Every finding on record at The Atrium Rehabilitation Center

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected his sexual behaviors and included a care plan regarding how to address the behaviors. This failure could place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings included:Record review of Resident #1's face sheet, dated 08/25/2026, revealed Resident #1 was a [AGE] year-old male, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia (a sudden life-threatening condition where the lungs cannot transfer enough oxygen into the blood stream), major depressive disorder (a serious mental health condition that causes a lasting feeling of sadness, emptiness, and a loss of interest in normal activities), and cerebral palsy (a group of permanent movement disorders that affect muscle control, balance, and posture). Record review of Resident #1's annual MDS assessment, dated 07/02/2026, revealed Resident #1's BIMS score was 8 out of 15 which indicated he had moderate cognitive impairment, did not have any physical or verbal behaviors symptoms directed toward others, such as abusing others sexually, and required Substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) to chair to bed transfer and Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) to toilet transfer. Record review of Resident #1's behavioral incident notes, dated 07/19/2026, revealed the resident masturbated in front of roommate. The facility notified the resident's daughter and psychiatric nurse practitioner for evaluation and made nursing staff monitor the resident closely. Further record review of the resident's behavioral incident notes, dated 07/20/2026, revealed the resident was observed by staff engaging in inappropriate physical contact toward another resident, and the charge nurse, DON, Administrator, social services, medical doctor, and psychiatric nurse practitioner were immediately notified, urine analysis was conducted, relocated the resident to private room located closely to the nursing station for closer observation, one to one supervision, and nursing staff were instructed to remove nebulizer machine because the resident used the machine's vibration when he masturbated. Further record review of the resident's behavioral incident notes, dated 08/03/2026, revealed the resident tried to touch another resident, and the facility staff immediately redirected the resident. The facility psychiatric doctor reviewed the resident's medications and increased the resident's Seroquel for inappropriate sexual behaviors from 50 milligram to 100 milligram. Since 08/03/2026, there were no more the resident's inappropriate behaviors reported. Record review of Resident #1's comprehensive care plan revealed the resident had the care plan regarding only using psychiatric medications for the resident's depression. Further record review of the care plan revealed there were no care plans regarding how to take care of Resident #1's sexually inappropriate behaviors. Interview on 08/25/2026 at 2:53 p.m. with the MDS nurse LVN-A he said he had responsibility to develop or update the care plans, and he knew that Resident #1 had sexually inappropriate behaviors, and the facility tried to implement new interventions to take care of the behaviors, such as conducting urine analysis, referring the resident to psychiatric doctor, changing the resident's psychiatric medications, and removing nebulizer after finishing the breathing treatment. Further interview with the MDS nurse LVN-A he said the facility did not put the new interventions that the facility already tried on the resident's comprehensive care plan because he was just recently hired as a part-time MDS nurse on end of July 2026, and he was in the middle of updating other residents' care plans. Interview on 08/25/2026 at 3:28 p.m. with the DON said Resident #1 had sexually inappropriate behaviors since 07/19/2026. Before 07/19/2026, the resident did not have any behavioral issues. The facility made new interventions to take care of Resident #1's sexually inappropriate behaviors, such as conducting urine analysis, referring the resident to psychiatric doctor, changing the resident's psychiatric medications, and removing nebulizer after finishing the breathing treatment. However, the facility did not have full time MDS nurses in July so they missed developing Resident #1's comprehensive care plan regarding his sexually inappropriate behaviors. Further interview with the DON stated the facility should have developed the interventions that the facility already implemented in Resident #1's care plan, and not developing a care plan for sexually inappropriate behaviors might cause inappropriate care, but the facility was providing correct care to Resident #1 regarding his sexually inappropriate behaviors as evidence that the resident was getting better after changing his psychiatric medications and monitoring the resident closely. Record review of the facility policy, titled Care Plans, Comprehensive, dated 12/2025, revealed . 8. The comprehensive, person-centered care plan will: . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.I. identify the professional services that are responsible for each element of care. o. reflect currently recognized standards of practice for problem areas and conditions.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, for 1 of 1 kitchen reviewed for food safety. The facility failed to label foods for safety, which were opened and available for use:X2 5lb. containers of cottage cheese without a date when the product was received, opened, and a date when the food should be thrown out.X2 5lb. containers of sour cream without a date when the product was received, opened, and a date when the food should be thrown out.The facility had personal items on kitchen counters where food was prepared:A personal electronic vape (battery-operated device that heats a liquid to create an aerosol, which is then inhaled into the lungs. Used as an alternative to smoking).A personal drink tumbler.X2 personal cell phones and cell phone charger and wires. These failures could place residents at risk for food borne illness.The findings included: During an observation and interview on 7/7/2026 at 11:00 AM, revealed the facility's refrigerator stored X2 5lb. containers of cottage cheese without a date when the product was received, opened, and a date when the food should be thrown out and X2 5lb. containers of sour cream without a date when the product was received, opened, and a date when the food should be thrown out. The FSM stated the food should have been labeled with the date the food was received, when the food was opened. The FSM stated the dates indicated when the food should be discarded, food which has been opened should be discarded after 7 days. The FSM stated the unlabeled foods which were available for meal service could potentially contribute to food borne illnesses. During an observation and interview on 7/7/2026 at 11:10 AM , the facility's kitchen food preparation counters had personal items which were in use. Observations revealed the following items:X2 personal cell phones.One was used to play musicOne was being charged by a wire and charger plugged into the electrical outlet.A personal electronic vapeA personal drink tumbler.The Food Service Manager stated the expectation was for those items not to be stored in the kitchen. The FSM stated the items belonged to the dietary staff which were currently in the kitchen preparing for the noon meal service. The FSM stated the personal items kept on the food preparation counters could potentially contribute to an unsanitary food preparation area. A record review of the facility's undated Food Safety policy revealed, We will insure all food purchased shall be wholesome and manufactured, processed, and prepared in compliance with all State, Federal, and local laws and regulations. Food shall be handled in a safe manner. Procedure: . 2. Food is to be wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated and stored properly. Perishable opened foods shall be used within 7 days or less, in compliance with the Texas Food Establishment rules. Non-perishable foods will be used as long as the quality of the product is maintained. 9. Do not keep potentially hazardous food in refrigerator past the labeled expiration date.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 8 Residents (Resident #26) reviewed for admission with a right foot fracture. Resident #26 was admitted to long term care without orders and care plans for a right foot fracture. These failures could place residents at risk for a decline in health status without physicians' orders and planned care.The findings included: A record review of Resident #26's admission record dated 7/9/2026 revealed an admission date of 4/30/2026 with a diagnosis of a right foot 3rd and 4th metatarsal fractures (Broken long bones in the mid-foot; metatarsals are a group of five long bones located in the midfoot, between your ankle and your toes.) A record review of Resident #26's admission MDS dated [DATE] revealed Resident #26 was a [AGE] year-old female admitted post hospitalization for a right foot fracture. Resident #26 was assessed with a BIMS score of 03 which indicated severe cognition impairment. A record review of Resident #26's hospital discharge records dated 4/30/2026 revealed Resident #26 was discharged with a right foot fracture and wore a camboot (a medical walking boot to immobilize the foot and ankle, protect healing tissues, and offload pressure.) A record review of Resident #26's base-line care plan dated 4/30/2026 revealed LVN C documented Resident #26 had a right foot fracture and was supported with a boot. A record review of Resident #26's physicians orders dated 5/9/2026 revealed no physicians care orders for Resident #26's right foot boot. A record review of Resident #26's care plan dated 7/9/2026 revealed there were no focuses, goals, nor interventions for Resident #26's right foot boot. During an observation on 7/7/2026 at 12:50 PM Resident #26 wore an orthopedic support boot on her right foot as she was seated in her wheelchair in the dining room. During an interview on 7/9/2026 at 10:08 AM LVN B stated she was the charge nurse for Resident #26. LVN B stated Resident #26 wore a boot on her right foot to immobilize her foot fracture. LVN B stated she reviewed Resident #26's medical record and recognized she did not have an order nor care plan for her boot. During an interview on 7/9/2026 at 3:10 PM the ADON stated Resident #26 had received a daily right foot orthopedic boot to support her right foot fracture. The ADON stated the expectation for Resident #26's foot boot was that it would be supported with a physicians' order and a care plan to detail the application and removal of the boot. The ADON stated Resident #26 did not have an order nor a cl for her right foot boot. The ADON stated there would be several points where the boot could have been addressed: upon leaderships' review of new admissions, the care plan meeting, and by charge nurse review of the residents' care plans. The ADON stated the potential negative outcome for Residents who received care without orders or care plans could be inconsistent care. A record review of the facility's Quality of Care Policy dated December 2025, revealed, Purpose:Our goal is to provide top-quality care. This policy keeps patients safe and ensures our staff meets all healthcare rules.2. Our Rules Patient Rights: We always treat clients with respect. We keep all health details private. Safety First: We watch for and report mistakes. We fix them fast to stop harm. Trained Staff: Only workers who have the right licenses help patients. Patient Feedback: We ask clients if they like our care. We use their answers to improve. 3. How We Check Our Work We look at patient records to check our own work. We hold staff meetings to talk about how to do better. If a rule is broken, we fix it immediately to protect the patient.

Based on observation, interview and record review, the facility failed to provide rooms that measured at least 80 square feet per resident in multiple resident bedrooms for 2 of 39 rooms (rooms [ROOM NUMBERS]) reviewed for physical environment. The facility failed to ensure residents were not admitted into double occupancy rooms [ROOM NUMBERS] measuring less than 80 square feet per resident while having unoccupied rooms available. This failure could lead to decreased quality of life of residents. Findings included: Record review of the facility document titled ROOMS LESS THAN REQUIRED SQUARE FEET undated/provided by the facility on 7/07/2026, reflected rooms 102, 104, 106, 108, 110, 202, 204, 206, 208, 210, 301, 302, 303, 304, 306, 307, 308, 309, 310, 311, 312, 313, 314, 315, 317, and 319 (26 total). Record review of the facility document titled Residents by Hall dated 7/07/2026 reflected rooms [ROOM NUMBERS] were both occupied by two residents. The other 24 rooms on the aforementioned list were occupied by only 1 resident per room. Additionally, rooms 101, 206, 207, 202, 305, 306, 307, 308, 310, 311, 312, 313, 314, 315, 317, and 319 (16 total rooms) were vacant or being temporarily repurposed for non-resident use. In an observation on 7/09/2026 at 11:21 AM, the Maint. Dir. measured the dimensions of room [ROOM NUMBER] with a tape measure as 15 feet 7.5 inches and 9 feet 3 inches, totaling 144.53 square feet, or 72.265 square feet per resident. In an observation on 7/09/2026 at 11:22 AM, the Maint. Dir. obtained the same dimensions for room [ROOM NUMBER], also equaling 72.265 square feet per resident. In an interview on 7/09/2026 at 9:00 AM, the ADM said she was aware the rooms on the list provided during entrance conference were licensed for two residents but had dimensions that equated to less than 80 square feet per resident. She said the reason rooms [ROOM NUMBERS] were occupied by two residents was the facility wanted to admit residents to the front halls of the facility first and keep the back of the facility closed until the census grew. She said the unoccupied rooms were able to be occupied, but it was convenient for the staff to keep the residents physically closer together. She said the facility had not applied for a room size waiver at the time the rooms [ROOM NUMBERS] became dually occupied. In an interview on 7/09/2026 at 12:00 PM, the VCSP said the facility did not have a policy related to room size requirements.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate administering of drugs, to meet the needs of each resident, for 1 of 4 residents (Resident #16) reviewed for medication administration. The facility failed to ensure Resident #16 received the ordered dosage of her antidepressant medication. This failure could lead to residents not receiving the intended therapeutic effects of prescribed medications. Findings included: Record review of Resident #16's Face Sheet dated 7/09/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included major depressive disorder, recurrent, unspecified [repeated episodes of low mood that impact daily functioning]. Record review of Resident #16's quarterly MDS dated [DATE] reflected a BIMS score of 13, which indicated intact cognition. Section N0415 of the MDS reflected Resident #16 was prescribed antidepressant medication. Record review of Resident #16's Order Summary Report dated 7/09/2026 reflected the following physician's order dated 6/25/2026:Sertraline HCl [a medication used to treat depression] Oral Tablet 100 MG (Sertraline HCl) Give 1.5 tablet by mouth in the morning for Depressiongive one and half tabs to = 150mg dose Qday Record review of Resident #16's progress notes reflected the following documentation dated 6/24/2026 authored by the DON:-Reviewed sertraline therapy; mood symptoms persist. Zoloft [brand name for sertraline] increased from 100 mg daily to 150 mg daily for improved symptom control. Record review of Resident #16's Medication Administration Record for July 2026 dated 7/09/2026 reflected the following scheduled medication: Sertraline HCl Oral Tablet 100mg (sertraline HCl)Give 1.5 tablet by mouth in the morning for Depression [sic] give [sic] one and half [sic] tabs tp = 150mg dose Q dayStart Date10/20/2026 19:00 In an observation on 7/09/2026 at 7:53 AM, MA A was observed preparing medications for administration to Resident #16. One of the medications was in a package with a label that identified the contents as sertraline HCl 100mg tab for Resident #16. The instructions on the label were Give 1 tablet by mouth in the morning for depression. MA A dispensed 1 tablet of sertraline 100mg tablets and administered the medication to Resident #16 with other scheduled medications. In an interview with MA A on 7/09/2026 immediately following the administration, approximately 8:00 AM, MA A was asked to clarify the dosage of sertraline administered to Resident #16 in comparison to the physician's order. MA A said she noticed when she was obtaining the medication that the order said one and a half tablets, but she was nervous and did not want to pause the medication administration to clarify the order prior to giving the medication. She said she was not informed by the nurse of a change to the sertraline dosage, and if she noticed a discrepancy in the medication order and medication label, she should notify the nurse. She said the potential harm of giving residents the incorrect dosage of medication was that the medication would not be effective. In an interview with the VPCS on 7/09/2026 at 10:15 AM, she said she was serving as DON due to unforeseen emergency. She said it is the responsibility of the nurse who accepts a changed medication order to label the medication package notifying staff the order has changed and to refer to the MAR prior to administration. She said staff should be checking all orders for all medications prior to administering medications, and the potential harm to residents was medication error. Record review of the facility policy titled Administering Oral Medications dated December 2025 reflected the following: . Steps in the procedure .3. Place the MAR within easy viewing distance .6. Check the label on the medication and confirm the medication name and dose with the MAR .8. Check the medication dose. Re-check to confirm the proper dose .

Based on interview and record review, the facility failed to ensure a resident's comprehensive care plan was reviewed and revised after each assessment for 1 of 8 residents (Resident #6) reviewed for care planning. The facility failed to ensure Resident #6's comprehensive care plan was revised to include planning and interventions for a fluid restriction ordered by the resident's physician. This failure could lead to residents not receiving intended care and decreased quality of life. Findings included: Record review of Resident #6's Face Sheet dated 7/09/2026 reflected an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included chronic combined systolic (congestive) and diastolic (congestive) heart failure [a condition in which parts of the heart are weakened or stiffened and cannot pump blood efficiently, leading to a back-up of fluid in the lungs, liver, and/or legs]. Record review of Resident #6's quarterly MDS dated [DATE] reflected a BIMS score of 15, which indicated intact cognition. Record review of Resident #6's Order Summary Report dated 7/09/2026 reflected the following physician's order dated 7/01/2026:1500cc Fluid Restriction/24 Hours- 300cc Total Nursing. 100cc (6-2), 100cc (2-10), 100cc (10-6). Total Dietary 1200cc. 480cc-breakfast, 360cc-Lunch, 360cc-Dinner Record review of Resident #6's Care Plan Report undated/ printed 7/09/2026 reflected the following care planning related to food/fluid intake:I am on a NAS Diet, THIN [sic] Liquids, REGULAR [sic] Texture. Date Initiated: 06/06/2026No additional care planning was in the care plan related to restriction of fluid intake. In an interview on 7/09/2026 at 1:37 PM, LVN B said Resident #6 was recently put on a fluid restriction by his doctor, and she said Resident #6 was typically non-compliant with the restriction. She said staff were all aware of the fluid restriction because of discussion and the physician's order. She was unsure if the fluid restriction was in Resident #6's care plan. In an interview on 7/09/2026 at 2:15 PM, the ADON said he is involved in updating care plans. He said Resident #6's newly ordered fluid restriction should have been added to his care plan, as well as his non-compliance with the order. He said care plans are revised by himself and the DON after any changes are noted to the residents' care. He said the potential risk of not including the fluid restriction in the care plan was staff not being aware of the fluid restriction. Record review of the facility policy titled Comprehensive Assessments and the Care Delivery Process dated December 2025 reflected the following: .Monitoring results and adjusting interventions includes:a. Periodically reviewing progress and adjusting treatments.1) Continue to define or refine the objectives of specific treatments as well as overall care and services .

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for medical records accuracy, in that: The facility failed to ensure Resident #1's medical record was free of medication administration time entry errors on 3/12/2026, 3/13/2026, 3/16/2026, 3/17/2026 and 3/31/2026 as documented on the MAR by LVNs A, C, D, and F. This failure could place residents at risk for an inaccurate clinical picture and errors in care and treatment. The findings were: Record review of Resident #1's face sheet, dated 4/17/2026, revealed a [AGE] year-old male admitted on [DATE] under hospice care with diagnoses which included: malignant neoplasm of middle third of esophagus (cancer of the esophagus), dysphagia (difficulty and/or discomfort with swallowing) and anemia. Record review of Resident #1's Care Plan, dated 3/17/2026, indicated he had acute and chronic pain with interventions to administer analgesia as per orders. The care plan also indicated the resident was on hospice services with interventions which included: administer pain medications as ordered. Record review of Resident #1's admission MDS assessment, dated 3/23/2026, revealed a BIMS of 10 which indicated a moderate cognitive impairment. Record review of Resident #1's Order Summary dated for March 2026 revealed the following orders:Lorazepam oral concentrate 2 mg/ml, give 0.5 mg by mouth every 2 hours for anxiety with a start date of 3/30/2036. Morphine Sulfate oral solution 20 mg/5 ml, give 0.5 ml every 2 hours for pain with a start date of 3/30/2026. Methadone HCL oral solution 10 mg/5ml, give 2.5 ml every 8 hours for pain by mouth with a start date of 3/12/2026. Record review of Resident #1's Medication Audit Report for March 2026 revealed the following meds were documented as administered late (later than one hour after the schedule administration time) with no corrections in time. -3/12/2026 Methadone 10 mg/5 ml, give 2.5 ml by mouth every 8 hours for pain, scheduled for 5:00 pm and documented as given at 7:20 pm by LVN A.-3/13/2026 Methadone 10 mg/5 ml, give 2.5 ml by mouth every 8 hours for pain, scheduled for 1:00 a.m. and documented as given at 4:38 a.m. LVN F.-3/16/2026 Methadone 10 mg/5 ml, give 2.5 ml by mouth every 8 hours for pain, scheduled for 9:00 am and documented as given at 11:17 am by LVN C. -3/16/2026 Methadone10 mg/5 ml, give 2.5 ml by mouth every 8 hours for pain, scheduled for 1:00 a.m. and documented as given at 4:24 a.m. by LVN D. -3/17/2026 Methadone 10 mg/5 ml, give 2.5 ml by mouth every 8 hours for pain, scheduled for 1:00 a.m. and documented as given at 3:41 a.m. by LVN F.-3/31/2026 Morphine 20 mg/5 ml, give 0.5 ml by mouth every 2 hours for pain scheduled at 4:00 a.m. and documented as given at 7:33 a.m. by LVN F.-3/31/2026 Lorazepam 2 mg/ml, give 0.5 ml by mouth every 2 hours for anxiety scheduled at 4:00 a.m. and documented as given at 7:33 am by LVN F. -3/31/2026 Morphine 20 mg/5 ml, give 0.5 ml by mouth every 2 hours for pain scheduled at 6:00 am and documented as given at 7:33 pm by LVN F.-3/31/2026 Lorazepam 2 mg/ml, give 0.5 ml by mouth every 2 hours for anxiety scheduled at 6:00 a.m. and documented as given at 7:33 a.m. by LVN F. During an interview on 4/17/2026 at 2:46 p.m., LVN A stated she administered Resident #1's Methadone as scheduled. She stated she was not sure why it was documented as administered late. She stated for the 5:00 p.m. scheduled dose was right in the middle of shift change. She stated she has one hour before and one hour after the scheduled dose to administer the medication per policy. She stated she prioritized insulin and pain medication administration and may have documented late after she was finished other change of shift tasks. She stated she was the only nurse working in the building due to low census at the time and was trying to prioritize tasks. During an Interview on 4/17/2026 at 3:16 p.m., LVN C stated she administered Resident #1's Methadone as scheduled on 3/16/2026. She stated she clicked it off (entered it into PCC) late. She stated the facility policy was to document medication as soon as the medication was given. She stated she did not know why she clicked it off late. During an interview on 4/17/2026 at 3:23 p.m., LVN F stated she administered Resident #1's scheduled medication on time. She stated she did not know why it was documented as late except that she clicked it off later during her shift when she was not busy. She stated she gave the medications on time but if she was busy, she would not document until later in the shift. LVN F stated she would get easily distracted with other tasks and have to go back later. She stated the facility policy indicated she should document or click off the medication as it was given. During an interview on 4/17/2026 at 3:35 p.m. LVN D stated she worked night shift. She stated at times during the night Resident #1 would refuse his methadone. She stated he had the right to refuse. She stated she would go back later and ask him if he was sure he did not want it and he would take it or he would ask for it and she would give it. She stated she did not correct the time entry to reflect the actual time she gave it. She would just click off the time it was scheduled (which did not reflect the actual time it was given). LVN D stated she did not make any notes in the medical record to indicate the medication was given late. She stated at other times, she just did not click it off at the same time she gave it because things happened. During an interview on 4/17/2026 at 4:22 p.m., the ADON stated his expectation was that the nurses should sign of medication administration on the electronic MAR immediately after the medication was given. He stated this was best practice to not get sidetracked. He stated someone else could accidentally administer the same medications if the medication had not been signed off when it was given. He stated he would expect staff to make a note in the MAR to indicate the correct time the medication was given. Record review of the facility's policy, titled Administering Oral Medications dated December 2025 revealed: Documentation: Follow guidelines in the procedure entitled Documentation of Medication Administration. Record review of the facility's policy, titled Documentation of Medication Administration dated December 2025 revealed: 2. Administration of medication must be documented immediately after (never before) it is given.

Based on interviews and record reviews the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and were systematically organized, for 2 of 8 residents (Resident #3 and #8) reviewed for consents for accurate medical records. 1. Resident #3 was prescribed and received the antipsychotic medication risperidone for schizophrenia without evidence in his medical record of the state consent form 3713. 2. Resident #8 was prescribed and received the antipsychotic medication aripiprazole for depression without evidence in her medical record of the state consent form 3713. These failures could place residents at risk for inaccurate and unorganized medical records. The findings included: 1. A record review of Resident #3's admission record dated 5/28/2025 revealed an admission date of 10/28/2023 with diagnoses which included schizophrenia (a chronic brain disorder characterized by symptoms like hallucinations, delusions, and disorganized thinking.). A record review of Resident #3's quarterly MDS assessment dated [DATE] revealed Resident #3 was a [AGE] year-old male admitted for long term care (LTC) and was assessed with a BIMS score of 8 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #3's care plan dated 2/11/2025 revealed, [Resident #3] resident rights will be respected and maintained through the review date February 11th 2025, . participation in my care: I have the right to: receive information about prescribed psychoactive medications, prescribed and administered, in a responsible manner as mandated the Texas Health and safety code 242 505 and the right to refuse consent to the prescription of psychoactive medications. Access personal and clinical records which will be maintained as confidential and may not be released without my consent. A record of Resident #3's physicians' orders, dated 4/27/2024 revealed the physician prescribed Resident #3 to receive risperidone 4mg every bedtime for his diagnosed schizophrenia. A record of Resident #3's medication administration record for the month of May 2025, revealed Resident #3 received risperidone 4mg every bedtime for his diagnosed schizophrenia. A record review of Resident #3's medical record from 4/27/2024 to 5/30/2025 revealed no evidence of a state required psychotropic medication consent form 3713. 2. A record review of Resident #8's admission record dated 5/30/2025 revealed an admission date of 08/24/2023 with diagnoses which included bi-polar disorder (a mental health condition characterized by extreme mood swings, ranging from periods of elevated mood (mania or hypomania) to periods of depression.). A record review of Resident #8's quarterly MDS assessment dated [DATE] revealed Resident #8 was a [AGE] year-old female admitted for long term care (LTC) and was assessed with a BIMS score of 15 out of a possible 15 which indicated no cognitive impairment. A record review of Resident #8's care plan dated 10/14/2024 revealed, I use antipsychotic medication for diagnosis of bipolar disease . give antipsychotic medications as ordered by physician A record of Resident #8's physician's orders, dated 4/4/2025 revealed the physician prescribed Resident #8 to receive aripiprazole 5mg every bedtime for her diagnosed depression / bi-polar disorder. A record of Resident #8's medication administration record for the month of May 2025, revealed Resident #8 received aripiprazole 5mg every bedtime for her diagnosed depression / bi-polar disorder. A record review of Resident #8's medical record from 10/14/2024 to 5/30/2025 revealed no evidence of a state required psychotropic medication consent form 3713. During an interview on 5/30/2025 at 3:00 PM the DON stated a record review for state required antipsychotic consent forms #3713 for Residents #3 and #8 were not in the medical record. The DON stated Residents #3 and #8 did have consents however the psychotropic consent forms were in her desk awaiting to be scanned into the medical record. During a joint interview on 5/30/2025 at 5pm with the Administrator and the DON, the DON stated, and the Administrator agreed, all residents who were prescribed and receive antipsychotic medications should have antipsychotic consent forms evidenced in their medical record. The DON stated the facility currently had no 1 specific staff member to scan medical records and the task of scanning antipsychotic consents had befallen on herself to which she had yet to scan into the record. The DON stated the risk to residents could be inaccurate medical records. A policy was requested, and the Administrator and the DON stated the facility followed HHSC guidelines.

Based on interviews and record reviews the facility failed to ensure that residents received treatments and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 8 residents (Resident #11) reviewed for professional standards with medication administration. On 5/25/2025 and 5/26/2025 Medication Aides B and C did not administer Resident #11's alprazolam (a medication which reduces brain sensitivity to stimulation, which has a calming effect) medications 4 out of a possible 5 opportunities. Medication Aides B and C did not report the missed medication administrations to the nursing leadership. These failures could place residents at risk for harm by adverse reactions to sudden cessation of the medication which could include seizures and thoughts of suicide. The findings included: A record review of Resident #11's admission record dated 5/30/2025 revealed an admission date of 1/23/2025 with diagnoses which included anxiety disorder and major depressive disorder. A record review of Resident #11's quarterly MDS assessment dated [DATE] revealed Resident #11 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 13 out of a possible 15 which indicated intact cognition. Resident #11 was assessed with moderate difficulty with hearing and highly impaired vision. A record review of Resident #11's care plan dated 5/17/2024 revealed, I use anti-anxiety medications related to anxiety disorder . I will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date . I am taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs, monitor for safety. A record review of Resident #11's physician's orders dated 1/30/2025 revealed the physician prescribed Resident #11 to receive alprazolam 0.5mg, for anxiety, 3 times a day, morning, noon, and evening. A record review of Resident #11's medication administration record for the month of May 2025 revealed on 5/25/2025 Resident #11 received only 1 of the 3 prescribed administrations of alprazolam, the morning medication which was administered by MA B. Further review revealed Medication Aide B (MA B) documented the 5/25/2025 the noon dose and the evening dose were not available. A record review of Resident #11's medication administration record for the month of May 2025 revealed on 5/26/2025 Resident #11 received only 1 of the 3 prescribed administrations of alprazolam, the evening medication. Further review revealed Medication Aide C (MA C) documented the 5/26/2025 morning dose and the noon dose were not available . Further review revealed the 5/26/2025 the evening dose was administered by medication Aide D (MA D). During an interview on 5/27/2025 at 10:02 AM Resident #11 stated she could not recall if she received all her medications over the last 2 days (Sunday and Monday). Resident #11 stated she had difficulty with her recollection, had difficulty with her vision, and hearing. Resident #11 stated she was feeling well and calm without any anxiety and was treated well by the staff. During an interview on 5/28/25 at 1:22 PM MA C stated she worked Monday 5/26/2025 as the medication aide from 6:00 AM to 2:00 PM. MA C stated Resident #11 did not have any alprazolam for her morning nor her noon medication administration. MA C stated she had reported the missed medication administration to the charge nurse LVN D. MA C stated she was unaware if Resident #11 had missed any other doses. MA C stated she had not reported the missed doses to anyone else other than the charge nurse LVN D. MA C stated she had not documented her verbal report to LVN D. MA C stated the alprazolam was an anti-anxiety medication and the missed doses could have the risk of not receiving the therapeutic effects of her anti-anxiety medication. MA C stated the facility had a pharmacy emergency kit and vaguely recalled LVN D stated the medication was not available from the pharmacy's emergency kit. During an interview on 5/29/2025 at 11:00 AM LVN D stated she worked Monday 5/26/2025 with MA C. LVN D stated she was not given any reports that Resident #11 had missed 4 of the 5 doses of alprazolam from 5/25/2025 noon to 5/26/2025 noon. LVN D stated the risk to Resident #11 for missing 4 consecutive doses could be varied to include anxiety. LVN D stated on the evening of 5/26/2025 she was given a report by MA E that Resident #11 had no alprazolam for the 5/26/2025 evening medication administration, accessed the pharmacy's emergency kit and supplied the alprazolam to MA E for administration. LVN D stated she SBAR'ed the PCP with no new orders and coordinated with the pharmacy for a refill of Resident #11's medication. LVN D stated she continued to access the medication from the pharmacy's emergency kit until Tuesday's (5/27/2025) refill from the pharmacy. During an interview on 5/30/2025 at 3:00 PM the DON stated she received a report from LVN D on 5/26/2025 of the lack of reporting and documenting where MA C had not reported to nursing leadership Resident #11's missed doses of alprazolam on 5/26/2025. The DON stated she investigated and discovered MA B and MA C had not administered Resident #11's alprazolam for 4 consecutive doses on Sunday 5/25/2025 to Monday 5/26/2025. The DON stated she terminated MA B and suspended MA C until further investigation. The DON stated MA C worked the weekends as a medication aide and would not take a shift until further review. The DON stated Resident #11 was assessed with no adverse reactions to the missed doses and her physician had received a report with no new orders. The DON stated the pharmacy refilled the medication and included the emergency kit on Tuesday 5/27/2025 . During an interview on 5/30/2025 at 4:50 PM with the Administrator and the DON, the DON stated, and the Administrator agreed, the expectation for any missed doses of medications was for the resident to be assessed by nursing, the physician to receive a report, and any new orders to be supported. The DON stated the alprazolam for Resident #11 should have been reordered by any staff who could for see the medication needed to be refilled and at a minimum by MAs B and C. The DON stated the medication aides should have reported to nursing leadership and documented the reports, that Resident #11 had missed the medication administration. The DON stated the risk for residents who missed their medication administration could be the missed therapeutic effects of their medications. A policy was requested and provided with the additional verbal statement The facility follows HHSC guidelines. A record review of the facility's Administering Oral Medications dated 12/2024, revealed, . Documentation: Follow documentation guidelines in the procedure entitled Documentation of Medication Administration. Reporting l. Notify the supervisor if the resident refuses the procedure. 2. Report other information in accordance with facility policy and professional standards of practice.

Based on record reviews and interviews the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of the State Long-Term Care (LTC) Ombudsman of the residents' transfer or discharge and the reasons for the move, for 4 of 8 residents (Residents #24, #25, #30, and #35) reviewed for notifying the LTC Ombudsman of the residents' discharge. 1. Resident #30 was discharged to the hospital on 3/29/2025 without a notice to the LTC state ombudsman. 2. Resident #35 was discharged on 4/15/2025 without a notice to the LTC state ombudsman. 3. Resident #25 was issued a 30-day notice on 5/8/2025 of an intended discharge on [DATE], without a notice to the LTC state ombudsman. 4. Resident #24 was issued a 30-day notice on 5/14/2025 of an intended discharge on [DATE], without a notice to the LTC state ombudsman. These failures could place residents at risk of not knowing their rights and receiving the services of the state LTC Ombudsman. The findings included: 1. A record review of Resident #30's admission record dated 5/30/2025 revealed an admission date of 2/12/2025 and a discharge date of 3/29/2025 with diagnoses which included end stage renal disease (kidney failure to the point they cannot keep someone alive) and dependence on renal hemodialysis (a real time treatment where a machine filters out toxins from a patient's blood, usually performed in a clinic 3 time a week.) A record review of Resident #30's quarterly MDS assessment dated [DATE] revealed Resident #30 was a [AGE] year-old male admitted for LTC and assessed with the need for hemodialysis and a BIMS score of 15 out of a possible 15 which indicated intact cognition. A record review of Resident #30's physicians' orders dated 9/16/2024 revealed Resident #30 received renal hemodialysis 3 times a week on Monday, Wednesday, and Fridays. A record review of Resident #30's hospital admission document dated 3/30/2025 revealed Resident #30 on the night of 3/29/2025 around 11 PM was in bed when he turned in bed and his dialysis access port caught on something and became dislodged and required hospitalization. A record review of Resident #30's medical record from 2/12/2025 through 5/30/2025 revealed no evidence of a notice to the state LTC ombudsman of Resident #30's discharge to the hospital. 2. A record review of Resident #35's admission record revealed an admission date of 2/26/2025 and a discharge date of 4/15/2025 with diagnoses which included atherosclerotic heart disease (the buildup of plaque leading in the arteries causing hardening and narrowing). A record review of Resident #35's discharge MDS assessment dated [DATE] revealed Resident #35 was a [AGE] year-old female admitted for rehabilitation care. A record review of Resident #35's progress notes revealed LVN D documented on 4/15/2025 Resident #35 was discharged home accompanied by her representative. A record review of Resident #35's medical record from 2/26/2025 through 5/30/2025 revealed no evidence of a notice to the state LTC ombudsman of Resident #35's home discharge. 3. A record review of Resident #25's admission record revealed an admission date of 1/29/2024 with diagnoses which included sepsis (a serious condition in which the body responds improperly to an infection. The infection-fighting processes turn on the body, causing the organs to work poorly) due to Escherichia coli (a bacteria that is commonly found in the lower intestine), chronic obstructive pulmonary disease (COPD an ongoing lung condition caused by swelling and irritation inside the airways that limit airflow into and out of the lungs), and dependence on other enabling machines and devices. A record review of Resident #25's quarterly MDS assessment dated [DATE] revealed Resident #25 was a [AGE] year-old female admitted for LTC and weighted 386 lbs. at a height of 5 feet 2 inches, could not bear weight and required mechanical assistance with transfers from bed to wheelchair. The resident was assessed with the need for continuous supplemental oxygen . The resident was assessed with a BIMS score of 15 out of a possible 15 which indicated intact cognition. A record review of Resident #25's medical record revealed a facility initiated Notice of 30-day Discharge letter dated 5/8/2025. The letter revealed the facility intended to discharge Resident #25 for her inability to pay for services. Further review revealed no evidence the ombudsman was notified. 4. Record review of Resident #24's admission record revealed a [AGE] year-old female resident with an admission date of 11/16/2024 with diagnoses which included unspecified dementia (group of thinking and social symptoms that interferes with daily functioning), hypertension (condition in which the force of the blood against the artery walls is too high), and chronic kidney disease. A record review of Resident #24's quarterly MDS assessment, dated 02/27/2025 revealed Resident #24 had a BIMS of 0, indicating severe cognitive impairment. Further review of Resident #24's MDS assessment revealed that she was dependent on all of the following activities of daily living: eating, oral hygiene, toileting hygiene, bathing, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Record review of Resident #24's medical record reflected a facility initiated, Notice of 30-Day Discharge letter, dated 5/14/2025. The letter revealed the facility intended to discharge Resident #24 for her inability to pay for services . Further review revealed no evidence the ombudsman was notified. During an interview on 5/27/2025 at 1:20 PM Resident #25 stated she was anxiously concerned she would be discharged with nowhere to go. Resident #25 stated she was vulnerable and could not survive without help. Resident #25 stated she was a widow and had utilized an attorney to assist her with the sale of her home and used the proceeds to pay for care at the facility and as of April 2025 she had run out of money and on May 8th, 2025, received a notice she would be discharged . Resident #25 was unaware of the services and oversight of the state LTC ombudsman and would like to be connected to her services and oversight. During an interview on 5/27/2025 at 2:00 PM the state LTC Ombudsman for the facility stated she had not received any discharge notices from the facility in the past year. The Ombudsman stated the lack of discharge notices denied residents the opportunity to avail themselves to the services and oversight of the ombudsman. The Ombudsman stated some of the services and oversight an ombudsman may provide varied and could include coordination with the resident and the facility to provide payor sources, and or to ensure the facility supported residents with their full exercise of their rights and potentially apply for government resources such as Medicaid services. During an interview on 5/30/2025 the LTC Ombudsman for the facility stated she had spoken to Resident #25 on 5/28/2025 and the Administrator and the facility would not discharge Resident #25 pending an appeal. During an interview on 5/27/2025 at 11:46 AM, Resident #24's and her representative stated they were not comfortable with Resident #24's discharge and had not been informed of a way to appeal the discharge. Resident #24's family member stated that he was a disabled veteran and would be unable to take care of Resident #24 appropriately, considering her level of care. Resident #24 stated the facility Administrator had not discussed options other than discharge for Resident #24. During an interview on 05/29/2025 at 9:11 AM, the Administrator stated he would not be able to evidence that 30-day discharge notices were sent to the office of the Ombudsman unless he went to the Ombudsman's office and looked through the Ombudsman's mail. The Administrator stated they would subpoena the mailman, if necessary, to show that the 30-day discharge notifications were mailed. During an interview on 5/30/2025 at 1:50 PM the Business Office Manager (BOM) stated she was responsible for reviewing residents for their ability to pay for services rendered either through private pay and or insurance supported payments. The BOM stated if a resident was approaching an instance where they would be reaching the end of a payor source, such as a payor source which would be depleted and or exhausted, the office would notify the resident of a pending 30-day discharge. The BOM stated she would mail a copy of the letter to the address of the LTC ombudsman, however the BOM stated she had no receipt to evidence the letter was mailed. The BOM stated she was not trained to keep evidence for the mailing of the letter. The BOM stated she had not notified the LTC Ombudsman of any discharges for any residents. The BOM stated she was unaware the notification to the LTC Ombudsman of any resident discharge was a requirement. During an interview on 5/30/2025 at 2:40 PM the DON stated she was unaware of the requirement for the facility to report any discharged residents to the LTC Ombudsman. The DON stated a record review of residents' records would not reveal evidence of discharge notices to the LTC Ombudsman because the facility was not reporting the discharged residents. During an interview on 5/30/2025 at 4:55 PM with the Administrator and the DON, the Administrator stated, and the DON agreed, the facility had not developed and implemented a system to ensure the state LTC Ombudsman received notices for residents who were discharged . The Administrator stated the risk for residents could be the residents would not receive the oversight and services of the state LTC Ombudsman. A policy was requested, and the Administrator stated the facility adheres to HHSC Guidelines. A record review of the facility's Transfer or Discharge Notice policy dated December 2016, revealed, Policy Statement: Our facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge. Policy Interpretation and Implementation: A resident, and/or his or her representative (sponsor), will be given a thirty (30)-day advance notice of an impending transfer or discharge from our facility. 4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman

Based on observations, interviews, and record reviews the facility failed to ensure standard and transmission-based precautions which included hand hygiene procedures, were followed by staff involved in direct resident contact, to prevent spread of infections, for 1 of 8 residents (Resident #8) reviewed for transmission-based precautions. On 5/29/2025 LVN A provided a wound care bandage change for Resident #8 and did not change gloves and continued with soiled gloves when he removed Resident #8's dirty bandage, cleaned the wound, applied wound care treatment medication, and applied a clean bandage. This failure could place residents at risk for infections. The findings included: A record review of Resident #8's admission record dated 5/30/2025, revealed an admission date of 3/20/2025 with diagnoses which included respiratory failure with hypercapnia (excess carbon dioxide in the blood stream), diabetes mMellitus, and laceration without foreign body, left lower leg (a wound to the left leg 'calf'). A record review of Resident #8's quarterly MDS assessment dated [DATE] revealed Resident #8 was a [AGE] year-old female admitted for long-term-care and assessed medically complex with a BIMS score of 15 out of a possible 15 which indicated no cognitive impairment. A record review of Resident #8's physician's orders dated 5/21/2025 revealed the physician ordered for Resident #8 to receive Enhanced Barrier Precautions (EBP) every shift and daily wound care to her left lower calf, Resident is on EBP, and standard precautions related to wound care. [NAME] [sic(wear)] PPE (personal protection Equipment) inside the room. Every shift or enhanced barrier precautions medical condition staff must [NAME] gown and gloves when performing high contact care such as bathing, showering, peri-care, brief changes, dressing changes . wound care: left medial [sic(middle)] calf: cleanse with wound cleanser, normal saline, pat dry with 4 by 4 gauze, apply collagen powder sic[a critical protein which maintained skin, tendons, bones, and connective tissue] and (sic[Brand name occlusive dressing is a sterile, non-adhering protective dressing consisting of absorbent, fine-mesh gauze impregnated with a petrolatum blend]) to the wound bed, then cover it with a dry dressing. During an observation and interview on 5/29/2025 at 2:49 PM revealed Resident #8 in her room in bed accepting wound care to her left calf from LVN A. Further observation revealed LVN A wore a gown and gloves. LVN A changed gloves, performed hand hygiene, and applied new gloves. LVN A proceed to remove Resident #8's old, soiled bandage from her wound located on her left lower inner calf. Continued observation revealed LVN A discarded the soiled bandage, did not change gloves, and continued with the same gloves. LVN A cleaned Resident #8's wound and applied collagen powder and a nonstick gauze and clean bandage. After the dressing change LVN A stated he had not changed gloves, performed hand hygiene, and applied new gloves and stated he should have to prevent infections. During an interview on 5/29/2025 at 3:01 PM the ADON Infection Preventionist (IP) stated the training and expectation was for all staff who perform wound care to change gloves whenever they were going from a soiled to clean situation and LVN A should have removed the soiled gloves, performed hand hygiene, and applied new clean gloves prior to cleaning the wound and again after cleaning the wound and applying the clean bandages. During a joint interview on 5/30/2025 at 4:31 PM with the Administrator and the DON, the DON stated the training and expectation was for all staff who perform wound care to change gloves whenever they were going from a soiled to clean situation and LVN A should have removed the soiled gloves, performed hand hygiene, and applied new clean gloves prior to cleaning the wound and again after cleaning the wound and applying the clean bandages. The DON and the Administrator stated the risk to residents was potential infections. A record review of the facility's Wound Care policy dated December 2024, revealed, Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the Procedure: . 2. Perform hand hygiene. 3. Position resident to facilitate the dressing change. 4. Put on exam gloves. Loosen tape and remove dressing, discard dressing into appropriate receptacle. 5. Remove gloves. Perform hand hygiene. 6. Put on gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids is likely. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. 8. Wear gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. 9. Wear gloves when physically touching the wound or holding a moist surface over the wound. [NAME]. Place one (1) gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape, or gauze with antiseptic or soap and water. 11. Apply treatments as indicated. 12. Dress wound. [NAME] dressing with initials, time, and date. Be certain all clean items are on clean field

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 facility reviewed for food service safety. The facility failed to maintain the cleanliness of the facility ice maker. This failure could place residents who receive food and/or snacks from the facility at risk for food borne illness. The findings included: Observation on 05/27/2025 at 09:18 AM revealed a black substance build-up within the ice maker. Interview on 05/29/2025 at 2:00 PM, the DON stated that she saw the buildup in the ice machine in the photo, and her expectation was for the ice machine to be appropriately cleaned. The DON stated the Kitchen Manager generally cleans the ice machine. Record review of Ice Machine Cleaning and Sanitizing Log reflected that the ice machine was cleaned once monthly on the following dates, 09/06/2024, 10/14/2024, 11/15/2024, 12/2/2024, 01/10/2025, 02/03/2025, 03/03/2025, 04/08/2025, and 05/05/2025. Record review of facility policy titled, Sanitization, dated revised October 2008, reflected, Ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy. No other facility policy regarding cleanliness of the facility ice maker was provided.

Based on interview and record review, the facility failed to conduct an accurate comprehensive assessment of each resident's functional capacity including the resident's needs, strengths, goals, life history and preferences for 2 of 8 Residents (Residents #9, #13) reviewed for assessments. Resident #9 and Resident #13's Quarterly MDS Assessments did not reflect their significant weight loss. This failure could place residents at risk for not receiving the care and services as needed. The findings included: Record review of Resident #9's face sheet, dated 05/30/2025, reflected an [AGE] year-old resident initially admitted on [DATE] with diagnoses of metabolic encephalopathy (change in how your brain works due to an underlying condition), dependence on renal dialysis, and end stage renal disease (kidney failure, where your kidneys no longer work as they should to meet your body's needs to adequately filter waste). Record review of Resident #9's medical record reflected that on 03/20/2025, Resident #9 weighed 118 lbs. and on 04/27/2025, Resident #9 weighted 109.2 lbs., which is a -7.46% loss in body weight. Due to the significant loss in weight, on 04/28/2025, the facility dietician recommended adding an appetite stimulant to Resident #9's medicine regiment. Record review of Resident #9's Quarterly MDS assessment dated [DATE], reflected under Section K - Swallowing/Nutritional Status, subsection Weight Loss reflected that Resident #9 did not have weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Record review of Resident #9's Care Plan, dated 05/30/2025, reflected that the resident had unplanned/unexpected weight loss with interventions such as providing dietary supplements as ordered by physician. Record review of Resident #13's face sheet, dated 05/30/2025, reflected a [AGE] year-old resident initially admitted on [DATE] with diagnoses of sepsis (a life-threatening complication of an infection), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), and type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Record review of Resident #13's medical record reflected that on 03/03/2025, Resident #13 weighed 242 lbs. and on 04/2/2025, Resident #9 weighed 225.4 lbs., which was a -7.00% loss in body weight. Record review of Resident #13's Quarterly MDS assessment dated [DATE], reflected under Section K - Swallowing/Nutritional Status, subsection Weight Loss reflected that Resident #13 did not have weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Record review of Resident #13's Care Plan, dated 05/30/2025, reflected that the resident had unplanned/unexpected weight loss with interventions such as alerting the dietician if the resident has poor food consumption for more than 48 hours and notifying the physician if there is more weight loss. Interview on 05/30/2025 at 10:22 AM, the MDS Coordinator stated she had just begun her employment at the facility and began completing MDS' in the first week of May of 2025. The MDS Coordinator stated both Resident #9 and Resident #13's significant weight loss should have been indicated in their MDS Assessments completed on 04/27/2025, and 04/22/2025, respectively. The MDS Coordinator stated she would take that into account moving forward and complete an audit to ensure all MDS' had accurate weight assessments and would correct any MDS' that did not .

Based on observations, interviews, and record reviews the facility failed to develop, within 7 days after completion of the comprehensive assessment, a care plan and invited, to the extent practicable, the participation of the resident and the resident's representative(s) with an explanation in the resident's medical record if the participation of the resident and their resident representative was determined not practicable for the development of the resident's care plan and reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 of 6 (#1, #5) residents reviewed for revised care plans. 1.Resident #1's care plan dated 9/27/2024 was not updated because the CP had current revision dates but did not coincide with the MDS dates. 2. The facility failed to revise Resident #5's care plan on 8/20/2024 with interventions to support Resident #5's hypothyroid diagnosis and hypothyroid medication regime. This failure could place residents at risk for harm by not having a plan of care to support their needs for care. The findings included: 1. Record review of Resident #1's Admission Record dated 9/27/2024, readmitted on [DATE] with dx of unspecified fx, for femur, renal dialysis, pressure sore on sacrum, vit D deficiency, ESRD (end stage renal disease), dysfunction of bladder, Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination.), diabetes II (a chronic, metabolic disease characterized by elevated levels of blood glucose (or blood sugar), which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves) , and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities. Record review of Resident #1's Quarterly MDS dated [DATE] revealed she had a BIMs score of 3 out of 15, severely impaired, she required set-up for eating and mobilized with a manual wheelchair. Record review of Resident #1's Quarterly MDS dated [DATE] revealed she had a BIMs score was 3 out of 15, severely impaired, required extensive assistance with transfers, supervision with eating and mobilized with a manual wheelchair. Record review of Resident #1's Care plan dated 9/27/2024 revealed she had a risk for falls, a fracture, Diabetes II, and eating was set-up. Resident #1's care plan had current revision dates but did not coincide with the MDS dates. 2. A record review of Resident #5's admission record revealed an admitted [DATE] with diagnoses which included cerebral infarction (stroke), Hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid stimulating hormone TSH), and Alzheimer's disease (a progressive and irreversible brain disorder that gradually destroys memory, thinking skills, and the ability to carry out everyday tasks.) A record review of Resident #5's quarterly MDS assessment dated [DATE] revealed Resident #5 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 2 out of a possible 15 which indicated a severely impaired cognition. Further review revealed a diagnosis of Hypothyroidism. A record review of Resident #5's physicians orders dated 01/22/2025 revealed the physician prescribed Resident #5 to receive levothyroxine 100mcg (a thyroid stimulating hormone) daily for hypothyroidism. Further review revealed the physician prescribed for Resident #5 to have weekly skin assessments, and weekly weights monitoring for Loss under 100 lbs. A record review of Resident #5's care plan dated 1/22/2025 revealed no focus's, goals, nor interventions regarding Resident #5's diagnosis of hypothyroidism. A record review of Resident #5's laboratory physicians order dated 6/13/2024 revealed the physician ordered a TSH Free T4 lab test (a test to reveal how much thyroid stimulating hormone the body is producing.) A record review of Resident #5's laboratory results dated [DATE] revealed a TSH T 4 level as greater than 100mu/L (million per microliter.) A record review of the United States of America's Department of Veterans Affairs website https://www.va.gov/WHOLEHEALTHLIBRARY/tools/hypothyroidism.asp Accessed 1/31/2025, titled Hypothyroidism revealed, In primary hypothyroidism, serum TSH is elevated (typically greater than 4.5mu/L) A record review of Resident #5's physician's orders revealed the physician began a new medication for Resident #5 to receive daily levothyroxine 25mcg for a new diagnosis of hypothyroidism. A record review of Resident #5's medical record from July 2024 through October 2024 revealed the physician continued to monitor Resident #5's TSH blood levels and continued to evidence high levels which indicated hypothyroidism and continued to increase Resident #5's levothyroxine in to reduce the high TSH levels as evidenced by the physician's order on 9/6/2024 when the physician prescribed Resident #5 to receive levothyroxine 100mcg daily. During an interview on 1/22/2025 at 4:53 PM Resident #5's representative stated she had never been invited to a care plan meeting although she visited Resident #5 weekly and may have inadvertently been involved in an informal care plan meeting with the nurses and may not have recognized it was a care plan meeting. Resident #5's representative stated she has hypothyroidism and believed Resident #5 also had hypothyroidism and had been receiving levothyroxine since 2023 prior to being admitted to the facility. Resident #5's representative stated she learned while Resident #5 was admitted to the facility she had not been diagnosed with hypothyroidism until June 2024 when Resident #5 had been diagnosed with hypothyroidism and had begun receiving levothyroxine. Resident #5's representative stated she was not aware Resident #5 had no interventions for monitoring, and or supporting Resident #5's needs for hypothyroidism and at a minimum would like for Resident #5 to be monitored for her TSH blood work regularly. During an observation and interview on 1/23/2025 at 2:00 PM revealed LVN J to review Resident #5's medical record to include Resident #5's care plan. LVN J stated she could not evidence any focus, goal, nor interventions for hypothyroidism. LVN J stated Resident #5 was monitored for her weight and her skin condition and stated hypothyroidism could affect a person's weight and skin condition. During an interview on 1/23/2025 at 2:59 PM the ADON stated there was no interventions for Resident #5's care plan and would review Resident #5's care plan and ensure there would be a focus for hypothyroidism to included goals and interventions to support management of Resident #5's hypothyroidism. Interview on 1/24/2025 at 2:09 PM with MDS stated she was new (date of hire 9/30/2024) and was not aware she had to start a new care plan for each resident MDS. MDS stated she was responsible for updating care plans. Interview on 1/24/2025 at 5:00 PM with the ADM stated this was an individual error and will educate, ADM stated care plans should be up to date. A policy for care plan revisions was requested on 1/23/2025 and as of exit on 1/23/2025 was not provided. A record review of the United states of America's Medicare.gov website accessed 1/31/2025 https://www.medicare.gov/providers-services/original-medicare/nursing-homes/care-plan , titled What's a nursing home care plan? revealed, A care plan says how staff at a nursing home will help manage your care. To prepare your care plan, the nursing home staff will get your health information and review your health condition. You (if you're able), your family (with your permission), or someone acting on your behalf has the right to take part in planning your care with the nursing home staff. The basic care plan included: A health assessment (a review of your health condition) that begins on the day you're admitted and must be completed within 14 days. A health assessment at least every 90 days after your first review, and possibly more often if your medical status changes, with?changes to your care plan as needed. Nursing homes are required to submit this information to the federal government. This information is used for quality measures, nursing home payment, and state inspections. Depending on your needs, your care plan may include: The personal or health care services you need. The type of staff that can give you the services. How often you need the services. The equipment or supplies you need (like a wheelchair or feeding tube). Describe your dietary needs and food preferences. How your care plan will help you reach your goals. If you plan on returning to the community and the plan to?help you meet that goal.

Based on observations, interviews, and record reviews the facility failed to ensure residents had the right to be free from misappropriation of resident property for 1 of 7 residents (Resident #4) reviewed for controlled narcotic medications. Resident #4 was hospitalized from 5/27/2024 to 6/2/2024 and upon admission to the facility, on 6/2/2025, the facility recognized they failed to secure and thereby lost, Resident #4's, 41 pills of hydrocodone acetaminophen 10mg/325mg. This failure could place residents at risk for harm by losing control of their medications. The findings included: A record review of Resident #4's admission record, dated 1/22/2025 revealed an admitted [DATE] with diagnoses which included pain, psychotic disorder with hallucinations due to known physiological condition (Psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions. People with psychoses lose touch with reality.) A record review of Resident #4's quarterly MDS assessment, dated 5/13/2025, revealed Resident #4 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 13 which indicated intact cognition. Further review of Resident #4's MDS revealed she was a quadriplegic (paralysis of all four limbs), diagnosed with coronary heart disease and a wound infection. Resident #4 was assessed as receiving scheduled and as needed pain medication for the period reviewed 5/8/2024 through 5/12/2024. The MDS assessment revealed, Ask Resident: have you had pain or hurting at any time in the last 5 days? . Yes . Pain Frequency: Ask Resident: How much of the time have you experienced pain or hurting? . Frequently . Ask Resident Over the past five days, how much of the time has pain made it hard for you to sleep at night? . Occasionally . Pain Intensity: Numeric rating scale 00-10 Ask Resident: Please rate your worst pain over the last 5 days on a 0 to 10 scale, with zero being no pain and 10 as the worst pain you can imagine. Seven . Prognosis: Does the Resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? . no A record review of Resident #4's care plan dated 1/22/2025 revealed, I have chronic pain r/t (related to) polyneuropathy, necrotizing fasciitis Date Initiated: 04/20/2024 Revision on: 01/18/2025 . Anticipate my need for pain relief and respond immediately to any complaint of pain CNA, Date Initiated: 04/20/2024, Revision on: 04/20/2024 .Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Identify previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function. Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. A record review of Resident #4's physicians orders revealed Resident #4 was prescribed to receive Oxycodone 10mg (according to the United States Drug Enforcement Agency Oxycodone is a semi-synthetic narcotic analgesic and historically has been a popular drug of abuse among the narcotic abusing population) with Acetaminophen 325mg (Tylenol), the physician's instructions were for Resident #4 to receive 1 tablet every 4 hours as needed for moderate to severe pain beginning on 5/9/2024. A record review of the United States of America's Drug Enforcement Agency's website https://www.dea.gov/sites/default/files/2020-06/Oxycodone-2020_0.pdf accessed 1/31/2025, revealed, WHAT IS OXYCODONE? Oxycodone is a semi-synthetic narcotic analgesic and historically has been a popular drug of abuse among the narcotic abusing population. WHAT IS ITS ORIGIN? Oxycodone is synthesized from thebaine, a constituent of the poppy plant. What are common street names? Common street names include: o Hillbilly Heroin, [NAME], OC, Ox, Roxy, Perc, and Oxy . How is it abused? Oxycodone is abused orally or intravenously. The tablets are crushed and sniffed or dissolved in water and injected. Others heat a tablet that has been placed on a piece of foil then inhale the vapors. What is its legal status in the United States? Oxycodone products are in Schedule II of the Controlled Substances Act. A record review of Resident #4's May 2024 Medication Administration Record revealed Resident #4 had received her Oxycodone 10mg / acetaminophen 325mg, as prescribed as Needed 19 times and administered by LVN A, LVN B, LVN C, LVN D, LVN E, and LVN F. A record review of Resident #4's nursing progress notes revealed Resident #4 was assessed by LVN A on 5/27/2025 at 8:15 PM with 10 out of 10 pain, cold and shivering, and hurting down to her bones. LVN A documented Resident #4 Was transferred to the hospital. A record review of Resident #4's nursing progress notes revealed the medical director documented on 6/2/2025 at 8:20 PM, seen and examined. Patient returned back from (hospital) after being treated for sepsis with uti (urinary tract infection), along with oral candidiasis (commonly known as oral thrush, is a fungal infection in the mouth caused by an overgrowth of yeast-like organisms called Candida) new orders noted start pt/ot (physical therapy / occupational therapy) pain meds revised discussed with RN. A record review of Resident #4's nursing progress notes revealed LVN B documented on 6/2/2025 at 9:08 PM, resident returned to facility from stay at (name) hospital admitted for severe sepsis d/t uti. Resident transferred to bed from Gernie sic(gurney) with s/s of pain voiced/observed. Resident A&Ox3, able to verbalize all needs/wants, recognized staff as well as location without cues. Resident stated my leg hurts bad they did nothing for it while beginning to cry while voicing discomfort with stay/current s/s. MD pending call back, after hours number with vmail left to return call promptly for review of orders. ADON/Supervisor aware of return arrival, pending MD return call. A record review of the Pharmacist's Medication Audit report dated 6/4/2024 revealed, June 4, 2024 Investigation Report Subject: Possible Drug Diversion at (The Facility) Investigator: (PharmD), RPh, Consultant Pharmacist I. Concern On June 3, 2024, I was contacted by facility that a medication card of Oxycodone/Acetaminophen 10/325mg Tablets for (Resident #4) could not be located. II. Findings On May 27, 2024, resident was noted to have abnormal vital signs and was sent out of the facility to the hospital. On June 2, 2024, resident returned late in the evening. Medication orders were restarted. It was discovered that resident's medication card for Oxycodone/Acetaminophen 10/325 was not with her other medications. Medication carts, locked control boxes, and medication rooms were searched looking for the missing card. Drug destruction areas were reviewed. The medication card was not located. The pink inventory sheet was also missing from control medication notebook. The medication card dispensed from the pharmacy was for a quantity of 60, and review noted that 19 doses had been administered. The lost card had 41 doses of Oxycodone/Acetaminophen 10/325mg tablets. The pharmacy was immediately contacted, and replacement medication was obtained. As resident was out of the facility for six days, it was unclear when the medication was lost or diverted. III. Recommendations The DON noted a new shift change inventory sheet for nurses/medication aides to ensure that medication cards are always inventoried with each change of shift. DON also had obtained a control inventory sheet that would track the number of controlled medications at beginning and end of every shift. This would ensure that if a medication card and the pink inventory sheet were removed, this would cause a discrepancy that could investigated quickly. IV. Conclusion There appears to have been an unexplained loss of a medication card of Oxycodone/Acetaminophen 10/325mg. The resident at no time was without medication. The facility thoroughly searched facility. The facility is instituting new tracking for controlled medication cards. Updating procedures and the additional step of inventorying the number of controlled medications in the facility will go a long way in helping to catch any discrepancy with missing medication cards. (PharmD), RPh During an interview on 1/22/2025 at 12:13 PM the ADON stated he reported to DON H and Administrator I that Resident #4 was missing her oxycodone drugs. The ADON stated the PharmD came in and investigated the medication loss. The ADON stated the staff involved were not drug tested however, through other actions they were terminated. The ADON stated the local police department were notified and visited the facility and gave a police report number. The ADON stated all the staff had received an in-service for ANE and medication storage to include controlled medications protocols. The ADON stated as a result the facility had provided an enhanced controlled medication accounting to include the addition of a master control log where all controlled medications were recorded when delivered by the pharmacy and the controlled drugs on the medication carts were audited with the master control log daily. The ADON stated upon recognition of the lost oxycodone for Resident #4 all residents who were prescribed controlled narcotics were identified as seven residents to include Resident #4. All residents were reviewed for their physical narcotic and only Resident #4 was missing medications. All 7 residents were assessed for adverse reactions from missing their narcotic medications and none were evidence with any adverse reactions, the ADON stated Resident #4 had received a new prescription from the pharmacy and in the interim she had received medications from the facility's emergency kit provided by the pharmacy. During an interview on 01/23/2025 at 10:00 AM the Administrator and the DON stated some of the staff who were involved with the missing narcotics for Resident #4 were terminated and included: MA F. MA G. LVN B. RN E. and LVN A. The Administrator and the DON stated they were not the DON and or the administrator at the time and date of the lost medication but had reviewed the actions of the previous Administrator I and DON H and continued with the practice of having an enhanced controlled medication accounting to include the addition of a master control log where all controlled medications were recorded when delivered by the pharmacy and the controlled drugs on the medication carts were audited with the master control log daily. During an interview on 1/22/2025 at 2:12 PM MA G stated she usually worked the 8a-8p shift and regarding Resident #4's missing oxycodone, she recalled administering the medication to Resident #4 on 5/27/2024 and counting the medication at end of her shift with the oncoming nurse. MA G stated she did not recall if Resident oxycodone specifically was counted the following day. MAG stated she had not removed the oxycodone medication from cart. During an interview on 1/22/2025 at 2:13 PM LVN B stated she usually worked 12-hour day shifts on the weekends and regarding Resident #4's missing oxycodone, she did not recall if oxycodone specifically was counted at change of shift during the previous weekend. LVN B stated she did not remove Resident #4's oxycodone medication from cart. During an interview on 1/22/2025 at 2:17 PM RN E stated usually worked 12-hour day shifts on the weekends and regarding Resident #4's missing oxycodone, she did not recall if oxycodone specifically was counted at change of shift during the previous weekend. RN E stated she did not remove Resident #4's oxycodone medication from cart. During an interview on 1/22/2025 at 3:25 PM LVN A stated he usually worked the 2p-10p shift and regarding Resident #4's missing oxycodone, he could not recall specifically counting oxycodone during change of shift. [NAME] stated he did not remove medication from cart. LVN A stated he did not remove Resident #4's oxycodone medication from cart. A record review of the facility's Controlled Substances policy dated December 2023 revealed, Policy Statement The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation: 1. Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. 2. The Director of Nursing Services will identify staff members who are authorized to handle controlled substances. 10. The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties and shall give the Administrator a written report of such findings. 11. The Director of Nursing Services shall consult with the provider pharmacy and the Administrator to determine whether any further legal action is indicated. A record review of the facility's master control binder, on-going dates, revealed the facility DON and or ADON audited the narcotics on the medication's carts with the control log daily. A record review of Resident's with narcotics counts sheets, on-going dates, revealed no discrepancies and were signed as the medications were administered. A record review of Resident #4's narcotic count sheet, on-going dates, revealed no discrepancies. During an observation and interview on 1/22/2025 at 6:10 PM revealed Resident #4 in her room dressed groomed seated in her wheelchair. Resident #4 could not recall missing any drugs and stated she did have recurrent pain and the pain was satisfied with her medications administered by the nurses. A record review of the facility's in-service dated 6/4/2024 titled Controlled medications revealed, Objectives 1) controlled substances will be counted on delivery and at the end of each shift. 2) discrepancies will be reported to the DON. 3) detailed narcotic Audit form will be updated and signed for new, discontinued, or completed controlled medications. Further review revealed LVN A, LVN B, LVN C, LVN D, RN E, MA F, and MA G signed the in-service. A record review of the facility's narcotic count sheet for the 100-hall medication cart, dated May 2024, revealed *All Controlled medications need to be counted by the On-coming and Off-going Certified Medication Aide at change of shift [NAME]. *Each Certified Medication Aide/Charge Nurse participating in the count should initial on the appropriate date/time. Further review revealed all shifts except 5/26/2025 2p-10p shift, had documented they counted the narcotics on the cart for the month of May 2024. A record review of the facility's narcotic count sheet for the 100-hall medication cart, dated January 2025, revealed *All Controlled medications need to be counted by the On-coming and Off-going Certified Medication Aide at change of shift [NAME]. *Each Certified Medication Aide/Charge Nurse participating in the count should initial on the appropriate date/time. Further review revealed all shifts had documented they counted the narcotics on the cart for the month of January 2025.

Based on interview and record review the facility failed to ensure the development and comprehensive-centered care plan for each resident, consistent with the resident rights, that measurable objectives and timeframes to meet a residents medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment. The comprehensive care plan must 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 as required under and the resident's goals for admission and desired outcomes for 2 of 3 (#2, #3) residents in that: 1. Resident #2's care plan dated 6/30/2024 was not updated with a manual wheelchair and that the resident had lower extremity impairment. 2. Resident #3 care plan dated 4/10/24 was not updated with several e-signatures or completed. This could affect all residents and could result in staff not providing care to residents. The findings included: 1. Record review of Resident #2's Admission record dated 1/24/2025 revealed she was admitted on [DATE], readmitted on [DATE] with diagnoses of pneumonia, lack of coordination, pressure ulcer, contractures, diabetes II, major depressive disorder, and seizures. Record review of Resident #2's Quarterly MDS dated [DATE] revealed her BIMs score was 0 of 15, severely impaired, had a manual wheelchair and had lower extremity impairment on both sides. Record review of Resident #2's Quarterly MDS dated [DATE] revealed her BIMs score was 0 of 15, severely impaired, had a manual wheelchair and had lower extremity impairment on both sides. Record review of Resident #2's CP dated 6/30/2024 revealed she was at risk for falls, diabetes II, spoke Spanish and had impaired cognitive function/dementia or impaired processes related to Dementia. 2. Record review of Resident #3's Admission Record dated 1/23/2025 revealed she was admitted on [DATE], readmitted on [DATE] with diagnoses of abnormal gait, heart disease without heart failure, major depressive disorder, and repeated falls. Record review of Resident #3's screen shot of Care plans revealed the following dates were waiting for e-signatures: 10/14/2024, 5/7/2024, 12/22/2023 and other previous dates (before the annual recert) and were not completed. Record review of Resident #3's Quarterly MDS dated [DATE] revealed her BIMs score was 15 out of 15, cognitively intact, and used a wheelchair to mobilize. Record review of Resident #3's care plan dated 4/10/24 revealed she was a risk for falls, attends activities and had bowel incontinence. Interview on 1/24/2025 at 2:09 PM with MDS stated she was new (date of hire 9/30/2024) and was not aware she had to start a new care plan for each resident's MDS. MDS stated she was responsible for updating care plans. Interview on 1/24/2025 at 5:00 PM with the ADM stated this was an individual error and will educate, ADM stated care plans should be up to date. No policy provided prior to exit on 01/24/2025.

Based on interview and record review the facility failed to ensure the resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay. The resident has the right to do, and the facility must make prompt efforts to resolve grievances for 1 of 3 (# 2) residents in that: Resident #2's family had a grievance that was not resolved by the ADM from 12/11/202 to current (43) days. ADM did not call family back to discuss the resolve. This could affect all residents and could result in residents/families not having their grievances resolved timely. The Finding included: Record review of Residents #2's family grievance form was dated 12/11/2024 by her family, revealed this concerned was reported to the ADM and stated: Documentation of Grievance/complaint- staff brought food tray into residents' room but informed it was for the roommate. Staff said she would return but continued to ignore resident's food. Then staff said that original tray was for resident. resident and family feel discriminated, and resident had a cold meal. Resident was also not changed/cleaned. Documentation of facility follow-up: blank What other action was taken to resolve concerns? blank Action taken: blank Resolution of Grievance/complaint: was grievance resolved-blank; identify the method used to notify the resident and/or resident representative for the resolution: blank, the signature and date was blank. Record review of Resident 2's Admission record dated 1/24/2025 revealed she was admitted on ,d+[DATE] /2009, readmitted on [DATE] with diagnoses of pneumonia, lack of coordination, pressure ulcer, contractures, diabetes II, major depressive disorder, and seizures. Record review of Resident 2's Quarterly MDS dated [DATE] revealed her BIMs score was 0 of 15, reflecting severely impaired, Resident had a manual wheelchair and had lower extremity impairment on both sides. Record review of Resident 2's was CP dated 6/30/2024 revealed she was a risk for falls, diabetes II, spoke Spanish and had impaired cognitive function/dementia or impaired processes related to Dementia. Record review of Resident #2's grievance dated 12/11/2024 by her family, revealed this concerned was reported to the ADM and stated: Documentation of Grievance/complaint- staff brought food tray into residents' room but informed it was for the roommate. she said she would return but continued to ignore resident's food. Then staff said that original tray was for resident. resident and family feel discriminated, and resident had a cold meal. resident was also not changed/cleaned. Documentation of facility follow-up: The previous DON documented the staff was confused with Resident #2's food tray and roommate. Went back in room is there a problem, how can I help you? she felt discriminated against because the food tray was sent after the fact, insisted it was given last, first name to ensure. What other action was taken to resolve concerns? Was told to give information of complaint to me and gave residents family member full name. Actions taken: discussion -educated staff on customer service, passing trays, assisting resident with dining room and in resident rooms and customer service techniques with resistant, families and other loved ones. Resolution of Grievance/complaint was grievance resolved-blank; identify the method used to notify the resident and/or resident representative for the resolution: blank, the signature and date was blank. Interview on 1/24/2025 at 4:00 PM with the ADM stated he had found the area where the complaints were, this grievance was resolved, but the area of Resolution of Grievance section, the method of notification and signature areas were blank. The ADM stated grievances were resolved within 24 hours. No policy was provided prior to exit.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 1 of 5 residents (Resident #2) reviewed for storage of drugs, in that: The facility failed to ensure Resident #2's nystatin powder [a medication for fungus] was secured. This failure could place residents at risk of medication misuse and diversion. The findings were: Record review of Resident #2's face sheet, dated 4/19/24, revealed Resident #2 was initially admitted to the facility on [DATE] with diagnoses of other lack of coordination, erythema intertrigo [redness on both sides of a skin fold], acute pyelonephritis [a type of urinary tract infection where one or both kidneys become infected], and obstructive and reflux uropathy [when urine is unable to drain through the urinary tract and causes urine to back up into the kidneys], unspecified. Record review of Resident #2's entry MDS, dated [DATE], revealed no BIMS score. Record review of Resident #2's physician orders, dated 4/18/24, revealed the following order, dated 2/13/24: Clean abdominal folds with wound cleanser, pat dry, sprinkle nystatin powder followed by ABD [abdominal] pad once daily/PRN. as needed for redness. During an observation and interview on 4/18/24 at 11:58 p.m., an unlabeled medication cup with white powder was on Resident #2's bedside table, unsecured and unattended. Resident #2 stated the white powder was a medicated powder for her skin folds. Resident #2 stated someone brought the medication into her room and left it on the bedside table. During an interview on 4/18/24 at 12:06 a.m., LVN D stated he was Resident #2's nurse. LVN D stated he ensured medication security by ensuring a resident took the medication and locking the medication cart. LVN D stated medications should not be in a resident's room unless there was an order for the medication to be in the room. LVN D stated he saw the medication cup of white powder in Resident #2's room earlier and he did not know how the medication got there or who put the medication in there. LVN D stated when he saw the medication cup of white powder earlier he should have removed it from Resident #2's room. During an interview on 4/19/24 at 12:17 p.m., the DON stated she just started in this position at this facility. The DON stated he and the ADON conducted rounds every day to ensure medications were secured appropriately. When asked what sort of negative effects could occur to the residents if medications were left in their rooms, the DON stated, anybody can get them and have access to them. Record review of a facility policy titled, Storage of Medications, dated December 2023, revealed the following: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems.

Based on observation, interview, and record review, the facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 residents (Resident #2) reviewed for incontinent care and catheter care, in that: The facility failed to ensure Resident #2's urinary catheter tubing was secured. This failure could place residents at risk for infection, pain, and skin break down due to improper care practices. Record review of Resident #2's face sheet, dated 4/19/24, revealed Resident #2 was initially admitted to the facility on [DATE] with diagnoses of other lack of coordination, erythema intertrigo [redness on both sides of a skin fold], acute pyelonephritis [a type of urinary tract infection where one or both kidneys become infected], and obstructive and reflux uropathy [when urine is unable to drain through the urinary tract and causes urine to back up into the kidneys], unspecified. Record review of Resident #2's entry MDS, dated [DATE], revealed no BIMS score. Record review of Resident #2's physician orders, dated 4/18/24, revealed the following order, dated 1/30/24: monitor foley catheter [a flexible tube that is inserted through the urethra and into the bladder to drain urine; a urinary catheter] leg strap for proper placement every shift. Observation of Resident #2's urinary catheter care on 4/18/24 at 11:01 a.m. revealed Resident #2 had a stabilization device placed on her left thigh, which was meant to prevent the urinary catheter tubing from moving and causing discomfort to Resident #2. Resident #2's urinary catheter was not anchored using the stabilization device. During an interview on 4/18/24 at 11:13 a.m., after Resident #2's urinary catheter care, CNA C stated the stabilization device on Resident #2s left high was to hold the urinary catheter. CNA C stated Resident #2's urinary catheter was disconnected from the stabilization device because she (CNA C) and another CNA were doing the urinary catheter care. CNA C stated Resident #2's LVN, LVN D, will reconnect the urinary catheter to the stabilization device. During an observation and interview on 4/18/24 at 11:58 a.m., Resident #2's urinary catheter was still not connected to the stabilization device. Resident #2 stated the device had been disconnected prior to the catheter care earlier but the facility staff had not reconnected the urinary catheter to the stabilization device. During an interview on 4/19/24 at 12:17 p.m., the DON stated she was new to the position at this facility. The DON stated she was not sure if the facility had a process to ensure urinary catheters were secured appropriately, but she knew the facility conducted rounds to check a resident's oxygen tubing, foley catheters, and gastrostomy tubes [an artificial opening to the stomach from the abdominal wall.] When asked what sort of negative effects could occur to the residents if their foley catheters were not secured appropriately, the DON stated, it could be pulled or dislodged or cause some kind of trauma. Record review of a facility policy titled, Catheter Care, Urinary, dated 6/18/18, revealed the following: Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.)

Based on observation, interview, and record review, the facility failed to provide services as outlined by the comprehensive care plan that meet professional standards of quality for 1 of 5 residents (Resident #1) reviewed for (insert type of care plan you were reviewing) in that: The facility failed to ensure Resident #1's care plan addressed his contractures. This failure could place residents at risk for not receiving the care and services to meet their needs. The findings were: Record review of Resident #1's face sheet, dated 4/18/24, revealed Resident #1 was initially admitted to the facility on [DATE] with diagnoses of cerebral infarction [stroke], contracture [a fixed tightening of muscle or tendons], right knee, contracture, left knee, muscle wasting and atrophy [shrinking of muscle or nerve tissue], not elsewhere classified, multiple sites, and pressure ulcer of other site, stage 3. Record review of Resident #1's entry MDS, dated [DATE], revealed Resident #1 had no BIMS score because Resident #1 was rarely/never understood. Further record review of this document revealed Resident #1 had the following Additional Active Diagnosis . contracture, right knee . contracture, left knee . muscle wasting and atrophy. Record review of Resident #1 care plan, dated 4/18/24, revealed Resident #1 did not have a care plan specifically for his contractures. Observation on 4/19/24 at 9:15 a.m., revealed Resident #1 was in bed and in no acute distress. Resident #1 had contractures in both lower extremities, causing his knees to bed. During an interview and record review on 4/19/24 at 11:54 a.m., the MDS Coordinator stated, diagnosis, code status, hospice . whatever applies to the patients, should be on the resident's care plan. The MDS Coordinator confirmed contractures should be on the care plan. The MDS Coordinator stated Resident #1 had contractures and stated she did not create Resident #1's care plan. The MDS Coordinator stated she did not know who created his care plan. Resident #1's care plan was reviewed with the MDS Coordinator and MDS Coordinator confirmed Resident #1's care plan did not have a care plan about his contractures. The MDS Coordinator stated the facility's corporate nurse went through the resident care plans but she (the MDS Coordinator) was not sure how frequently the corporate nurse did this. When asked what sort of negative effects could occur to the residents if their care plans did not include contractures, the MDS Coordinator stated, I couldn't answer that question. Record review of a facility policy titled, Care Plans, Comprehensive, dated December 2023, revealed the following: the comprehensive, person-centered care plan will: .describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being[.] Record review of a facility policy titled, Resident Mobility and Range of Motion, dated December 2023, revealed the following: The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion.

Based on observation, interviews, and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 (Resident #6) residents reviewed for accidents. Resident #6 eloped from the facility on 03/07/24 after a visitor opened the front door, pushed Resident #6 in her wheelchair out of the facility and another individual pushed Resident #6 across the street to Hospital C where she was found several hours later. This non-compliance was identified as past non-compliance IJ. The non-compliance began on 3/07/2024 and removed on 3/07/2024. The facility had corrected the noncompliance before survey began. This failure could place residents at risk for harm due to risk of elopement. The findings included: Record review of Resident #6's face sheet, dated 3/12/24, revealed she was admitted to the facility from an acute care hospital (Hospital D) on 03/01/24 with diagnoses which included schizophrenia (a mental disorder characterized by reoccurring episodes of psychosis), bipolar disorder (mental disorder characterized by periods of depressing and periods of abnormally elevated mood), heart failure, osteoarthritis (degenerative joint disease that results from breakdown of joint cartilage and bone) of right knee, and right artificial knee joint. Further review of the face sheet revealed Resident #6 was discharged from the facility on 03/08/24 to Nursing Home H. Record review of Resident #6's paperwork from Hospital D from 2/20/24 to 03/01/24, provided to the facility upon admission, revealed no notation of elopement behaviors or need for one-on-one monitoring for Resident #6. Record review of Resident #6's facility's Skilled Nursing Evaluation, completed 03/01/24 at admission, revealed the resident used a manual wheelchair to propel herself around the facility. Record review of Resident #6's Physician Progress Note, dated 03/01/24, revealed the resident was admitted to the facility after hospitalization at a local rehabilitation hospital, had a total knee replacement in January 2024, and quit tobacco use 2 years ago. Record review of Resident #6's nurses' notes from 3/1/24 to 3/6/24 indicated the resident would propel herself around the facility in her wheelchair, did not have any exit seeking behaviors and did not ask for cigarettes. Record review of Resident #6's nurses' note, dated 03/07/24, by the DON revealed she was notified by staff nurse at approximately 8:30 PM Resident #6 could not be located. A sweep of all the rooms and bathrooms was completed by onsite staff along with a sweep of the facility perimeter and nearby street. The Administrator reviewed facility camera footage and noted a male visitor assisted the resident outside. The resident was sitting outside in her wheelchair when a male walking by spoke to the resident, and he assisted her over to Hospital C across the street. Resident #6 was found in the hospital at 9:30 PM. The DON spoke to Resident #6 who initially refused to return to the facility, and stated she went to the hospital to get help. When the DON asked what she needed help with, Resident #6 asked for cigarettes. Resident #6 agreed to return to the facility after the DON informed the resident her family would be contacted and asked if they could bring the resident some cigarettes. Resident #6 was brought back to the facility via wheelchair, assessed for pain and injuries. Resident #6 denied pain and no apparent new injuries were noted. Resident #6's Responsible Party and physician were notified. Record review of Resident #6's nurses' note, dated 03/08/24, by the DON revealed Resident #6's RP was contacted and the RP verbalized understanding that Resident #6 was exit seeking trying to get cigarettes and agreed to transfer the resident to another facility that had a wander guard system. DON informed RP the facility would arrange transport to the agreed upon facility. Record review of Resident #6's March 2024 Physician Orders revealed an order dated 03/08/24 to discharge the resident to Nursing Home H. Record review of Resident #6's Interdisciplinary Discharge Summary, dated 03/09/24, revealed the resident was transferred on 03/08/24 to Nursing Home H with a wander guard system after the resident exited the facility. The transfer was initiated for resident safety with the assistance and support of family after Resident #6 eloped from facility. Record review of Resident #6's MDS revealed a Quarterly/Medicare 5-day assessment was in progress. Record review of Resident #6's BIMS Evaluation, dated 03/01/24, revealed a score of 11 out of 15, indication of moderate cognitive impairment in making decisions about tasks of daily life. Record review of Resident #6's Elopement Evaluation, dated 03/07/24 at 10:40 PM, revealed the resident did not have a history of elopement when at home, did not have a history of elopement or attempted leaving the facility without informing staff, and did not wander aimlessly or had non-goal-directed wandering. It was checked the resident had verbally expressed the desire to go home or stayed near an exit door and the resident had recently been admitted and was not accepting the situation, and a risk for wandering was identified. Record review of Resident #6's Care Plans revealed a care plan initiated on 03/07/24 for the Risk for Elopement related to wanting to smoke outside. Elopement on 3/7/24 - Resident #6 exited the facility .to find someone to borrow cigarettes from. Resident educated on not leaving facility. Admin [Administrator] working on alternative placement at a smoking facility/wander guard per resident request. Record review of the Provider Investigation Report, dated 3/13/24 revealed on 03/07/24, Resident #6, who had the capacity to make informed decisions and was not independently ambulatory, was discovered missing from the facility around 8 PM during room rounds. The DON and Administrator were notified, arrived at the facility, and determined a time frame of when the resident was last seen. The Administrator was able to locate the resident on the facility's cameras and determined at approximately 6:15 PM, Resident #6 was seen in the front lobby area in her wheelchair when a visitor was seen holding the door open and assisted Resident #6 out of the facility. Resident #6 remained in the front area for several minutes before she propelled herself towards the sidewalk. A stranger walked by, had a discussion with Resident #6 and then pushed her across the street to Hospital C. The Administrator and DON went to the hospital to find the resident and found Resident #6 propelling herself in the hospital hallway. Resident #6 was assisted back to the facility, assessed by the DON with no injuries noted. Resident #6's physician and responsible party were notified. Resident #6 remained on elopement watch until she was discharged to another facility with a wander guard system. Staff were in-serviced on Elopement Policy and Procedure. Resident #6's care plan was updated to reflect the resident's risk of elopement. The Elopement Monitoring sheet for Resident #6 was included in the PIR along with Resident #6's updated care plan. Observation on 03/09/24 at 7:55 AM revealed the front door of the facility faced a street, and was located across from Hospital C. The front door was not locked and there was no code to punch to open the door when the surveyor entered the facility. Inside the front lobby a female staff member (HR Employee) sat at the desk in the lobby area. In an interview on 03/09/24 at 8:24 AM, HR Employee stated Resident #6 had been transferred to another nursing home on 03/08/24. In a telephone interview on 03/09/24 at 9:01 AM, the Regional Nurse Consultant stated the facility had recently reported the elopement of Resident #6 [to HHSC] when a visitor had let the resident out of the facility. The Regional Nurse Consultant stated Resident #6 wanted to go out of the facility to get a cigarette, she was in a wheelchair and physically could not open the front door because it was too heavy for the resident. The Regional Nurse stated Resident #6 was slightly cognitively impaired due to the resident's mental diagnoses but Resident #6 could present herself as being cognitively with it to someone who did not know her. The Regional Nurse Consultant said Resident #6 was transferred to another facility that allowed smoking, had a wander guard system, and because the resident could try to convince someone to let her out of the facility and this facility did not have a wander guard system (a device placed on a resident who was confused that would cause the door to lock and not open when the resident was near the door preventing them from leaving the facility). In an interview on 03/09/24 at 10:47 AM, CNA E stated Resident #6 would be in the hallway in her wheelchair asking for ice, would sit in the front lobby area, and had not tried to exit the facility. CNA E stated on 03/07/24 she saw Resident #6 in the dining room during the evening meal, then she thought the resident went to her room. CNA E stated around 8 PM when she was doing room rounds, she did not see Resident #6, informed the nurse, they searched the building, the patio area and they could not find the resident. CNA E stated the nurse notified the DON and Administrator who came to the facility. The CNA thought the Administrator found Resident #6. In an interview on 03/09/24 at 2:50 PM, the Activity Director stated Resident #6 had been in the facility for one week, liked to sit outside in front of the building in view of the front receptionist/HR employee and could not open the front door herself. Observation on 03/10/24 at 7:55 AM revealed the front door was not locked, there was no keypad to punch to unlock the door, and no alarm sounded when the surveyor entered the facility, and there was no signage directing visitors to not let residents out of the facility without notifying staff. Inside the front lobby the HR Employee sat at the desk in the lobby area. In an interview on 03/10/24 at 9:08 AM, CNA F stated Resident #6 would propel herself around the facility in the hallways and could not open the front door by herself. In a telephone interview on 03/10/24 at 10:19 AM, CNA G stated she worked the 10 PM to 6 AM shift and Resident #6 would sleep a couple of hours at night, would propel herself around the facility in her wheelchair, sit at the front door and the CNA never saw the resident touch the front door or try to leave the facility. CNA G said she worked the night shift on 03/07/24 (into 03/08/24) after Resident #6 had eloped and the CNA had to lay eyes on the resident every 30 minutes which was documented on an elopement monitoring form and was in-serviced on elopement. In an interview on 03/10/24 at 2:33 PM, the DON stated Resident #6 wanted to be independent, would propel herself around in the hallways, would sit in the front and out in front of the facility and the HR Employee would watch Resident #6. The DON said Resident #6 could not open the front door herself, had not tried to do it before the elopement and a visitor assisted the resident out of the facility the evening she eloped. The DON stated Resident #6 was found across the street at Hospital C, she was assessed for injuries with none noted, the resident's family and physician were notified. After Resident #6 was brought back to the facility, the DON said monitoring was done on Resident #6 every 30 minutes until an alternative facility was found for Resident #6 where she could be more secured. The DON stated the facility did not have a wander guard system. In an interview on 03/10/24 at 3:32 PM the Administrator stated he was at home when the DON informed him staff could not find Resident #6 in her room. They looked in all the rooms and immediate area outside the facility, could not find the resident and contacted the DON and him. The Administrator said he looked at the facility's cameras which showed Resident #6 left the dining room after the evening meal, then down 300 hall (which was between the hall w/ the dining room and the front area) into the front lobby. A visitor went out the front door and pushed Resident #6 out the front door. Resident #6 was in front of the facility and another stranger assisted Resident #6 by pushing her across the street to the hospital. The Administrator stated he and the DON went to the hospital, searched the hospital halls and found Resident #6, brought her back to the facility, started 30-minute monitoring of the resident which was documented until Resident #6 was transferred to another facility that had a wander guard system. The Administrator said there was nothing in Resident #6's prior history that indicated the resident was an elopement risk, the resident could not open the front door herself and if it had not been for the visitor, Resident #6 would not have gotten out of the facility by herself. Observation and interview on 03/11/24 at 8:15 AM of Resident #6 in Nursing Home H, revealed the resident was in a wheelchair and could propel herself without assistance. Resident #6 stated she went to the hospital because she wanted her leg to be looked at. Resident #6 pulled her gown up over her right knee and showed the surveyor a healed surgical scar over the knee cap. Resident #6 said she had someone help her walk across to the hospital. When asked if she could open the front door of the facility without assistance, Resident #6 became agitated and asked, why are you asking these questions? Observation on 03/11/24 at 9:15 AM revealed when the surveyor entered the facility, the front door was unlocked, there was no signage at the entrance directing visitors to not let residents out of the facility without notifying staff, and the HR Employee was at the front desk in the lobby area. In an interview on 03/11/24 at 9:47 AM, the Administrator stated the facility's cameras showed a visitor held the door open, let Resident #6 go out of the building and assisted with pushing her over the door threshold. Resident #6 sat in front of the building for about 10 minutes, then propelled herself to the edge of the driveway when a person walking by stopped to talk with Resident #6 and then pushed her across the street to the hospital. The Administrator said the time from when Resident #6 was pushed out of the facility and then across the street was about 30 minutes. The Administrator stated since this incident, staff had been in-serviced on elopements and the red-alarm on top of the front door would be turned on when the HR employee was not at the front desk. In a further interview on 03/11/24 at 10:31 AM, the Administrator stated half of the staff had been in-serviced on Elopement and the other half would be in-serviced on 03/11/24. In an interview on 03/11/24 at 10:44 AM, MA I stated on 03/07/24 she saw Resident #6 sitting in front of the Administrator's office, in the font lobby with HR Employee and did not remember the resident talk about cigarettes. In an interview on 03/11/24 at 10:51 AM, CNA F stated on 03/07/24 Resident #6 was propelling herself around the facility in her wheelchair, asking for coffee, then she sat by the nurse's station, and did not mention anything about cigarettes to the CNA during the day. CNA F said, I didn't know she smoked. In an interview on 03/11/24 at 10:55 AM, HR Employee said Resident #6 would frequently be in the front lobby and if the resident wanted to go outside she would assist the resident outside and have her in front of the window to watch the resident. HR Employee stated on 03/07/24 she took Resident #6 outside and watched her through the window, the resident requested coffee, candy and only mentioned she wanted to put a cigarette into her mouth which the HR Employee discouraged the resident from doing so. The HR Employee said she took Resident #6 to the nurse's station when she left the facility at 5 PM. In an interview on 03/11/24 at 11:27 AM LVN J stated she worked the 2 PM to 10 PM shift on 03/07/24. LVN J said Resident #6 was propelling herself in the hallways and had asked for ice. LVN J stated she directed Resident #6 to the dining room around dinner time. LVN J stated when the CNAs were doing their last rounds for the evening, they could not find Resident #6. LVN J said she asked the aides when they last saw the resident which was when she had been in the dining room at the dinner meal. LVJ J stated they started to look for Resident #6 and when they could not find her they called the DON and Administrator. LVN J stated on 03/08/24 she monitored Resident #6 by making sure the resident was in her visual line of sight which was recorded on the monitoring sheet until the resident was transferred to another facility. In a telephone interview on 03/11/24 at 11:54 AM CNA E, who worked from 6 AM to 10 PM on 03/07/24, stated Resident #6 had mentioned she wanted to call her family, did not mention cigarettes or about wanting to try to leave the facility. CNA E stated around 6 PM a family member rang the doorbell because the front door was locked, she let them into the facility, made sure the door was closed after she let them into the building because it would make a locking sound when pulled all the way shut, and the red alarm on the front door was not turned on. In a telephone interview on 03/11/24 at 12:06 PM CNA K stated he worked the 2 PM to 10 PM shift on 03/07/24, he did not remember Resident #6 asking for cigarettes that day, had not seen the resident try to push the front door open and the last time he saw the resident was after dinner in front of her room. CNA K stated after Resident #6 was brought back to the facility a visual eye was kept on the resident and recorded on the monitoring log. In an interview on 03/11/24 at 12:17 PM, HR Employee stated when the front door was locked, visitors and staff could not enter the facility without ringing the doorbell but staff and visitors inside the building could exit the facility when the front door was locked by pushing on the bar. In a telephone interview on 03/11/24 at 12:20 PM CNA L stated she worked the 2 PM to 10 PM shift on 03/07/24 and Resident #6 was asking for ice, propelled herself around the facility, she did not ask for any cigarettes and last saw the resident in the dining room after dinner around 6 PM. CNA L said she was on her dinner break at 8 PM when CNA E asked CNA L when she last saw Resident #6 because they could not find her. CNA L stated they looked around the facility for the resident and the DON and Administrator came to assist with searching for the resident. CNA L stated the next day there was a monitoring sheet kept at the nurse's station that staff would initial that Resident #6 had been seen and she was in-serviced on elopement. In an interview on 03/11/24 at 1:24 PM, the Administrator stated because the facility does not have a wander guard system they would never accept any resident who had a history of elopement or elopement type behaviors. The Administrator said the red alarm on the top of the front door had been there when Resident #6 eloped from the facility, was not on when she left the building and after her elopement they started to turn it on when there was no one at the front desk. In an interview on 03/11/24 at 1:25 PM, the Regional Nurse Consultant said she completed the pre-admission screening for Resident #6 and there was no indication in the preadmission paperwork or hospital paperwork that the resident was an elopement risk or required one-on-one monitoring. The Regional Nurse stated if Resident #6 had a history of elopement, the resident would have been referred to a facility that had a wander guard system. Further interview on 03/11/24 at 4:20 PM, the Regional Nurse Consultant stated Resident #6's Hospital D's paperwork did not indicate Resident had eloped, therefore Resident #6's baseline care plan assessment was not checked that the resident was at risk for elopement because there had not been any previous elopements. Observation on 03/12/24 at 8:10 AM revealed there was no signage on the front door directing visitors to not let residents out of the facility without notifying staff. Record review of the policy Elopements, dated December 2023, revealed Staff shall investigate and report all cases of missing residents 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. 3. When a departing individual returns to the facility, the Director of Nursing services or Charge Nurse shall: a. Examine the resident for injuries; b. Notify the Attending Physician; c. Notify the resident's legal representative (sponsor) of the incident; d. Complete and file Report of Incident/Accident; and e. Document the event in the resident's medical record. 4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on a authorized leave or pass; b. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative, the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.); d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area. 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Contact the Attending Physician and report findings and conditions of the resident; c. Notify the resident's legal representative; d. Notify search teams that the resident has been located; e. Complete and file an incident report; and f. Document relevant information in the resident's medical record. This non-compliance was identified as past non-compliance IJ. The non-compliance began on 3/07/2024 and removed on 3/07/2024. The facility had corrected the noncompliance before survey began.

Based on observation, interviews, and record reviews the facility failed to ensure that the resident environment remained safe, clean, comfortable and homelike for 1 of 1 (Resident #8) resident reviewed. LVN A brought a handgun into the facility, unbeknownst to staff, hid in the oxygen supply closet, ran down the hallway into an empty room and broke a window. Then ran down another hallway into Resident #8's room while the resident was sleeping, hid in the closet, emerged from the closet, and pointed the gun at the BOM and Maintenance director who lured the LVN out of resident #8's room and told LVN A to leave the facility. The non-compliance was identified as past non-compliance IJ. The non-compliance began on 12/04/2023 and ended on 12/04/2023. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk for harm due to not receiving protection for safe daily living. The findings include: 1. Record review of the facility's Provider Investigation Report (PIR) dated 12/04/23 revealed on 12/04/23 around 7:50 AM, the 10 PM to 6 AM nurse (LVN A) started acting erratic after he finished his shift. LVN A hid in the oxygen supply closet for approximately an hour before coming out of the closet with a gun in his hand, which was not seen by staff, and ran to room [ROOM NUMBER] which was empty and broke the window. He then proceeded to run down the hall into Resident #8's room into the closet while the resident was sleeping. BOM and the Maintenance Director were informed LVN A ran into a resident's room looking suspicious and when they went to investigate, LVN A came out of the closet in Resident #8's room, pointed the gun at them briefly before putting it in his pocket. Staff immediately called 911 and started closing residents' doors. Staff attempted to keep LVN A away from residents' rooms and at the nurses' station and attempted to get him to leave. LVN A left before the police arrived. LVN A was terminated and reported to the Texas Board of Nursing. The code on the back door was changed, the front door was kept locked for a month. The pharmacist representative did an audit of the medication carts with no discrepancies found. The window to room [ROOM NUMBER] was repaired. The social worker interviewed all residents on 200 hall to ensure they felt safe, which included Resident #8. The Medical Director was notified. Staff were in-serviced with in-service on active shooter and workplace violence. The local police department was asked to perform patrol car rounds at the facility. Record review of the undated In-Service Training Report, included in the PIR, for the topic Active Shooter revealed 26 employees had signed they were in-serviced. Record review of the undated In-Service Training Report, included in the PIR, for the topic Work Place Violence revealed 26 employees had signed they were in-serviced. Record review of the Texas Board of Nursing Complaint form, included in the PIR, was submitted on 12/04/23 at 10:56 AM and noted LVN A .went into a manic state. Pacing through the hallway breaking a back window and later pointing a gun at two staff members, BOM and Maintenance Director. The complaint form indicated no patient/resident harm occurred and LVN A was terminated. Record review of resident interviews included in the PIR revealed 8 residents who resided on the same hall as Resident #8 and Resident #8 were interviewed by the Social Worker on 12/04/23 with none of the residents reported any concerns with the way staff treated them and no reports of anything unusual happening that morning. Record review of Resident #8's face sheet, dated 3/12/24, revealed he was admitted to the facility on [DATE] with diagnoses which included swallowing difficulty, cognitive communication deficit (difficulty thinking and use of language), alcohol-induced dementia (decline in cognitive abilities that impacts a person's ability to perform daily tasks), and high blood pressure; and was discharged from the facility on 01/15/24. Record review of Resident #8's Social Services Note, dated 12/04/23, revealed the social worker was unable to ask Resident #8 questions about the incident that occurred in his room because he was asleep throughout the entire incident and remained asleep when the social worker tried to interview him. Record review of Resident #8's Nurse's Notes, dated 12/04/23, written by the ADON, revealed the resident's mood was pleasant and no injuries noted. Record review of Resident #8's Physician Progress Note, dated 12/04/23 revealed the resident had history of psychiatric disorder and alcohol abuse, was a poor historian, and the resident was doing well. Record review of Resident #8's Social Worker Note, dated 12/07/23 revealed the resident was not feeling down or depressed. Record review of Resident #8's MDS, a Quarterly assessment dated [DATE], revealed a BIMS score of 5 out of 15, indication of severe cognitive impairment, and no signs that the resident was feeling down or sad. Record review of LVN A's employee file revealed he was hired on 10/24/23 as an LVN, his license was current, required background checks were conducted before employment without any restrictions against the LVN, and he was terminated on 12/04/23 for misconduct. Included in LVN A's employee file was an Acknowledgement Receipt form signed by LVN A on 10/24/23 in which he acknowledged receipt of the facility's Employee Handbook. Record review of the facility's Employee Handbook, revised March 2014, revealed on pages 9-10 under Employee Conduct and Work Rules was To ensure orderly operations and provide the best possible work environment, the Facility expects employees to follow rules of conduct that will protect the interests and safety of all employees, patients [residents] and the Facility .The following are examples of infractions of rules of conduct that may result in disciplinary action, up to and including termination of employment: .Possession of dangerous or unauthorized materials such as explosives or firearms (including concealed weapons carried under license), in the workplace . Record review of the undated facility's Disciplinary Action Policy revealed Employees are subject to disciplinary action according to the criteria outlined below. Employees discharged for cause under any part of this policy are not eligible for rehire Category I: These offenses are most serious and may subject an employee to immediate discharge without rehire privileges .9. Possession of a firearm or other weapon on the facility premises. Observation on 03/09/24 at 5:05 p.m. revealed a large sign was posted outside the facility near the front door that stated no firearms were permitted in the facility. In a telephone interview on 03/09/24 at 4:27 PM the former BOM stated she was the BOM for the facility when the incident occurred with LVN A. The BOM stated before the incident she had very little interaction with LVN A. On 12/04/23, the BOM stated she arrived at the facility at 7:30 AM, started her day as usual, when a CNA came to her office and told her LVN A was acting weird. The CNA left her office, came back, and said LVN A was still acting weird, and he ran into a resident's room, and advised the BOM to not go by herself when she investigated the situation. The BOM stated the Maintenance Director was in the facility and asked her if she heard the noise. The BOM said to the Maintenance Director what loud noise and he replied that a window had been broken. The BOM stated they were by the nurse's station and saw drops of blood on the floor. They followed the drops of blood on the floor down the hall into the second to the last room on the hall (Resident #8's room). The BOM said she knocked on Resident #8's door several times announcing the resident's name and she did not hear anything, so she slowly opened the door and walked into the room. Suddenly LVN A burst out of the closet in Resident #8's room and pointed a gun at the BOM. The BOM said he was waving the gun around briefly before he put the gun in his pocket and was saying They're here, they're out there, and they're after him. The BOM stated she slowly backed out of the room as LVN A was saying that people were after him and she told LVN A there was nothing going on. The BOM said she and the Maintenance Director were able to get LVN A out of Resident #8's room and down to the nurse's station and LVN A was dripping blood as he walked towards the nurse's station. The BOM stated she asked LVN A to get his belongings and leave and LVN A responded no he couldn't go. The BOM said the nurse who relieved LVN A was on the phone with the police while the BOM was luring LVN A out of the resident's room down to the nurses' station. The BOM stated LVN A went into the bathroom at the nurse's station and when he came out, he asked if the cops were on the way. The BOM said she did not answer this question because she knew LVN A had a gun in his pocket. The BOM stated LVN A then went around the nurse's station into the oxygen supply closet (located near the nurse's station), got his backpack and left the facility about five minutes before the police arrived at the facility. The BOM stated she called the Administrator, but LVN A left the facility before the Administrator arrived. In an interview on 03/10/24 at 9:31 AM, the Maintenance Director stated he usually arrives at the facility around 7 AM. On 12/04/23 he was in his office which was outside behind the facility in a shed when he heard a loud bang sound and got up to investigate. The Maintenance Director said he noticed a window was busted out from the inside with glass on the outside of the building on the 300 hall side which did not have any residents. He went inside and saw glass on the floor inside room [ROOM NUMBER], which was empty, and drops of blood on the floor. The Maintenance Director stated he followed the drops of blood up to the nurse's station where he ran into the BOM and a CNA. The Maintenance Director said they asked him did you see LVN A, he is running up and down, acting crazy, to which he replied no. The Maintenance Director stated he asked them if they had seen the blood on the floor and the BOM stated no, so he and the BOM followed the blood trail which led to Resident #8's room. The Maintenance Director said the BOM knocked on Resident #8's door, asked for the resident's name, and LVN A came out of the resident's closet, swung a gun at the BOM and the Maintenance Director, saying a curse word and asked, where are they. The Maintenance Director stated the BOM said to LVN A nobody is here, you are at work, you are alright, and LVN A put the gun in his sweatpants pocket and walked out of the room. The Maintenance Director stated he kept asking LVN A if he was ok and told him his shift ended. The Maintenance Director said as LVN A walked towards the nurse's station he was bleeding from his hand, so the Maintenance Director got LVN A a rag for his hand, then someone called LVN A on LVN A's cell phone and told him he needed to leave. The Maintenance Director stated LVN A then went into the oxygen supply closet, grabbed his backpack, and walked out of the facility. The Maintenance Director stated Resident #8 was no longer in the facility, his interaction with LVN A prior to this incident was brief only saying hi to him when the Maintenance Director entered the facility and he had not seen LVN A bring a gun to the facility before that day. In a telephone interview on 03/10/24 at 10:19 AM, CNA G revealed she worked the 10 PM to 6 AM shift with LVN A. CNA G stated LVN A was nice to the residents, he did his work, and she had not seen any erratic behavior from LVN A. CNA G said LVN A would bring food and energy drinks to work, saw him drink a lot of energy drinks and had not seen the nurse bring a weapon into the facility. CNA G stated she worked the night shift with LVN A on 12/03/23 into 12/04/23, she did not see any unusual behavior from the nurse during the shift and he was kind of tired. CNA G stated she would usually get a ride home from LVN A but that morning he was rushed at the end of the shift and by 6 AM she didn't want to wait for him to finish his work, so she left the facility. In an interview on 03/12/24 at 2:30 PM, LVN M stated she was the on-coming nurse on 12/04/23; she arrived at the facility at 6 AM, received report from LVN A, counted medications with him and he looked like he was a bit distracted. LVN M said she saw him walk towards the timeclock (located next to the oxygen supply closet), thought he clocked out and left the building. LVN M stated she last saw LVN A at 6:30 AM and did not see him until 8 AM when she saw him come out of Resident #8's room. LVN M said she called the Administrator, then called 911 and LVN A left before the administrator and the police arrived at the facility. LVN M stated LVN A was bleeding from his hand, he did not have his gun out when he came out of the resident's room and when he was at the nurse's station. LVN M stated LVN A would bring a backpack to work but she did not see a gun. In an interview on 03/10/24 at 8:48 a.m. the Administrator stated the Social Worker interviewed residents who resided on the hall where the incident happened. In a telephone interview on 03/10/24 at 10:47 AM, the Social Worker stated she works in a sister facility and had been assisting this facility since September 2023. The Social Worker said the facility contacted her about the situation with LVN A bringing a gun into the facility and asked her to talk with the residents who resided on the hall were LVN A went into Resident #8's room. The Social Worker stated she interviewed the residents who resided on the same hall as Resident #8, and none of them were aware of what happened which included Resident #8 who happened to be asleep when she tried to interview him. In an interview on 03/10/24 at 2:33 PM, the DON stated LVN A worked the night shift (10 PM to 6 AM), she had not seen any odd or erratic behavior from him before this incident and this was not something she expected from him. The DON said LVN A would bring a backpack to work, and she saw him pull out pens, notebook, stethoscope, and other nursing supplies, and had not seen a gun. In an interview on 03/10/24 at 3:32 PM, the Administrator stated he was not in the facility when the incident happened, he was on his way to an appointment when LVN M called him and told the Administrator to come to the facility because LVN A was acting weird. The Administrator said he told LVN M to call the police, ask LVN A to leave the building and he was on his way to the facility. The Administrator said LVN A had left the facility by the time he arrived, so the Administrator reviewed the camera footage which showed after LVN A's shift ended, he went into the oxygen supply closet and stayed there for over an hour. Then the cameras showed LVN A came out with a gun in his hand, he ran down to the 300 hall into an empty room and broke a window, then ran down the hall where Resident #8 resided and into Resident #8's room. The Administrator stated staff did not know LVN A had a gun at this point and the cameras showed the BOM and the Maintenance Director went down the hall were Resident #8 resided and they encouraged LVN A to come out of the resident's room to the nurses' station. The Administrator said the cameras showed staff were closing the doors to residents' rooms on the hall where Resident #8 resided and LVN A left the facility before the police arrived. The Administrator said he reviewed the camera footage for the night shift (on 12/03/23 and 12/04/23) that LVN A had just worked and LVN A appeared to be completely normal during his shift, he was passing medications and doing other nursing things. The Administrator stated LVN A was terminated and referred to the Board of Nursing. The Administrator said after the incident, the codes to the doors were changed, the front door was kept locked, police did frequent rounds by the facility. The Administrator said the pharmacist consultant did an audit of the medication carts with no discrepancies noted. In an interview on 03/11/24 at 4:50 PM, the Administrator stated the facility does not allow staff to bring handguns into the facility, a sign is posted outside the facility, and it was included in the Employee Handbook. When asked how he ensures handguns were not brought into the facility, he stated he would have staff follow the facility's polices by informing them of the policies, through the posting that handguns were not allowed in the facility, and it was covered in the employee orientation process. In an interview on 03/11/24 at 4:52 PM, the Regional Nurse Consultant stated staff were encouraged to keep their personal items in their vehicles or to not bring personal items into the facility. In an interview on 03/11/24 at 4:52 PM, the Administrator stated staff were in-serviced on 12/07/24 on workplace violence in addition to trainings done immediately after the incident. In an interview on 03/11/24 at 5:55 PM, the Administrator stated in December 2023 the facility had 28 employees. In an interview on 03/12/24 at 10:14 AM, the Administrator stated the facility had police do frequent rounds around the facility and the front door was kept locked for a month. In an interview on 03/12/24 at 11:43 AM, the Administrator stated there were only two ways into the facility, through the back door which had a code and the front door. The Administrator stated after LVN A left the building on 12/04/23, he immediately changed the code to the back door, the front door was kept locked and visitors had to ring a doorbell to be let into the facility. The Administrator stated LVN A's paycheck was sent to him via direct deposit. The Administrator said when he called LVN A to inform him he was terminated, the call went directly to voicemail, the LVN did not call him back, and he did not have any contact with the LVN after the incident. The Administrator was notified of a Past-Noncompliance Immediate Jeopardy (IJ) on 03/12/2024 at 1:27 PM and was given a copy of the IJ Template. It was determined these failures placed Resident #8 in an Immediate Jeopardy (IJ) situation from 12/04/2023 through 12/04/2023. The facility took the following actions to correct the non-compliance following the incident, to include: 1. The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date:12/04/2023) -The social worker completed random resident interviews that included Resident #8, none were aware of the incident and no distress noted. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. -LVN A was immediately located and escorted away from resident living areas and voluntarily exited the facility before police arrived. Completion date: 12/4/2023 -Staff immediately called 911 and notified the facility Administrator. Police arrived. Completion date: 12/4/2023 -LVN A was immediately terminated and LVN A nurse's license was reported to the Texas Board of Nursing. Completion date: 12/4/2023 -Active shooter in service conducted with 26 of 28 employees on 12/4/2023. The two employees not in serviced were PRN and didn't pick up any shifts during that time frame. Completion date: 12/4/2023 -The facility has a sign in front of the facility by the front door that states handguns are not permitted in the facility. Completion date: has been in place for years. -The employee handbook presented to all employees during facility orientation states that handguns are not permitted in the facility. Completion date: 10/23/2023 -Law enforcement stated that they would do frequent rounds at the facility for the rest of the week. Date completed: 12/8/2023 -The front door always remained locked for a month to ensure the facility was secure. Completion date: 1/4/2024 -The code to the back door was changed. Completion date: 12/4/2023 -Pharmacy consultant was contacted to perform a medication review with no errors found. Completion date: 12/4/2023 3. The facility completed a reportable to HHSC (Intake # 468258) on 12/04/2023 in reference to the initial case from 12/04/2023. Interviews on 03/12/24 from 1:33 PM to 2:45 PM with 3 CNAs (one from each shift), 2 nurses, 3 dietary employees, 1 housekeeping staff, and 1 laundry staff revealed they had been in-serviced in December 2023 on workplace violence and how to handle an active shooter in the facility. The non-compliance was identified as past non-compliance IJ. The non-compliance began on 12/04/2023 and ended on 12/04/2023. The facility had corrected the non-compliance before the survey began. The facility implemented interventions listed above to prevent LVN A from entering the facility.

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents and supervision, in that: Resident # 1 was mechanically lifted by two staff members from bed to shower chair and was left unsupervised in his room. Resident #1 fell from the shower chair resulting in the resident hitting his head and suffered abrasions, facial bruising and head injury. The resident was sent to the ER for evaluation. This failure could result in residents experiencing accidents, injuries and/or a diminished quality of life. The findings were: Record review of Resident #1's electronic face sheet revealed a male resident, age 38, that was admitted on [DATE] for respite care with diagnoses that included, [CONDITION(S)] (a heredity condition marked by progressive weakening and wasting of the muscles), [CONDITION(S)], and [CONDITION(S)] (short movements). Record review of the admission MDS dated [DATE] revealed Resident #1 had a BIMS score of 8, which indicated moderate cognitive impairment. Further record review revealed Resident #1 total dependence for transfer and mobility with two person assist. Toileting was coded as total dependence with one person assist. Resident #1 was continent of bowel and bladder. During an interview on 5/20/21 at 10:04 AM, the MDS Nurse stated .one person assist means assist with hygiene and emptying the urinal and bed pan .would have to stay with resident to hold the urinal .once the resident is positioned the staff needs to be near and give privacy for bowel movement .give dignity . Record review of the Incident Log for March, April, May 2021 revealed Resident #1 had a fall in his room while trying to have a bowel movement on 4/29/21. Resident was attempting to adjust himself on the shower chair [the shower chair was not in the toilet but rather in the resident's room with a bag under [NAME] the seat to capture body waste. Immediate action taken was an .assessment of resident with vital signs. Resident transferred to ER for evaluation due to resident hitting his face and head . Record review of statement by Nurse C revealed, resident fell and Nurse C was alerted. The resident was found on the floor with a small wet to the head and a small cut to the bridge of the nose .EMS contacted [family was notified] .resident returned at 4:30 AM .no orders given . Record review of statement by Nurse D revealed, .I heard a loud cry .resident was on the floor .(resident stated) he tried to move himself .call 911 . Record review of ER report for Resident #1, dated 4/29/21 read, .abrasions .facial bruise (contusion) .[and] head injury . There were no orders at discharge and only a recommendation of follow-up with physician. During an observation and interview on 05/19/21 at 10:35 a.m., Resident #1 stated, .I fell in my room from a shower chair I was trying to adjust my weight and loss balance .I fell forward and hit my head and got a swelling .my feet could not move .or lift myself . and I could not reach the call light .I yelled for help .and Nurse Aide arrived sometime shortly .I was left alone in the shower chair for a bowel movement .don't know why .first time this happened .since 4/29/21 have not been left alone .before 4/29/21 a nurse aide would stay with me . During an observation and interview on 05/19/21 at 2:30 p.m., Resident #1, in his room, he stated, .the fall happened in my room .Staff (Nurse Aide B) and ( Nurse Aide A ) put me in a shower chair for me to have a bowel movement .they left .I fell .it was not in the shower room .it was the first time this happened .in the past they stayed with me . During a joint interview on 05/19/21 at 2:35 p.m., Resident #1's family stated, .we were told about the fall by a Nurse C .she stated the staff wanted to give (the Resident) privacy .we believe that safety trumps privacy .(the Resident) cannot bear weight and needs to be watched in the bathroom .we will send you pictures showing the bruises to the head . During a telephone interview on 05/19/21 at 4:05 p.m., CNA A stated, she confirmed being present during the fall incident and added: .we (CNA A and CNA B) transferred the Resident (Resident #1) from bed to shower chair for him to have a bowel movement (per his request) .I was by the door inside the room with the curtain pulled so as to give him privacy . [CNA A did not hear Resident #1's fall]I .I heard him yelling .left to call for help .after the incident we got training from the DON . the training involved providing assistance and staying with residents that were a risk (for accidents and falls) .to keep an eye on Residents like (Resident #1) during a bowel movement .I also received training on abuse and neglect . During an interview on 5/19/21 at 4:10 PM, the DON stated, .I in-service the Nurse Aides that worked with Resident (#1) after the incident .but did not document the training .the training involved the monitoring of a Resident like (Resident #1) .[that is] residents who are continent but requires assistance and supervision .the training included to provide assistance [ per MDS and CP] .we reached an understanding with the family that (Resident #1's) door would be kept opened .curtain drawn .and frequent monitoring of the Resident .the issue with (Resident #1) was that it would take him one hour to 90 minutes for the Resident to have a bowel movement .at night the Nurse Aides have other Residents to provide care to .the Resident was given privacy .and staff responded to the fall .the training was not documented [no reason given for the lack of documentation on training]. During a telephone interview on 5/19/21 at 4:20 PM, CNA B stated, she confirmed being present during the fall incident and added: .we put the resident in a shower room chair .we left to give the resident privacy .no one stayed in the room .while walking down the hallway I heard him (Resident #1) screaming for help .CNA A was not in the resident's room .I entered the room and called for (nursing) help .the DON has provided us training on observing Resident (#1) when he has bowel movements .to encourage him to use a bed pan .and to go to sleep late at night .we left to give him privacy .[training was on providing supervision for residents that were at risk for falls] .after the incident we stayed with the resident when he wanted a bowel or bladder movement at night .I received training on abuse and neglect .yes .the practice was to leave the room prior to the incident so as to give the resident privacy . During telephone interview on 5/19/21 at 7:40 p.m., Nurse C stated, .the CNAs (notified me that) Resident (#1) had fallen .I found him on the floor with an injury .he hit his face hard on the floor (in his room) .he (Resident #1) told me he fell while adjusting himself in the shower chair and not using the call light for assistance .the CNAs were down the hallway nearby the resident .this had never happened before .I called his (family) and the resident was sent to the ER for an evaluation .the DON provided (in-service to the CNAs) .the training consisted of CNAs staying with residents that required (ADL) assistance .Resident (#1) was the only resident that required the assistance in bowel movement (assistance/supervision) .I have received training on abuse and neglect .the CNAs were respecting the resident's privacy by not being inside the room .[MDS was the assessment completed listing the supervision Resident # 1 . During an interview on 5/20/21 at 9:27 a.m., Nurse D stated, . I was (called) by the CNA's to respond to a fall .I saw the resident on the floor .the resident stated he was trying to adjust himself and fell .he is never left alone .there is always someone in the hallway .he was sent to the ER because of his diagnoses and bruise to the nose and head . (nursing assessment was) Resident had a fall with bruises to face and head .I wanted an overall assessment .the initial training on neglect is done at hiring .DON did an informal training to the CNAs .do not know about training for the whole facility .we implemented practice to keep door open and curtain opened .call bell in reach .frequently monitor residents who are put on a shower chair . During an interview on 5/20/21 at 11:06 AM, the DON stated, .the definition one person assist for toileting means holding the urinal and emptying the urinal, if needed, .emptying the bedpan .and doing hygiene .for Resident (#1) one person assist meant .holding the urinal .assisting with clothes removal .put on a shower chair .make sure the resident is okay .put the call light to his shirt .and step outside the room .close the door .gave privacy . the staff would stay with him only to use the urinal .not to have a bowel movement .as for training .I spoke to the night and day shift about to constantly check on him during bowel movement .it was not a formal in-service .we did not have QAPI meeting about the issue involving the fall on 4/29/21 . nursing assessment was that resident suffered bruises to face and head from fall .the Charge Nurse sent the resident to the ER for a more thorough assessment .we did have a CP meeting with the family to discuss the fall and additional preventative measures . Record review of pictures sent by email on 05/19/21 by family revealed injury to forehead and top of skull and blood on top of the nose. During an interview on 5/20/21 at 11:49 PM, the Administrator stated, .we discussed the need for staff being present when he (Resident #1) had a bowel movement . we discussed the issue of dignity and privacy as oppose to safety .resident never had another fall after our discussion .we did not report it to the state because the resident was able to explain the fall to staff . Record review of facility's Fall and Fall Risk, Managing policy dated, December , read, .Based on previous evaluations and current data, the staff will identify interventions related to resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling .