educated that [Resident #1] was a 'heavy wetter.' Nursing team will have in-services regarding no double briefing . Retraining was an intervention. SW asked RP regarding resident safety. RP stated that [Resident #1] does feel safe .Record review of the facility's In-Service Training: Double Briefing of residents is never allowed, dated 03/09/26, with all staff signatures noted under Attendees. In-service training provided by DON and ADONs.In an interview on 03/31/26 at 9:27 AM with Resident #1's family member, he stated he was present on Saturday 03/07/26 in the morning when he smelled a strong odor of urine and feces from Resident #1. He stated he requested assistance from the nursing staff, and he waited outside while Resident #1 had her brief changed. He stated after some minutes, nursing staff left and the family member went back into Resident #1's room and it still smelled like urine and feces. He stated he requested the nurse on the floor to assist, and it was founded Resident #1 had two briefs on, one brief was soiled with urine and feces. He stated he was unable to recall the staff names but stated there was a meeting with the Social Worker, the Treatment Nurse, and the Administrator, regarding the allegation. He stated it was acknowledged Resident #1 was double briefed in the meeting by the nursing staff and stated it was done because Resident #1 was a heavy wetter. He stated the facility staff provided the solution to have CNA A does not provide Resident #1 care, which he agreed to.In an interview on 03/31/26 at 1:58 PM with CNA B, she stated residents having two briefs on at once was not an acceptable practice. She stated the potential risk to residents for double briefing included skin breakdown. CNA B stated double briefing was a form of Abuse and would be reported to the floor nurse right away if observed on the floor.In an interview on 03/31/26 at 2:35 PM with the Treatment Nurse, he stated he recalled the incident with Resident #1 and he was notified of the family member's allegation that Monday 03/09/26 which the Treatment Nurse completed a skin assessment with no findings or changes of Resident #1's skin status. He stated double briefing was not an acceptable practice because it included the risk of infection or illness, including UTIs or skin breakdown. He stated Resident #1 was unable to communicate what happened, and Resident #1's family member was present and witnessed the incident and made the allegation. In an interview on 03/31/26 at 3:00 PM with CNA C, she stated nursing staff was responsible for changing the residents' briefs per policy, including CNAs. She stated having residents with two briefs on at once was negligence and was to be reported to the nurse on the floor, or the DON, immediately if observed. She stated the risk of residents using two briefs at once was an infection control issue which could cause the residents to become sick.In an interview on 03/31/26 at 4:02 PM with LVN D, she stated that all allegations of abuse and neglect were to be reported to the DON and the Administrator, so an investigation could be conducted. She stated double briefing was not acceptable and was a form of neglect. She stated the risks to residents that had two briefs on at once included potential for skin infections or UTI's.In an interview on 04/01/26 at 02:05 PM with the DON, she stated double briefing was not an acceptable practice in the facility. She stated having residents with two briefs on at once could be seen as a form of abuse, neglect, and was a dignity issue. She stated other potential risks of double briefing residents included skin breakdown and infection. She stated the CNAs were responsible for their brief changing skill, which was checked off when nursing staff was hired, and annually by Nursing Supervisors. In an interview on 04/01//26 at 3:31 PM with the ADON, she stated she was notified by nursing staff of Resident #1 being double briefed. She stated she worked as the floor nurse over the weekend, but she did not see Resident #1's brief in that incident. The ADON stated she interviewed CNA A, which CNA A admitted to double briefing Resident #1 and apologized. She stated that CNA A was not suspended, and the allegation was not investigated.Record review of the facility's policy Abuse/Neglect with revision date 03/29/2018, read in part: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . It continued to read: The Facility will provide and ensure the promotion and protection of resident rights.Record review of the facility's policy Perineal Care Female, with no date, read in part: Procedural Guidelines- H. Gently wash perineal [referring to the genital and anal area] area . H.c. Continue to wash the rest of the perineal area . H.d. change gloves. H.g. Pat dry the perineal area . H.h. Change gloves. and read, J. Closing steps- J.a. If gloved, remove and discard gloves, wash hands.

Based on interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement quality of life for two residents (Resident #1 and Resident #2) of six residents who were reviewed for dignity.The facility failed to report Resident #1's allegation of being double briefed on 03/09/26 to HHSC.The facility failed to report Resident #2's allegation of an unnamed nurse stating she did not speak Spanish to Resident #2 and left without meeting her needs or sending other staff to assist when made aware 02/11/26.This failure could place the residents at risk of poor self-esteem and decrease self-worth.Findings included:Record review of Resident #1's face-sheet dated 03/30/26 revealed an [AGE] year-old female with initial admission date 12/12/24, and re-admission date 08/01/25.Record review of Resident #1's Health and Physical dated 02/16/26, revealed a medical history of: Alzheimer's disease (a form of Dementia, a loss of brain function), Diabetes Mellitus II (a chronic condition causing high levels of sugar in the blood), and a history of falls.Record review of Resident #1's Quarterly MDS dated [DATE], revealed the BIMS was not completed as Resident #1 was noted to be rarely/never understood.Record review of Resident #1's progress note dated 03/11/25 by the Social Worker, revealed a Care Plan meeting was held with Resident #1's family member, IDT, SW, and the Treatment Nurse. It read: RP (Responsible Party) showed a picture of [Resident #1] being double briefed. RP mentioned that bed is soiled. Picture showed feces and urine . Treatment Nurse reported no redness, breakdown, peri area [groin area] was good. RP educated that [Resident #1] was a 'heavy wetter.' Nursing team will have in-services regarding no double briefing . Retraining was an intervention. SW asked RP regarding resident safety. RP stated that [Resident #1] does feel safe .Record review of Resident #2's face-sheet dated 04/01/26, revealed an [AGE] year-old female with initial admission date 08/15/25 and re-admission date 03/23/26.Record review of Resident #2's Health and Physical dated 03/18/26 revealed medical history of Acute Kidney Injury (when the kidney suddenly cannot filter the wastes from the blood), and Diabetes Mellitus.Record review of Resident #2's Discharge MDS dated [DATE] revealed no BIMS score.Record review of the facility's Grievances revealed a grievance dated 02/11/2026 regarding an allegation made by Resident #2's family member. The grievance noted Resident #2 alleged an unnamed nurse went into her room the night before to answer Resident #2's call light but allegedly stated no [NAME] (No Spanish), when spoken to by Resident #2, and left without providing assistance or sending another staff to assist.Record review of the facility's In-Service Training: Double Briefing of residents is never allowed, dated 03/09/26, with all staff signatures noted under Attendees. In-service training provided by DON and ADONs.In an interview on 03/31/26 at 9:27 AM with Resident #1's family member, he stated he was present on Saturday 03/07/26 in the morning when he smelled a strong odor of urine and feces from Resident #1. He stated he requested assistance from the nursing staff, and he waited outside while Resident #1 had her brief changed. He stated after some minutes, nursing staff left and the family member went back into Resident #1's room and it still smelled like urine and feces. He stated he requested the nurse on the floor to assist, and it was found that Resident #1 had two briefs on, one brief was soiled with urine and feces. He stated he was unable to recall the staff names but stated there was a meeting with the Social Worker, the Treatment Nurse, and the Administrator, regarding the allegation. He stated it was acknowledged Resident #1 was double briefed in the meeting by the nursing staff and stated it was done because Resident #1 was a heavy wetter. He stated the facility staff provided the solution to have CNA A does not provide Resident #1 care, which he agreed to.In an interview on 03/31/26 at 1:58 PM with CNA B, she stated residents having two briefs on at once was not an acceptable practice. She stated the potential risk to residents for double briefing included skin breakdown. CNA B stated double briefing was a form of Abuse and would be reported to the floor nurse right away if observed on the floor.In an interview on 03/31/26 at 2:35 PM with the Treatment Nurse, he stated leaving a resident unattended or leaving the resident and not meeting their needs was Neglect. He stated he recalled the incident with Resident #1 and he was notified of the family member's allegation that Monday 03/09/26 which the Treatment Nurse completed a skin assessment with no findings or changes of Resident #1's skin status. He stated double briefing was not an acceptable practice because it included the risk of infection or illness, including UTIs or skin breakdown. He stated Resident #1 was unable to communicate what happened, and Resident #1's family member was present and witnessed the incident and made the allegation. In an interview on 03/31/26 at 3:00 PM with CNA C, she stated nursing staff was responsible for changing the residents' briefs per policy, including CNAs. She stated having residents with two briefs on at once was negligence and was to be reported to the nurse on the floor, or the DON, immediately if observed. She stated the risk of residents using two briefs at once was an infection control issue which could cause the residents to become sick.In an interview on 03/31/26 at 4:02 PM with LVN D, she stated staff not answering the call light or not meeting residents' needs and turning off the call light anyway was a form of Abuse and Neglect. She stated that all allegations of abuse and neglect were to be reported to the DON and the Administrator, so an investigation could be conducted. She stated double briefing was not acceptable and was a form of neglect. She stated the risks to residents that had two briefs on at once included potential for skin infections or UTI's.Phone interview attempts were made on 04/01/26 at 2:20 PM, 3:34 PM, and 3:56 PM to CNA A, with no answer or call back to the State Investigator before exit. In an interview on 04/01/26 at 11:06 AM with RN E, he stated not changing residents' briefs was abuse. She stated placing two briefs on a resident at the same time was not acceptable and was a dignity issue. She stated double briefing placed residents at risk for skin impairment issues, and it was to be reported to the DON right away.In an interview on 04/01/26 at 02:05 PM with the DON, she stated she was out on personal leave during the allegation of Resident #2. She stated the facility staff were expected to report all allegations of Abuse and Neglect to the Administrator immediately. She stated that allegations made by Resident #1's and Resident #2's family members were allegations of Abuse or Neglect, and they warranted for an internal investigation. She stated there was no written documentation of investigations being conducted for either resident's allegations. She stated the purpose of investigating allegations of Abuse or Neglect was for the safety of the residents and to prevent harm to them. She stated herself as the DON, and the Administrator, were responsible for investigating allegations of abuse and neglect. She stated double briefing was not an acceptable practice and was a form of abuse and neglect. The DON stated the risk of double briefing was skin breakdown from excessive moisture and placed a dignity issue. She stated she was informed by the ADON of Resident #1's family member's allegation and knew CNA A was in-serviced for double briefing. She stated CNA A was not suspended for the allegation regarding Resident #1. The DON stated there was no suspension of any staff for Resident #2's grievance. She stated the Administrator was responsible for reporting all allegations of Abuse, Neglect, and Exploitation, to the State HHSC.In a phone interview on 04/01/26 at 2:30 PM with RN F, she stated she was familiar with Resident #2 but not able to recall any details about her shift on 02/11/26. She denied being aware or being reported concerns regarding Resident #2's allegation. She stated call lights were to be turned off when needs were met.In an interview on 04/01/26 at 2:43 PM with the Administrator, she stated double briefing was not acceptable and there was no rationale for the practice. She stated she recalled the meeting with Resident #1's family member and other staff present, regarding the double brief allegation. The Administrator stated that a skin assessment was completed by the Treatment Nurse on 03/09/26 and there were no changes or concerns identified in Resident #1's skin. She stated CNA A was in-serviced regarding the allegation but was not suspended. The Administrator stated there was an internal investigation conducted but did not have it documented to provide to this investigator. She stated that the ADONs, DON, and the Treatment Nurse monitor nursing staff every shift. She stated the risks of double briefing included for residents to experience skin breakdown, infection including UTIs. The Administrator stated Resident #2's grievance was investigated internally but did not have it documented to provide. She stated she spoke with assigned staff during Resident #2's family member allegations, but the staff denied the allegations. She stated no staff was suspended. The Administrator stated the purpose of investigating allegations were to find out accurate information that occurred and verify facts of what happened and the timeline. She stated suspension was done with the purpose of residents feeling safe in the nursing facility and validated with their concerns being addressed. She stated it was done for residents' safety. The Administrator stated she did not believe these allegations were forms of Abuse or Neglect and did not believe they needed to be reported to HHSC.In an interview on 04/01//26 at 3:31 PM with the ADON, she stated she was notified by nursing staff of Resident #1 being double briefed. She stated she worked as the floor nurse over the weekend, but she did not see Resident #1's brief in that incident. The ADON stated she interviewed CNA A, which CNA A admitted to double briefing Resident #1 and apologized. She stated that CNA A was not suspended, and the allegation was not investigated.Record review of the facility's policy Abuse/Neglect with revision date 03/29/2018, read in part: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . It continued to read: The Facility will provide and ensure the promotion and protection of resident rights. Under E. Reporting, 3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of provider Letter 19-17 dated 07/10/19. it also stated if the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.Record review of the Long-Term Care Regulation Provider Letter, provided by the Adminstrator, with revision date 01/22/26, read in part: 2.1 Incidents that Providers Must Report to HHSC: Abuse, Neglect . with the time frame being reporting to HHSC was noted as immediately but not later than 24 hours after the incident or allegation occurs. It also read: Definitions and Examples of ANE and other Reportable Incidents- Neglect: HHSC rules define neglect as, 'the failure to provide for oneself the goods or services, including medical services, that are necessary to avoid physical or emotional harm, pain, or the failure of a caregiver to provide such goods or services.

Based on observation, interview, and record review, that facility failed to extend to the resident representative ' s the right to make decisions on behalf of the resident for 1 of 6 (Resident #1) residents reviewed for resident rights in that: The facility failed to establish who Resident #1 wanted as a responsible party during his stay at the Nursing Facility. This failure could place residents at risk of not having their preferred responsible party represent them in care decisions. Findings include: Record review of Resident #1's face sheet dated 02/26/2026 revealed a [AGE] year-old male who was admitted on [DATE] and listed family member #2 as the responsible party. Record review of Resident #1's history and physical note dated 02/05/2026 revealed a diagnosis of terminal diagnosis of senile degeneration of the brain (final stage of severe age-related brain disease). The note revealed that Resident #1 was alert and oriented to person, place and situation but demonstrated significant forgetfulness and impaired insight.Record review of Resident # 1's entry MDS dated [DATE] revealed no BIMS score.Record review of Resident #1's BIMS assessment dated [DATE] revealed a BIMS score of 08 indicating moderate cognitive impairment.Record review of Resident #1's orders revealed an order for DNR/Hospice care initiated on 02/06/2026.Record review of Resident #1's hospice paperwork dated 02/06/2026 revealed the resident was placed under hospice care on 02/06/26, and was signed by Family Member #2.Record review of Resident #1's PASRR Level Screening dated 02/04/2026 revealed a next of kin listed a family member #3.In an interview on 02/24/2026 at 10:21am with, Resident #1's Family Member #3 revealed that Resident #1 was placed on hospice by family member #2 prior to transferring to long-term care facility from a local hospital. She stated that she was notified after the fact. She stated that at the current facility, Resident #1 was stating to the facility that he did not want Family Member #2 to be his responsible party because she did not treat him well. She stated that Resident #1 did not have the power of attorney. She stated that the current facility did not consult with the family members or the resident concerning who he wanted as a representative. She stated that the facility just kept the same responsible party as the hospital because Resident #1 lived with Family Member #2 prior to entering the long-term care facility. She stated that she did not want Resident #1 under hospice because she believed that he did not need it, she stated that Family Member #2 had him placed under hospice because at the time they were told that he was dying, but he got better but Family Member #2 still kept him under hospice services. She stated that she voiced to the Nursing Facility that she felt that Resident #1 did not need to be under hospice services during a care plan meeting held on 02/12/2026, however she was told that Resident #1's next of kin was Family Member #2 and that he had come with her designated as next of kin when he was admitted to the Nursing Facility.In an interview on 02/24/2026 at 2:21 pm with the Administrator revealed that Resident #1 was admitted with hospice orders. She stated that the hospice paperwork was signed by the current representative who was Family Member #2. She stated that Resident #1 had the representative appointed when he came into facility. She stated that she was not aware of PASSR paperwork listing Family Member #3 as next of kin. She stated that she was aware that the resident was voicing not wanting to be in hospice when he arrived to the facility. She stated that the Social worker had requested for a BIMS assessment to be done on the resident to assess cognition, but that it had not been done because resident was on hospice services. She stated the representatives were determined by the family; it would be a family conversation on who the representative/ power of attorney would be. She stated that the facility relied on the information on the hospice paperwork and the facility did not look further into who the next of kin was or asked the resident who he wanted as a representative. She stated that when the facility spoke to the hospice agency, they had mentioned that the representative was Family Member #2 and that Family Member #2 was also stating that she was the representative. She stated that the facility usually followed whoever was listed as the next of kin to serve as the representative. She stated that the risk of not verifying who the correct next of kin or representative was would be miscommunication in resident care and a possible delay in care as well. In an interview on 02/24/2026 at 3:00 pm with the Social Worker reveled that she was not aware that Resident #1 had a next of kin. She stated that once a resident was admitted to the facility, she looked at the system to inform herself about who the guardian/power of attorney/representative was. She stated that in this case, in the system, F family Mmember #2 was listed as the responsible party. She stated that in her interactions with Resident #1, she noticed that he was alert and oriented to person, place and situation. She stated that she requested a BIMS assessment to be done to better gauge his cognition. She stated that the therapy department was the ones to perform the assessment and at the time, therapy stated that since Resident #1 was under hospice care, they could not perform the BIMS assessment, therefore, the resident did not have a BIMS assessment done. She stated that the resident was admitted with an open APS case involving family dynamics. She stated that she was aware of some family dynamic issues within the family, but that ultimately the case was closed. She stated that a risk of not ensuring the right responsible party or next of kin was assigned would be a miscommunication of resident's care. In an interview on 02/26/2026 at with Resident #1 revealed that he did not know how he ended up at the facility under hospice. He stated that Family Member #2 left him there because she did not want him back home. He stated that he did not want to be under hospice services and that he wanted Family Member #3 as his responsible party to be able to make decisions on his behalf. He stated that the Nursing Facility never asked him who he wanted as a responsible party when he arrived to the facility.Review of facility policy and procedure titled Resident Rights, undated, read in part the resident has the right to identify individuals or roles to be included in the planning process .

Based on observation, interview and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 3 (Resident #41, Resident #60, Resident #250) of 12 residents reviewed for call lights. The facility failed to ensure Resident #41, and Resident #60 had their call lights within reach. The facility failed to ensure Resident #250 had a call light in her room. These failures could place residents at risk for decreased quality of life, self-worth, and dignity. Findings included: Resident #41 Review of Resident #41's face sheet dated 02/13/2025 reflected a [AGE] year-old female admitted to the facility on 11/17/2023, with diagnoses of Other abnormalities of gait and mobility (walking patterns that deviate from normal), other lack of coordination, cognitive communication deficit (communication difficultly) and weakness. Review of Resident #41's quarterly MDS assessment dated [DATE] reflected brief interview for mental status score of 03/15 indicating severe cognitive impairment. Review of Resident #41's Comprehensive Care Plan revised 11/28/2024 reflected Resident #41 was a risk for falls, interventions included making sure the residents' call light was within reach and to encourage resident to use it for assistance as needed. Observation on 02/10/2025 at 10:15 am revealed Resident #41 was asleep in her bed and her call light was on the floor, on fall mat. Observation on 02/10/2025 at 1:15 PM revealed Resident #41 still asleep in bed with call light still on floor on fall mat. Resident #60 Record Review of Resident #60's face sheet dated 02/10/25 revealed resident is an [AGE] year-old female initially admitted to the facility 09/16/2022 and readmitted [DATE]. Resident #60 has diagnoses of Muscle Wasting and Atrophy (gradual shrinking or wasting away of muscle tissue), abnormalities of gait (a manner of walking or moving on foot) and mobility, and lack of coordination. Record Review of Resident #60's quarterly MDS dated [DATE] revealed BIMS score of 2 out of 15 indicating severe cognitive impairment. Record Review of Resident #60's Comprehensive Care Plan dated 2/13/25 revealed that Resident #60 is at risk for falls related to muscle weakness, poor safety awareness, psychotropic medication use. The interventions per the Care Plan include for staff to ensure Resident #60 has her call light within reach. Resident #250 Record Review of Resident #250's face sheet dated 02/13/25 revealed that resident is a [AGE] year-old female with initial admitted [DATE], and re-admitted [DATE]. Record Review of Resident #250's quarterly MDS dated [DATE] revealed her BIMS score of 7 out of 15, indicating severe cognitive impairment. Record review of Resident #250's Comprehensive Care Plan dated 2/13/25 revealed resident is at risk for falls related to impaired mobility and interventions include for staff to ensure resident has a working and reachable call light. In an observation on 02/10/25 at 09:44 AM, Resident #60 was in bed and her call light was clipped on the wall light cord located behind resident's bed, and out of her reach. In an observation on 02/10/25 at 09:20 AM, Resident #250 was in bed and there was no call light in her room for her use. An interview On 02/12/2025 at 11:00 am with CNA G, revealed that she had been working at the facility for [AGE] years. She stated that the purpose of the call light was for the resident to use to ask for help. She stated that it Should always be within reach for the resident, meaning it was easily accessible for the resident to use if needed. For example, the resident should have had it on the bed next to them. She stated that everyone was responsible for making sure call light in within reach, especially CNA staff. She also stated that rounding every 2 hours to make sure call lights were within reach. She recalled that the facility did conduct Inservice on call lights regularly with the last one being approximately one month ago. She stated that If call light was not within reach, residents could fall or would not be able to call for assistance because they would not be able to call for help. She stated that Resident #41's and #60's call light was not considered to be within reach. An interview on 02/12/2025 at 11:13 am with CNA H revealed that she had been working at the facility for a year. She stated that call lights should be within reach so residents could call whenever they needed something. She stated that everyone as in facility staff, CNAs especially are responsible to make sure call lights were within reach. She states that she frequently did walk rounds to make sure that call lights were within reach. She stated that the last Inservice regarding call lights was held approximately 2 months ago. She stated that they were required to do a monthly training online. She stated that residents could fall when trying to reach for the call light, and it was not within reach. She stated Resident #41's and #60's call light was not considered to be within reach. An interview on 2/12/2025 at 11:30 am with LVN E revealed that she had been working at the facility for 2 years. She stated that the purpose of the call light was to notify staff that resident needed assistance. She stated that call lights should be within residents reach. She stated that all staff was responsible including nursing assistants, and anyone who goes into room was responsible to make sure call lights were within reach. She stated that residents needs may have not be met, if residents call light was within reach. She stated that unless resident was unable to stand then it was not a fall risk for resident if call light was not to be in their reach. She stated Resident #41 had a fall mat next to her bed, she was considered a fall risk and she agreed that call light was considered not to be within reach for her. She stated that Resident #60's call light is not considered within reach. An interview with the DON on 2/12/2025 at 12:32 pm revealed that staff was trained that all call lights should be within residents reach, meaning the call light should be next to resident on bed. She stated that department heads do champion rounds throughout their shift. She explained that they were assigned to different rooms throughout the different halls to check call lights, and maintenance issues daily. She stated that other than those rounds the DON, CNA's, and LVNs all had the responsibility to make sure call lights were within reach for the residents. She stated that there in an emergency, residents could not call for help. She stated that residents could fall trying to get up themselves, and there could also be a delay in care. She stated Resident #41's and #60's call light was not within reach. On 2/11/25 at 9:20 am, DON stated that the facility does not have a specific policy regarding call lights.

Based on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 2 (Resident #20 and Resident #87) of 12 residents observed for oxygen management. The facility failed to clean the oxygen concentrator air filter for Resident #20 while the oxygen was in use. The facility failed to post an Oxygen sign outside Resident # 87's room who received oxygen. The facility failed to ensure Resident # 87's oxygen tank was properly stored when not in use. This failure could place residents at risk of being exposed to combustion or flammability that may lead to physical harm. Findings included: Resident #20 Record review of Resident #20's face sheet dated 02/13/2025, revealed the [AGE] year-old resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Respiratory failure, unspecified with hypercapnia (body fails to remove carbon dioxide from the blood leading to elevated levels of carbon dioxide). Record review of Resident # 20's MDS dated [DATE] revealed a brief interview for mental status score of 0, indicating severe cognitive impairment. Record review of Resident #20's Physician's orders, dated 02/13/2025, revealed an order for continuous oxygen use at 2 liters per min via nasal canula every shift for shortness of breath/ dyspnea (trouble breathing) related to respiratory failure, unspecified with hypercapnia effective 05/28/2018. During an observation of Resident #20 in her room on 02/10/25 at 10:32 AM noted that the resident's oxygen concentrator was in operation and the air filter had dust collected on it along with a couple of strands of hair. During an interview with LVN F on 02/12/2025 at 1:00 PM, LVN F stated that the nurses on the unit are responsible for cleaning oxygen concentrator air filters. He stated that the CNA's will notice sometimes and will alert the nurses, the nurses will then clean it under running water. She stated that the machine itself would also start beeping and that would alert the nurse that filter may needed to be changed. During an interview with the DON on 02/12/25 at 2:00 PM, the DON stated that she did was not sure about how often oxygen concentrator filters needed to be changed because it depended on the manufacturer. Risks of having a dirty filter were, reduced efficiency of machine. During an interview with the Central supply personnel on 1/25/24 at 1:45 PM, she stated that oxygen concentrator filters were cleaned back in December 2024, filters were changed every 6 to 12 months or as needed per manufacture depending on concentrator being used. She stated Resident # 20's air filter did look dirty, and since it was a machine from hospice, she would have to contact the hospice provider to let them know that filter needed cleaning. She was not aware of risks to the resident of oxygen concentrator air filters being dirty. Record review of the Oxygen Administration Policy and procedure revised 07/21/2023 revealed in part change or clean concentrator filters according to manufacturer recommendations. Facility did not provide manufacuturer recomendations to surveyor prior to exit. Resident # 87 Record review of Resident #87's face sheet dated 12/13/25 revealed he was admitted on [DATE]. Record review of Resident #87's history and physical dated 02/04/25 revealed he was a [AGE] year-old male diagnosed with pulmonary embolism (a serious medical condition that occurs when a blood clot lodges in an artery in the lungs, blocking blood flow), acute respiratory failure with hypoxia(a condition in which the body or a region of the body is deprived of adequate oxygen supply), muscle wasting atrophy and cognitive communication deficit. Record review of Resident #87's MDS dated [DATE] revealed he had a BIMS score of 00 indicating severe cognitive impairment. It indicated the resident had respiratory failure with hypoxia (a deficiency in the amount of oxygen reaching the tissues of the body), and indicated he required oxygen therapy. Record review of Resident #87's care plan reviewed on 01/27/25 revealed Resident # 87 was receiving oxygen therapy ordered to be maintained on oxygen saturations (a measure of how much oxygen your blood is carrying as a percentage) of 90% or greater. In an observation on 02/10/25 at 11:23 AM in Resident # 87's room, an oxygen tank was observed next to the entrance door. A hissing sound came from the oxygen tank. There was no oxygen sign posted outside the room. Resident # 87 was in the hallway near the nurses' station at this time. LVN E stated she had just exchanged Resident # 87's oxygen tank with a full tank and had left the used one inside the room by mistake. She stated the tank was open, and the leftover oxygen in the tank was escaping the cylinder. LVN E closed the valve and took the cylinder outside the room and to storage. In an interview on 02/11/25 at 02:10 PM with RN B, she said every resident who received oxygen needed to have an oxygen sign posted outside of the door and the tank needed to be on a caddy. She stated posting oxygen signs needed to be posted so staff could be able to tell which residents are on oxygen to monitor them closely for their saturations and oxygen levels and for people to know there were tanks inside the residents' rooms. RN B said the tank was making hissing sounds because it was either broken or not closed correctly and this would also pose a potential fire hazard if oxygen was escaping the tank and there was a spark, the tank could potentially explode harming residents and staff from the facility. In an interview on 02/11/25 at 02:34 PM with CNA C she stated whenever a resident was receiving oxygen in their room there should be an oxygen sign posted outside of their room. She said the purpose of the oxygen sign was for all residents and visitors to take caution and be advised there was oxygen in use inside the room to avoid fire hazards and be careful not to drop a tank. CNA C said it was a non-smoking facility but there were fire hazards as long as there was oxygen in use. CNA C stated regarding the oxygen tank found in room [ROOM NUMBER] there could be a risk of fire or explosion because the tank was open and flowing with leftover oxygen inside the cylinder. In an interview on 02/11/25 at 03:10 PM with LVN D she said oxygen signs needed to be put up by the door where there was oxygen in use. She stated this was for safety purposes and to remind and let other staff know to check on residents in those rooms to make sure they had their head elevated, monitored their oxygen levels and checked for vitals. They also served as a warning for other residents and family members to be aware not to smoke in the facility or introduce anything that could create a spark. LVN D said by having an open oxygen tank left inside the room open, there could be a risk of explosions or fire hazards which could affect residents and staff members equally. LVN D said oxygen tanks needed to be stored in the storage room and not left in a resident's room when not in use. In an interview on 02/12/25 at 10:53 AM with the Administrator, he stated there had to be an oxygen sign posted outside of a room where a resident receives oxygen therapy. The Administrator said the purpose of the sign was to make everybody aware that there was oxygen in use inside of the room to avoid potential fire hazards. The Administrator said by not having an oxygen sign posted there was a potential for fire hazards or there could potentially be an exploding hazard from a tank who had oxygen escaping the tank. The Administrator stated the nursing department was responsible for making sure that oxygen signs were posted outside of the rooms and that oxygen tanks were closed and secured. In an interview on 02/12/25 at 11:10 AM with the DON regarding the open oxygen tank that was found Resident # 87's room, she said there was risk of a fire hazard or even explosion if there was a spark near the oxygen tank. DON said there was also a potential risk that somebody could take the tank out of the room and put other individuals at risk. DON said oxygen signs had to be outside the rooms of those residents who received oxygen therapy so that it would caution whoever goes near the room that there is oxygen in use. DON said the potential risks for not posting oxygen signs outside a resident room would be the same; there would be fire risks or staff would potentially not check for oxygen levels for the resident in that room. DON said RNs and LVNs receive training on how to properly store oxygen tanks and how to change them when the residents need a new tank full of oxygen. In an interview on 02/12/25 at 11:32 AM with LVN E she stated oxygen signs needed to be posted outside a resident's room who has oxygen inside the room. LVN E said the purpose of the sign was to alert anyone who comes near the room that there was oxygen in use. LVN E said there was a potential for a fire hazard of explosion if there was an oxygen tank left inside of a room. She said it was the nurse's responsibility to check oxygen signs were posted and also to make sure the tanks were closed and secure. LVN E said she had received training on how to change oxygen tanks and how to properly store them when not in use but did not recall when she received this training. Record Review of the facility's policy and procedures dated 3/21/2023 titled Oxygen Administration read in part: Place no smoking signs in area when oxygen is administered and stored. Store oxygen canister in an area free of flammable substances. Avoid the use of electrical appliances in the area of oxygen use as well.

Based on observation, interview, and record review the facility failed to have a safe, clean, comfortable and homelike environment for 1 (room # 104) of 12 rooms reviewed for environment in that: A brown and thick substance was on the floor of room [ROOM NUMBER]' entry way. This failure could have placed residents at risk of residing in an unsafe, unsanitary, and uncomfortable environment. Findings included: Record review of Resident #49's face sheet dated 02/18/25 revealed he was admitted on [DATE]. Record review of Resident #49's history and physical dated 12/27/24 revealed he was a [AGE] year-old male diagnosed with obsessive-compulsive disorder, muscle atrophy and dementia. Record review of Resident #49's MDS dated [DATE] revealed he had a BIMS score of 13 indicating he was cognitively intact. It indicated in the Care Area Assessment that Resident # 49 had triggered the care area for falls and that it was care planned. Record review of Resident #49's care plan reviewed reviewed by the facility on 02/12/25 revealed Resident # 49 was at risk for falls related to weakness. It revealed the facility needed to anticipate and meet the resident's needs by ensuring the resident was wearing appropriate footwear when ambulating or mobilizing to avoid falls. The care plan revealed Resident #49 required antidepressant medication related to obsessive-compulsive disorder and insomnia and for staff to document and monitor the resident for signs of irritability, feelings of shame and worthlessness. In an observation of room [ROOM NUMBER] and interview on 02/10/25 at 9:26 AM with Resident # 49 he reported a spill of a thick, brown substance, resembling maple syrup, at the entrance to his room. He denied knowing what it was and stated he had not handled food in that area. Resident # 49 said the staff who delivered his breakfast that morning might have spilled it , though he was not certain. Resident # 49 added that staff sometimes took a while to clean his room, and he disliked seeing it dirty as it made him uncomfortable. In an interview on 02/12/25 at 10:48 PM with the Administrator, he stated the process to ensure the facility was clean started with housekeeping and it was followed by rounds conducted by nurses and CNAs to ensure cleanliness. The Administrator stated it was expected all staff to either clean themselves or to report it to housekeeping if it was something they could not clean on their own. The Administrator said there was a risk of making a resident feel depressed living in an environment that looked dirty. He said that a spill like the one observed at Resident # 49 doorway could pose a risk of falls and potentially injure other residents and staff. He stated that another potential outcome could be that food residues such as the sugar in the corn syrup or coffee, could potentially attract pests such as ants and roaches. The Administrator stated he believed the facility staff failed to closely monitor the resident's room to make sure they were clean and sanitary. In an interview on 02/12/25 at 11:02 AM with the DON she explained the facility's protocol to ensure the resident's rooms are clean. DON said the department heads such as charge nurses, assigned rooms and through rounds, nurses and CNAs checked for cleanliness. She stated if through round check staff detected something needed to be cleaned and they did not have the time to do it, it was expected for them to notify housekeeping so they could go in and clean the residents' rooms. The DON stated the potential for resident discomfort in dirty environments, as well as the risk of slips, falls, and pest attraction because of not cleaning spills like the one observed at Resident # 49 doorway. Record review of the facility's policy, not dated, titled Fundamentals of Infection Control Precautions, read in part: The room and beside equipment of residents on standard precautions is cleaned and disinfected with an approved cleaning agent.

Based on interview and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental and psychological well-being, in accordance with the comprehensive assessment and plan of care, for 1 (Resident #1) of 5 residents with falls who were reviewed for quality of care. Resident #1 fell before 7 pm on the evening of 8/7/16 and had an x-ray done due to pain to her right hip. X-ray results were faxed to the facility on [DATE] at 10:28 p.m. showing that the resident had an intertrochanteric fracture. Facility staff did not follow up on the x-ray or search for the results until 8/8/16 at 5:37 a.m. when they faxed the results to the physician ' s office. Resident #1 experienced extreme pain overnight and until 10:44 a.m. when she was transferred to the hospital for treatment. This deficient practice resulted in an immediate jeopardy identified on 8/25/16. While the immediate jeopardy was removed on 8/26/16, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. This failure to manage pain could place 105 residents residing in the facility at risk of not receiving necessary care and services which could lead to experiencing severe unrelieved pain and a decline in their health status. The findings included: Review of undated face sheet documented Resident #1 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicates Resident #1 was cognitively intact. Review of Care Plan dated as Reviewed/Revised 8/23/16 for Resident #1 did not address pain. Review of Provider Investigation Report dated 8/15/16 for an unwitnessed fall on 8/7/16 documented Resident #1 was noted face down on the floor, the charge nurse and Certified Nursing Assistant (CNA) asked the resident to move and she was able to provide with range of motion with moderate discomfort voiced. Resident #1 was assisted to sitting and standing position and transferred back to bed with moderate to extensive assistance. As the evening progressed Resident #1 complained of pain to right knee and right side. As the pain increased resident was given Tylenol. In an interview on 8/25/16 at 2:04 PM with Interpreter ID# 4, Resident #1 said she remembered the fall. She said she fell really hard and she was in a lot of pain immediately. The pain did not go away and it was a 10 out of 10 on the pain scale of 0 - 10 and she told staff. Resident #1 said it took all night to get her to the hospital and she was in pain (10 out of 10) during the entire time from the time she fell until she went to the hospital. In an interview on 8/23/16 at 3:05 PM CNA D said she was working on Sunday 8/7/16 the evening (2-10pm) shift. CNA D said Resident #1 had family visit her and after the visit her family walked with her to her room and then they left. CNA D said Resident #1 ambulated with a walker on her own and was very steady. CNA D said she walked into the room with linen for Resident #1 ' s roommate ' s bed when she saw Resident #1 face down on the floor. CNA D did not know what time it was when she walked into the room. CNA D said she instructed Resident #1 not to move and she went to get the nurse. Licensed Vocational Nurse (LVN) A came back to the room with her and assessed Resident #1 and they got her up and put her in bed. CNA D said Resident #1 was complaining of a lot of pain and LVN A gave her pain medication (Tylenol). CNA D said Resident #1 was talking confused like she was at home with her children and she never did that before the fall. She stated Resident #1 was very alert and oriented. CNA D said she reported these changes to LVN A and he continued sitting at the rotunda and said it was probably because of her medicine. In an interview on 8/25/16 at 9:26 AM LVN A said he was sitting at the desk doing paperwork on 8/7/16 when CNA D came and told him Resident #1 was on the floor face down. LVN A said he went to the room, doesn ' t remember the exact time, and Resident #1 was face down on the floor, ROM (range of motion) was fine and he got her up to her bed. LVN A said in a few minutes CNA D came and reported Resident #1 was complaining of extreme pain to her hip. LVN A said Resident #1 had an order for [REDACTED]. The X-Ray tech came and he assisted him. LVN A said the CNA did report the confusion to him, but he thought it was probably due to her sleeping pill. LVN A said he never thought about the confusion could be from the fall or injury or pain. (Tylenol Uses: temporarily relieves minor aches and pains due to headache, the common cold, muscular aches, minor pain of arthritis. www.tylenol.com <http://www.tylenol.com> ) accessed 09/08/2016 Record review of Medication Administration Record [REDACTED] Tylenol 325mg 2 tabs was administered at 7:05 PM on 8/7/16 - results recorded as effective [MEDICATION NAME] 50mg 1 tab was administered at 4:11 AM on 8/8/16 - results recorded as somewhat effective ([MEDICATION NAME] is used to relieve moderate to moderately severe pain, including pain after surgery. http://www.mayoclinic.org/drugs-supplements/[MEDICATION NAME]-oral-route/description/drg- 050) accessed on 09/08/2016 In an interview on 8/25/16 at 3:34 PM CNA E said she worked 10:00 PM 8/7/16 to 6:00 AM on 8/8/16 and when she reported to work she was told Resident #1 fell earlier that evening. CNA E said she thought Resident #1 was in a lot of pain all night because of her sudden change in orientation and awareness. CNA E said Resident #1 was talking to family who were not there all night but she appeared asleep. CNA E said she reported it to LVN B and he told her it was due to medication. CNA E said she checked on Resident #1 frequently because she knew something was wrong and was very worried about her because Resident #1 had never behaved like that before. CNA E said Resident #1 was dry all night so she did not change her brief until 4:00 AM and she could not turn on her side due to pain. CNA E asked LVN B for help and they took the brief off and slid a pad under Resident #1. In an interview on 8/25/16 at 9:45 AM LVN B said as far as he knew Resident #1 was asleep all night, he thought the confusion CNA E had reported was due to [MEDICATION NAME] (medication used for sleep). LVN B said Resident #1 received [MEDICATION NAME] every night and had never gotten confused after taking it. LVN B also said he never considered the new onset of confusion could be related to pain or her fall. LVN B said Resident #1 was asleep until CNA E went to change her and Resident #1 had extreme pain, she was crying and screaming out in pain when she was moved. LVN B said he gave Resident #1 a PRN [MEDICATION NAME] at 4:11 AM and it helped. LVN B said it was time for shift change and he reported to the on-coming nurse. LVN B said he did not check the FAX during the night for the STAT X-Ray results, he thought if anything was abnormal the X-Ray company would call him. LVN B said he checked the FAX on 8/8/16 in the morning and found the STAT results which showed a fracture, he faxed the results to the physician ' s FAX and called the physician and the nurse practitioner on their personal cell phones and left messages. LVN B said he did not call the physician's answering service, it was shift change so he reported it to the oncoming nurse. Review of the STAT X-Ray report date of service 8/7/16 documented the report was faxed to the facility on [DATE] at 10:28 PM. The results of the X-Ray were: ALERT - Acute right intertrochanteric fracture. In an interview on 8/25/16 at 1:30 PM the X-Ray company representative said reports are faxed to the nursing facility but not called. He said about 1 ½ years ago they stopped calling results and did a lengthy training program for facility staff that they had to keep their fax turned on, full of paper and ink and to check it frequently. Review of the facility Fax Journal Report documented the STAT X-Ray report was faxed to the physician fax number on 8/8/16 at 5:37 AM. In an interview on 8/23/16 at 2:29 PM LVN C said she came in to work on Monday morning 8/8/16 and the night nurse reported to her Resident #1 had a fall on 8/7/16 and had a lot of pain during the night. LVN C said she assessed Resident #1 and resident reported pain was 10 out of 10 on the numeric pain scale. LVN C said she offered Tylenol but the resident refused. LVN C said at 8:58 AM on 8/8/16 she spoke to the nurse practitioner and he said to send Resident #1 to the emergency room . LVN C said usually Resident #1 ambulates with a walker without difficulty. Review of nurses' notes dated 8/8/16 revealed assessed .X-ray results sent to NP at 7:37 a.m. pending call back .8:58 new orders received from NP Okay to transfer to hosp (hospital) for further eval (evaluation) dx (diagnosis): right intertrochanteric fracture .9:01 a.m. RP (responsible party), DON and ADON made aware .9:09 a.m. called (ambulance service) for pick up .10:44 a.m. picked up. There was no documentation that the facility staff informed the NP of the resident's rating of pain at 10 out of 10. In an interview on 8/25/16 at 12:02 PM the son of Resident #1 said the nurse had called and left a message on his cell phone but he didn ' t know until the next morning when he woke up. Resident #1 ' s son said he got to the facility on [DATE] at 8:30 AM and his mother was in a lot of pain and was confused. He said Resident #1 was very, very strong and could take a lot more pain than most people so for her to be still in pain he knew the pain was horrible. He said the facility took too long to get his mother to the hospital after her fall. Review of policy and procedure Assessing Falls and Their Causes dated 2010 documented in part: When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone. Nursing staff will observe for delayed complications of a fall for approximately forty-eight hours. Review of policy and procedure Pain Management dated 2013 documented in part: The staff will discuss significant changes in levels of comfort with the Attending Physician who will consider adjusting interventions accordingly. Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after [MEDICATION NAME] relief is obtained. The assessment shall consist of at least the following components: a. Whether pain has improved or worsened since the last assessment; b. The general condition of the resident; c. Verbal and non-verbal signs of pain; d. Level of consciousness; and e. Evidence or reports of adverse consequences related to medications. In an interview on 8/23/16 at 4:25 PM the Director of Nursing (DON) said nurses should call a doctor and continue to call until they reach them, not just fax a report. The DON said she finds out about falls and other incidents when she comes to work, she does not have a system to be notified right away. The DON said when she comes to work and there has been a fall or incident she has her ADONs, who are LVNs, review the incident. In an interview on 8/25/16 at 3:31 PM the Assistant Director of Nursing (ADON) said she reviewed the documentation of Resident #1 ' s fall and follow-up. ADON said she saw that the nurses should have assessed the pain better and more frequently and called about pain control as well as calling the physician not just leaving a message on the cell phone. An immediate jeopardy was identified on 8/25/16 and the Nursing Facility Administrator (NFA) was informed at 2:40 PM. In an interview on 8/25/16 at 3:35 PM the DON said looking back at the incident now she recognizes the lack of follow through for notification of physician with x-ray results. The DON said she also recognized pain was not addressed appropriately. The DON said definitely sudden [MEDICAL CONDITION] was a sign and symptom of pain. ([MEDICAL CONDITION] is an acute, transient, usually reversible, fluctuating disturbance in attention, cognition, and consciousness level. Caused by stress of any kind. http://www.merckmanuals.com/professional/neurologic-disorders/[MEDICAL CONDITION]-and-dementia/[MEDICAL CONDITION]) accessed on 09/08/2016 On 8/26/16 the facility submitted their 3rd corrective action plan of removal: Resident #1 fell on [DATE] at 6:39 p.m. Dr. ordered x-ray on 8/7/16 at 7:27 p.m. X-ray results received on 8/7/16 at 10:28 p.m. via fax Doctor notified by fax on 8/7/16 at 5:45 a.m. Nurse Practitioner was notified of findings of x-ray on 8/8/16 at 7:37 a.m. via text Facility nurse phoned and spoke with Nurse Practitioner, orders received to transfer to hospital on [DATE] at 8:58 a.m. Other residents at risk for level of pain not being addressed and timely notification of Physician, with results of x-ray/lab services have been identified as all residents. 100% of residents were assessed for pain on 8/26/16 beginning at 8:30 a.m., completed at 12:30 p.m. This was completed by 4 licensed nurses, documented on a pain observation report. Pain medication will be given if indicated as ordered by MD. Post incidents/accidents: Residents will be assessed for pain and medicated according to MD orders. From this point forward: New orders will be obtained for higher level of breakthrough pain if needed. MD will be notified immediately upon receiving abnormal lab/x-ray results. If positive x-ray results received, MD will be notified and resident will be sent to emergency room for medical evaluation. All Nursing staff was notified of requirement to attend in-service on 8/26/16 at 4:30 p.m. - 6:30 p.m. The above procedure was implemented thereafter. The 3 nursing employees not in attendance will be in-serviced by ADONs (Assistant Director of Nursing) on above before coming shift. Documentation of in servicing was verified by Director of Nursing (DON)/Administrator, checking signature page to nursing employee list. All nurses will be in-serviced on 8/26/16 at 11:30 a.m. - 12:30 p.m., specifically covering immediate notification of Administrator and DON of falls/incidents. The Director of Nursing and Administrator will be notified immediately of falls via phone call and text. Thereafter, DON will monitor daily x-ray/lab results for abnormal findings, pain level management, notification of MD with abnormal findings and transfers to ER as stated above. Administrator will conduct 25% random sample daily of all incidents to ensure monitoring of x-ray/lab results, notification of MD and implementation of pain management services and appropriate interventions are effective. Interviews on 8/26/16 at 3:46 pm with 5 LVNs confirmed they were in-serviced and were aware of the policy and procedures put into place: 1. pain management: assess, offer options, follow-up and notify MD 2. fall follow-up: call until physician responds, obtain x-ray report ASAP, notify physician, notify DON and NFA After the surveyor verified the plan of removal was implemented, the administrator was informed the immediate jeopardy was removed effective 8/26/16 at 4:05 PM. The facility remained out of compliance at a scope and severity at a pattern of actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. Review of the census provided on 8/23/16 by the NFA documented 105 residents.