Every finding on record at The Belmont at Twin Creeks

Based on observations, interviews, and record reviews, the facility failed to ensure the residents had the right to personal privacy and confidentiality of his or her personal space for 2 of 4 residents (Resident #103 & Resident #90) reviewed for privacy.The facility failed to ensure that that the roommates of residents with AEM had signed consents in the active section of the EHR from the roommate or their RP acknowledging the AEM in the shared room since 01/28/2026.This failure could place residents at risk of having medical or personal information or conversations recorded or exposed to others, and cause residents to feel a loss of privacy, dignity, and decreased self-worth and self-esteem.Findings Included: Record Review of Resident # 103 admission Record dated 07/16/2026, revealed a [AGE] year-old female who had original admission date of 04/03/2024 and most recent re-admission date of 08/29/2025. Resident #103 was noted to have diagnoses including Alzheimer's Disease with Early onset (progressive, irreversible disorder that causes brain cells to degenerate, shrink, and die, resulting in memory loss, cognitive decline, and behavioral changes developing in individuals aged 65 or older, with risks increasing significantly with age), Aphasia (a communication disorder resulting from damage to brain areas responsible for language) following Cerebral Infarction (stroke), and Dysphagia (a language disorder characterized by partial impairment of comprehension or expression of spoken words) following Cerebral Infarction. Attempts to interview Resident #103 RP via telephone on 07/16/2026 at 10:00 am and 1:15 pm and 2:29 pm were unsuccessful.Record Review of Resident #103's quarterly MDS assessment dated [DATE], revealed resident was noted to have been able to make herself understood and had the ability to understand other some of the time. Resident #103 had a BIMS (standardized assessment tool to evaluate cognitive function, specifically memory and orientation) score of 6 indicating severe cognitive impairment. Resident #103 was noted to need substantial/maximal assistance for toileting hygiene, lower body dressing, putting on/taking off footwear; partial/moderate assistance for oral hygiene, upper body dressing, and personal hygiene. Resident #103 was noted to need supervision or touching assistance for functional abilities of roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair, bed-to-chair transfer, and sit to stand, Resident was noted to need partial/moderate assistance for toilet transfer and walking.Record Review of Resident #103 Care Plan, last updated on 02/03/2026, revealed no indication of any signed RP AEM consent documents, placing resident #103 being in a room that currently had ongoing AEM. Observation on 07/14/2026 at 11:57 AM of the room door for Resident #103 revealed a sign stating, This room is being electronically monitored. With a digital camera in plain view monitoring resident #103. Record review of Resident #90's admission Record dated 07/16/2026 revealed a [AGE] year-old male who had an original admission date of 11/15/2024, and most recent re-admission date of 02/17/2025. Resident #90 was noted to have diagnosis including type 2 diabetes Mellitus without Complications (chronic metabolic condition where the body develops insulin resistance, causing high blood sugar levels because cells fail to respond to insulin properly, but has not yet caused organ damage), schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia (such as hallucinations, delusions, or disorganized thinking) with a major mood disorder, such as bipolar or unipolar (depressive) disorder), Acute respiratory failure with hypoxia is a sudden, life-threatening condition in which the lungs fail to deliver sufficient oxygen to the blood, resulting in low oxygen levels in the tissues.Record Review of Resident #90's quarterly MDS dated [DATE], revealed Resident #90 had a BIMS score of 11 indicating moderately impaired cognition. Record Review of Resident #90's Care Plan, last updated 07/06/2026, revealed no indication of resident being in a room that currently had ongoing AEM. Record review for Resident #90 revealed no consent from the resident/RP being moved into a room with ongoing AEM of roommate (Resident #48). Record review for Resident # 48's admission Record dated 07/16/2026, revealed Resident #48 a [AGE] year-old male who had original admission date of 06/15/2021 and most recent admission date of 06/20/2025. Resident #48 was noted to have diagnoses including Schizophrenia, unspecified (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), Anxiety disorder, unspecified (racing heart, sweating, trembling shortness of breath, chest tightness, nausea, dizziness, and fatigue). Behavioral symptoms (avoidance of situations that trigger anxiety, restlessness, or compulsive behaviors to manage stress). Record review of Resident #48's quarterly MDS dated [DATE], revealed Resident #48 had a BIMS score of 0 indicating severe cognitive impairment. Record review of Resident # 48's Care Plan, last updated 06/11/2026 revealed no indication of resident consent noted for ongoing AEM. Record review for Resident #48 revealed a signed AEM consent form, from the RP. This did not include current resident #90. Observation on 07/14/2026 at 1:23 PM of the shared room door for Resident #90 and Resident # 48 revealed a sign stating, This room is being electronically monitored. During an interview on 07/16/2026 at 10:10 AM, CNA B has been here at this facility for about 5 years. HE/SHE revealed that when a resident is being prepared for a room change, the staff member was to notify the resident or RP of the AEM in the room and be sure the curtain was pulled for privacy of the resident not being monitored. CNA B agreed that consent was needed from a resident or RP being moved into a room with AEM, that way if the resident or family were not wanting to possibly be on camera or overheard, the facility would offer a different room.During an interview on 07/16/2026 at 10:30 AM, LVN F stated she had been a nurse their about 2 years. LVN F stated the family member requests for AEM a consent form is provided for them to fill out. Once it is completed it is sent to either of the department heads DON and SW. If they ask, they make sure that they have the consent for electronic monitoring to be in effect. The camera should only be pointed at intended, monitored resident, but could still end up recording the non-monitored roommate on camera too if the camera has sound recording that could pick up private conversations the roommate may not want heard. LVN F stated that obtaining consents are the responsibility of all nursing staff. LVN F stated whoever is speaking with the resident or RP about a specific room for the resident, should inform them of the AEM, and request the consent, or the room will need to be changed to one without AEM.During an interview on 07/16/2026 at 12:08 PM, SW stated if it pertains to AEM it would involve social services. SW stated if a family requested electronic monitoring, we would send them a AEM form and let them complete it. SW stated once completed, the form is placed in the bin outside of SW office. Then let the RP set up the camera and advise them to set it up not to catch it outside of the area. Staff and other residents passing outside the resident room. If not, this is a HIPAA violation. Once signed it is sent to the medical records profile of the resident's portion of PCC. Technically, it would be the same we would have to draw the curtain so that it doesn't catch the roommate. The roommate must be made aware of the camera being placed in the room. Roommate would need to sign a different form consenting to being recorded in the room. During an interview on 07/16/2026 at 12:34 PM, DON revealed for AEM to be approved by the facility, a consent from the resident or RP, and any roommate or their RP, was required to be obtained. DON stated in addition, the facility would post a sign on the room door. DON stated that AEM consent was obtained by the admitting nurse when monitoring was requested on admission to the facility from the family or resident, or by the DON or ADON when a room change was made after admission. DON stated the signed consent form should be in the miscellaneous or documents tab of the EHR. DON stated that the risks of not having the signed consent was that there was no evidence the resident or RP was made aware they could possibly be filmed. there may be audio recording capabilities as well; and this would be a privacy violation, and that ultimately the DON was responsible to ensure all consents were obtained and in the EHR.During an interview on 07/16/2026 at 12:40 PM, MR stated when medical records are received from staff, it is scanned and uploaded into the appropriate category in PCC. This includes AEM.A record request from the ADMIN on was made for their AEM policy. The ADMIN stated, We don't have a policy other than following HHSC guidelines for AEM.

Based on interview and record review, the facility failed to ensure residents were informed orally of their rights for 4 (Resident # 106, Resident #102, Resident #33 and Resident #52) of 7 residents interviewed during the confidential group meeting. Residents were not provided on going communication of their rights, during their stay in the facility. This failure could place residents at risk of a decreased quality of life, decreased awareness of their rights and decreased execution of their rights.During a confidential group meeting on 07/15/2026 at 11:35 a.m., Resident # 106, Resident #102, Resident #33 and Resident #52 stated they did not know what their rights were. They stated that the activity director does not go over specific resident rights during their monthly Resident Council meetings and they requested to have a copy of their rights provided to them during the group meeting. Record review on 07/15/2026 at 12:10 p.m. of the monthly resident council meeting minutes revealed resident rights were not reviewed for the past 7 months; January, February, March, April, May, June and July of 2026. In an interview on 07/15/2026 at 1:24 p.m. with the Activity Director revealed that he talked about resident rights but he did not go over a specific one every month nor had he documented that each month in the resident council minutes. He stated the risk to the residents was it could put the residents at a disadvantage because of them not knowing what their rights were. In an interview on 07/16/2026 at 2:15 p.m. with the Administrator revealed that her expectation was that the Activity Director should be going over at least one right per month and it should be documented in the minutes. She stated the risk to the residents was they would not know what they could do in the facility. Review of the facility's policy, Resident Rights, dated 12/01/2025 reflected the following, The facility will inform the resident both orally and in writing of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay at the facility.

Based on observation, interview, and record review, the facility's interdisciplinary team failed to create and implement a resident comprehensive care plan to reflect the current condition of 1 (Resident #22) of 8 residents reviewed for comprehensive care plans. The facility failed to adequately create and implement Resident #22's care plan to reflect recent behaviors exhibited on 06/24/2026. This deficient practice could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.Findings include: In review of Resident #22's Face Sheet on 07/16/2026 revealed she was an [AGE] year-old female admitted for rehabilitation on 06/08/2026 and who was discharged prior to survey on 07/03/2026. Relevant diagnoses included osteomyelitis of left leg (bone infection) and subsequent amputation (removal,) peripheral vascular disease (circulatory compromise,) and diabetes (insulin resistance.) In review of Resident #22's MDS assessment, dated 06/15/2026, revealed she had the ability to make herself understood and understand others. Resident #22 had a BIMS score of 15 indicating her cognition was intact. She was assessed as having no behavioral symptoms that would have any impact on the resident, and no behaviors of rejection of care and/or wandering. Resident #22 required the use of a wheelchair for mobility, and was independent with shower/baths, but required substantial assistance with toileting. In review of Resident #22's Comprehensive Care Plan, dated 07/16/2026 revealed she had no documented behaviors of abuse allegations noted in her care plan, but she did exhibit: -Behavior problems of picking at the skin on her fingers and hands-Resistive to cares that included medications/injections-Physical behavioral symptoms directed towards others including throwing objects-Verbal behavioral symptoms that included yelling out at staff Review of facility grievances with a look back period of 6 months on 07/16/2026 at 9:40 am revealed no documentation of any grievances filed by or on behalf of Resident #22. Attempts to interview Resident #22 via telephone on 07/16/2026 at 10:00 am and 1:15 pm and 07/22/2026 at 12:29 pm were unsuccessful. Attempts to interview Resident #22's family member via telephone on 07/16/2026 at 9:47 am and 2:45 pm were unsuccessful. In an interview with RN Y on 07/16/2026 at 9:51 am, he stated on 06/24/2026, Resident #22 called 911 and told [paramedics] she got pinched during incontinent care. He stated the facility sent her out promptly for evaluation to [Hospital] and upon her return, he went to speak with her about the allegation. During his interview, she stated the reason she made the allegation was that she was just pissed. He stated that she reported to him that the staff were slow to respond to her call light prior to calling 911. RN Y asked her if she got pinched or received any abuse, and she told him she did not get pinched and denied any abuse at the facility. He stated the facility still conducted an exhaustive investigation and Resident #22 was assessed head to toe for any injuries and no injuries were observed. He stated she had been admitted a few times over the years for rehabilitation, and she was alert, oriented, and could make her needs known. He stated Resident #22 was really nice, and liked a lot of attention, but had never made any allegations like this in the past; this was a new behavior. He stated Resident #22 completed her rehabilitation and was discharged back home. In interview with the wound care nurse, LVN X, on 07/16/2026 at 10:23 am, she stated Resident #22 was always pleasant when she interacted with her during her care; although she was impatient and would scream out at times. She stated she was alert and oriented, and made her needs well known to all the staff. LVN X stated she observed Resident #22's skin frequently and never saw any signs or symptoms of abuse nor was suspicious of any abuse towards Resident #22. LVN X stated she never received any allegations of abuse from Resident #22, and they had a good rapport with each other. In interview with the DON on 07/16/2026 at 12:46 pm, she stated Resident #22 had been admitted repeatedly for rehabilitation to the facility. She stated, during her latest admission, she called 911 and was sent out to [Hospital] and returned back to the facility the same day. She stated when she was told that Resident #22 alleged abuse from the facility, and she asked her about it, Resident #22 told her she was not abused. She stated this was a new behavior that should have been updated on Resident #22's comprehensive care plan so the facility can be aware of [Resident #22]'s condition, and stated it was the nurse's responsibility to update and revise each resident's comprehensive care plan as Resident #22 care needs evolved. Review of the facility's policy Comprehensive Care Plans, revised 10/01/2025 revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality .

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible for one of eighteen residents (Residents #105) reviewed for accident hazards. 1. The facility failed to ensure the germicidal wipes were secured after they were observed unattended on a medication cart in the 600 & 800 hallway on 7/15/2026 at 10:48 a.m. 2. The facility failed to ensure denture cleanser tablets in Resident #85's room were stored in a manner that prevented access by other residents on 07/14/2026 at 12:42 p.m. These failures could place the residents at risk of accidental overdose, misuse of products, and possible adverse reactions.Record review of Resident #85's Face Sheet, dated 07/16/2026, reflected that the resident admitted to the facility on [DATE].Resident #85 is a [AGE] year-old female. Record review of Resident #85's Quarterly MDS Assessment, dated 03/31/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 7. Record review of Resident #85's Care Plan, dated 07/06/2026, reflected the resident was diagnosed with dysphagia, oropharyngeal phase, and muscle weakness (generalized). The care plan indicated the resident required assistance with medication administration and nursing care. During an observation on 07/14/2026 at 12:42 p.m., Resident #85 was observed in her room. Denture cleanser tablets were observed on the resident's nightstand and were accessible within the resident's room. During an interview on 07/16/2026 at 1:26 p.m., LVN A stated nursing staff were responsible for medicated treatment products were secured after providing care. She stated resident rooms were checked each time staff enter the room, and if found, staff were expected to immediately report them to the Director of Nursing (DON). LVN A stated she had received training regarding proper storage. She said she was not aware of denture cleanser tablets being left in residents' rooms and had never observed medicated wipes left unattended in the facility. During an interview on 07/16/2026 at 1:42 p.m., CNA A stated she had received in-service training on proper medication storage the previous weekend. After reviewing photographs of the denture cleanser tablets, CNA A stated she would have removed the item and reported it to the charge nurse and DON had she observed them. During an interview on 07/16/2026 at 1:50 p.m., the Corporate Nurse stated if medicated treatment products were found in a resident's room, staff should remove the items and report the findings to the charge nurse and DON. He stated the facility faces challenges because residents and families may bring items into the facility, and staff must respect residents' privacy. However, residents and families were educated regarding items that should not be kept in resident rooms. He stated he was unsure why the denture cleanser tablets was left in the residents' rooms, and stated those items should not have been there. During an interview on 07/16/2026 at 2:00 p.m., the DON medicated treatment products should never be left unattended in residents' rooms unless the resident has authorization to self-administer and are secured in an approved lock box. Record review of the facility's policy, Medication Storage, dated 12/01/2025, reflected, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations. Policy Explanation and Compliance Guidelines. 1. General Guidelines. a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observation, interview, and record review, the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of eighteen residents (Resident #105) reviewed for medication storage. The facility failed to ensure several packets of ointment in Resident #105's room was stored in a manner that prevented access by other residents. The ointment is a moisture barrier skin protectant used to help protect intact skin from irritation associated with prolonged exposure to moisture, such as urine, feces, wound drainage, and perspiration on 07/14/2026 at 12:26 p.m. These failures could place the residents at risk of accidental overdose, misuse of medications, and possible adverse reactions. 1.Record review of Resident #105's Face Sheet, dated 07/16/2026, reflected that the resident admitted to the facility on [DATE]. The resident was diagnosed with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. Resident #105 was an [AGE] year-old female. Record review of Resident #105's Quarterly Comprehensive MDS Assessment, dated 04/26/2026, reflected the resident had moderate impairment in cognition with a BIMS score of 11. Record review of Resident #105's Care Plan, dated 07/15/2026, reflected the resident had impaired skin integrity to the groin with redness, bladder incontinence, and fragile skin. Interventions included completing weekly skin assessments and providing treatment as ordered. During an observation on 07/14/2026 at 12:26 p.m., Resident #105 was observed in her room. Several individual packets of ointment were observed on the resident's bedside table. Resident #105 stated nursing staff left the medication in her room. She stated the medication was being used to treat a rash on her inner thigh/groin area and that she did not administer the medication herself. During an interview on 07/16/2026 at 1:26 p.m., LVN A stated medications should be stored in the resident-specific locked box on the medication cart when not in use. She said nursing staff were responsible for ensuring medications and medicated treatment products are secured after providing care. She stated resident rooms are checked each time staff enter the room, and if medications are found, staff are expected to immediately report them to the Director of Nursing (DON). LVN A stated she had received training regarding proper medication storage. She said she was not aware that the ointment was left in residents' room. During an interview on 07/16/2026 at 1:42 p.m., CNA A stated all medications should be secured and not left in residents' rooms. She stated nursing staff were responsible for securing medications, although all staff are expected to monitor for improperly stored medications during routine rounds. She stated if medications are found in a resident's room, staff should immediately remove the items and report them to the nurse. CNA A stated she had received in-service training on proper medication storage the previous weekend. After reviewing photographs of the ointment, CNA A stated she would have removed the items and reported them to the charge nurse and DON had she observed them. During an interview on 07/16/2026 at 1:50 p.m., the Corporate Nurse stated medications should be stored on the locked medication cart when not in use. He stated if medications or medicated treatment products were found in a resident's room, staff should remove the items and report the findings to the charge nurse and DON. He stated the facility faces challenges because residents and families may bring items into the facility, and staff must respect residents' privacy. However, residents and families are educated regarding items that should not be kept in resident rooms. He stated he was unsure why the ointment was left in the residents' room and stated those items should not have been there. During an interview on 07/16/2026 at 2:00 p.m., the DON stated medications should be stored in a locked location and out of residents' reach. She stated there are a limited number of residents authorized to self-administer medications, and those residents have medications secured in resident-specific lock boxes. She stated all staff are responsible for identifying improperly stored medications during rounds, removing the medications when found, and notifying nursing staff. She stated medications and medicated treatment products should never be left unattended in residents' rooms unless the resident has authorization to self-administer and the medications are secured in an approved lock box. Record review of the facility's policy, Medication Storage, dated 12/01/2025, reflected, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations. Policy Explanation and Compliance Guidelines. 1. General Guidelines. a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observations, interviews, and record review the facility failed to ensure that residents who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three of six residents (Residents #2, #3, and #4) reviewed for respiratory care. 1.The facility failed to ensure Resident #2's BiPAP (bilevel positive airway pressure: normalizes breathing by delivering pressurized air into the upper airway leading into the lungs) mask was properly stored when not in use on 05/29/2026.2.The facility failed to ensure Resident #3's CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) mask was properly stored when not in use on 05/29/2026.3.The facility failed to ensure Resident #4's CPAP mask was properly stored when not in use on 05/29/2026.These failures could place residents at risk of respiratory infection and not having their respiratory needs met.Findings included: 1.Record review of Resident #2's Face Sheet, dated 05/30/2026, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with respiratory failure (respiratory system cannot adequately supply oxygen to the body) with hypercapnia (too much carbon dioxide in the blood). Record review of Resident #2's Comprehensive MDS Assessment, dated 05/20/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident was using a non-invasive mechanical ventilator (provides respiratory support without the need for invasive procedures).Record review of Resident #2's Comprehensive Care Plan, dated 04/27/2026, reflected that the resident required the use of BiPAP and one of the interventions was nursing to apply device as ordered.Record review of Resident #2's Physician Order, dated 05/27/2026, reflected BIPAP @ [ (14/6) with 3-4 LPM of oxygen bled into adaptor]. in the morning related to ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPERCAPNIA . Remove BIPAP.During an observation and interview on 05/29/2026 at 7:25 a.m., Resident #2 was in her bed, awake. A BiPAP machine was on top of the resident's side table with a mask connected to it. The mask was unbagged and was sitting on top of the machine. The resident said she used the BiPAP every night. She said the nurses would put it on and the nurses would take it off in the morning. During an interview on 05/29/2026 at 1:42 p.m., LVN D said Resident #2's BiPAP mask should be bagged to prevent respiratory infections. She said she did not know who took it off, but whoever did should have placed it inside a bag to keep it clean. She said she had already placed it inside a bag.2.Record review of Resident #3's Face Sheet, dated 05/30/2026, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Record review of Resident #3's Comprehensive MDS Assessment, dated 04/24/2026, reflected that the resident had a severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated that the resident was using a non-invasive mechanical ventilator. Record review of Resident #3's Comprehensive Care Plan, dated 03/20/2026, reflected that the resident required the use of CPAP and one of the interventions was nursing to apply device as ordered.Record review of Resident #3's Physician Order, dated 09/16/2025, reflected CPAP QHS in the morning Remove CPAP.During an observation on 05/29/2026 at 7:47 a.m. revealed Resident #3 was in her bed with eyes closed. A CPAP machine was on top of the resident's side table with a mask connected to it. The mask was not bagged, and a piece of cloth was on top of the mask.During an observation and interview on 05/29/2026 at 7:50 a.m., LVN B Resident #3 used her CPAP every night. She went inside the resident's room and saw that CPAP mask was not bagged. She said she was not the one who took off the resident's CPAP mask. She said, maybe, it was the hospice aide who took off the CPAP mask. She said she did not notice that the mask was not bagged when she checked on the resident. She said the mask should be bagged to prevent any respiratory issues. She took the piece of cloth covering the CPAP mask and said the piece of cloth could be dirty and should not be in contact with the CPAP mask. She said she would clean the mask and would put it inside a bag.3.Record review of Resident #4's Face Sheet, dated 05/30/2026, reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with sleep apnea. Record review of Resident #4's Comprehensive MDS Assessment, dated 03/04/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated that the resident was using a non-invasive mechanical ventilator.Record review of Resident #4's Comprehensive Care Plan, dated 03/04/2026, reflected that the resident required the use of CPAP and one of the interventions was nursing to apply device as ordered.Record review of Resident #4's Physician Order, dated 09/05/2025, reflected APPLY CPAP at night with O2 at 2l via an Adapter to the CPAP at bedtime for SLEEP APNEA and remove per schedule.During an interview on 05/29/2026 at 7:55 a.m., the Financial Manager said she was just doing her rounds. She said the CPAP mask should be bagged so it would not be dirty. She said she would tell the nurse about Resident #4's CPAP mask.During an interview on 05/29/2026 at 4:11 p.m., ADON A said the BiPAP and CPAP masks should be in plastic bags when not in use to prevent cross contamination and respiratory infection. She said the staff were responsible for bagging the masks. She said she would coordinate with the DON about respiratory care.During an interview on 05/30/2026 at 1:41 p.m., the DON said the BiPAP and CPAP masks should be inside plastic bags when the residents were not using them to maintain cleanliness as well as patency (unobstructed). She said bagging the BiPAP mask was important to prevent cross contamination and development of infections. She said the staff were responsible for bagging the mask or at least provided a bag and educated the residents of the reason why the masks should be bagged. She said she would remind the staff to bag the masks after taking them off. During an interview on 05/30/2026 at 2:11 p.m., the Administrator said she called the hospice agency to ask the hospice aide if she was the one who took off Resident #3's CPAP mask. She said the hospice aide admitted that she was the one who took off the mask. She said the agency would in-service the hospice aide. She said the BiPAP and CPAP masks should be bagged to prevent any probable infections. She said they were currently correcting the same non-compliance from a visit dated 04/21/2026.Record review of the facility's policy Oxygen Concentrator P & P Committee implemented November 11, 2025 reflected Policy: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators . Policy Explanation and Compliance Guidelines . 4. Use of the Concentrator . l. Keep delivery devices covered in plastic bag when not in use.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for three of ten residents (Residents #2, #5, and #6) reviewed for labelling of drugs and biologicals.1.The facility failed to ensure Resident #2's zinc oxide (a form of barrier cream used to treat skin irritations, diaper rash, and other skin conditions) was not left on top of the resident's overbed table on 05/29/2026.2.The facility failed to ensure Resident #5 did not have medications for shortness of breath inside his room on 05/29/2026.3.The facility failed to ensure Resident #6 did not have a nasal spray inside her room on 05/29/2026. These failures could place residents at risk of wrong medication administration, not getting the getting the full benefit of the medication, accidental overdose, misuse of medications, and possible adverse reactions.Findings include: 1.Record review of Resident #2's Face Sheet, dated 05/30/2026, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #2's Comprehensive MDS Assessment, dated 05/20/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident was incontinent (unable to control) for bowel and bladder.Record review of Resident #2's Comprehensive Care Plan, dated 04/27/2026, reflected that the resident had ADL self-care performance deficit and one of the interventions was provide assistance for toileting. During an observation and interview on 05/29/2026 at 7:25 a.m. revealed Resident #2 was in her bed, awake. It was observed that a tube of zinc oxide was on top of the resident's side table. She said the staff would use it everytime they clean and change her. She said the tube of zinc oxide had always been on her side table.During an interview on 05/29/2026 at 1:42 p.m., LVN D said barrier creams should not be left accessible to the resident or other residents because they might use it inappropriately like consume the cream or put them in their eyes resulting in irritation. She said she would go to the resident's room and check if the zinc oxide was already secured.2.Record review of Resident #5's Face Sheet, dated 05/30/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs).Record review of Resident #5's Quarterly MDS Assessment, dated 05/15/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident had chronic obstructive pulmonary disease.Record review of Resident #5's Comprehensive Care Plan, dated 05/13/2026, reflected the resident was receiving respiratory therapy and one of the interventions was to monitor oxygen saturation at beginning and end of treatment.Record review of Resident #5's Physician Order, dated 05/09/2026, reflected Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT (Fluticasone-Umeclidinium-Vilanterol) 1 puff inhale orally one time a day for sob.Record review of Resident #5's Physician Order, dated 05/08/2026, reflected Symbicort Inhalation Aerosol 80-4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate)1 puff inhale orally two times a day for sob.Record review on 05/29/2026 of Resident #5's Assessment Notes reflected the resident did not have an assessment for self-administration of medications.During an observation and interview on 05/29/026 at 7:17 a.m. revealed Resident #5 was in his bed, awake. It was observed that two medications for shortness of breath were on top of the resident's overbed table. The medications were on plain view. He said he would seldom use the medications depending on his need. He said the nurse knew he had medications for shortness of breath inside his room.During an interview on 05/29/2026 at 1:11 p.m., LVN C said she did not know that Resident #5 had medications inside his room. She said the nurses were the ones administering the medications routinely but if he had the same medications, he might administer them on top of the ones being administered. She said it could result in overdosing. She said she would go to the resident's room and check if the medications were still inside the room.3.Record review of Resident #6's Face Sheet, dated 05/30/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease and dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #6's Quarterly MDS Assessment, dated 04/26/2026, reflected the resident had a moderate cognitive impairment (resident may need additional support and monitoring) with a BIMS score of 11. The Quarterly MDS Assessment indicated the resident had chronic obstructive pulmonary disease and dementia.Record review of Resident #6's Comprehensive Care Plan, dated 04/30/2026, reflected the resident had altered respiratory status and one of the interventions was to administer medications as ordered.Record review of Resident #6's Physician Order, dated 04/09/2026, reflected Flonase Allergy Relief Nasal Suspension (Fluticasone Propionate (Nasal)) 1 spray in each nostril two times a day for Allergy.Record review on 05/29/2026 of Resident #6's Assessment Notes reflected the resident did not have an assessment for self-administration of medications.During an observation and interview on 05/29/2026 at 7:36 a.m., Resident #6 was in her bed, awake. It was observed that she had a nasal spray on top of her side table. The resident said the nasal spray had been in her table since the previous day.During an interview on 05/29/2026 at 1:29 p.m., LVN B said she did not know that Resident #6 has a nasal spray inside her room. She said the medication should not be inside the room because the resident might be confused and use it more than what was required. She said, maybe, her daughter brought it.During an interview on 05/29/2026 at 4:11 p.m., ADON A said barrier creams were a form of topical medications because they were used to prevent skin breakdown. She said it should be stored where the residents could not access them. She said confused residents could use the cream in their eyes. She said residents that wandered around the facility and could go inside the room and get hold of the zinc oxide and use them also inappropriately. She said medications inside the rooms could cause overdose because the staff would not know how many times the residents were administering the medications. She said, what if the staff already administered the medication and then the resident would administer it again. She said that would be dangerous. She said she would coordinate with the DON about the issue and would go room to room to see if there were medications inside the residents' rooms.During an interview on 05/30/2026 at 1:41 p.m., the DON said medications should not be inside the rooms of the residents because it could cause probable harm such as overmedication, undermedication, or allergic reactions. She said the residents should have an assessment for self-medication to determine if they were able to administer medications by themselves. She said the same rationale applied to the zinc oxides. She said confused residents might use the creams inappropriately. She said she would continually remind the staff not to leave the zinc oxide within reach of any residents and to scan the room of the residents for any medications.During an interview on 05/30/2026 at 2:11 p.m., the Administrator said zinc oxides should not be accessible to the residents because they might accidentally consume them or put them in their eyes. She said no medications should be inside the rooms of the residents because they might use them more than what was required. She said they were currently correcting the same non-compliance from a visit dated 04/21/2026.Record review of the facility's policy Medication Storage P & P Committee implemented December 01, 2025 reflected Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms . Policy Explanation and Compliance Guidelines . 1. General Guidelines . a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) . b. Only authorized personnel will have access to the keys to locked compartments.

Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during medical treatment and personal care and confidentiality of personal and medical records for one of five residents (Residents #1) reviewed for privacy and confidentiality. The facility failed to ensure Resident #1's pharmacy slip, with his name and the name of his medication on it, was not left at the ledge of the nurse's station on 05/29/2026.This failure could place the residents at risk of having their personal and medical record exposed to unauthorized individuals.Findings included: Record review of Resident #1's Face Sheet, dated 05/30/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with peripheral vascular disease (a slow and progressive circulation disorder that could lead to non-healing wounds) and non-pressure ulcer (wound that was not caused by prolonged pressure on the skin) to the left calf. Record review of Resident #1's Comprehensive MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 03/25/2026, reflected that the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS (screening tool used to assess cognitive status) score of 13. The Comprehensive MDS Assessment indicated the resident had a non-pressure ulcer. Record review of Resident #1's Comprehensive Care Plan, dated 04/13/2026, reflected that the resident had an actual impairment to the skin related to venous wound of the left calf and one of the interventions was to administer treatments as ordered. Record review of Resident #1's Physician Order, dated 05/28/2026, reflected Ammonium Lactate External Lotion 12 % (Lactic Acid (Ammonium Lactate) Apply to Left Leg topically (applied to the surface of the skin) every day shift every Tue, Thu, Sat for Wound care.During an observation on 05/29/2026 at 7:30 a.m., a piece of pink paper was on top of the ledge of the nurse's station. On the piece of paper was written Resident #1's name and his medication. It was observed that no staff were inside the nurse's station.During an observation on 05/29/2026 at 7:58 a.m., the piece of pink paper was still on top of the ledge of the nurse's station. The piece of paper still had Resident #1's name and his medication. It was observed that no staff were inside the nurse's station.During an interview on 05/29/2026 at 2:00 p.m., LVN C said she did not notice the pink piece of paper that was on top of the ledge of the nurse's station. She said the pink slip was the facility's copy for the medication delivered for Resident #1. She said they have a place inside the nurse's station where they put the delivery slips. She said she was not the one who received Resident #1's medication and left the pink slip on top of the ledge. She said whoever received the medication should have secured it because it contained the resident's name and the medication being administered to him.During an interview on 05/29/2026 at 4:11 p.m., ADON A said the delivery form should have been secured because it had Resident #1's name of medication. She said whoever received the medication should have placed it inside the nurse's station. She said the expectation was that the residents' personal and medical information were secured. She said she would coordinate with the DON about the issue.During an interview on 05/30/2026 at 1:41 p.m., the DON said leaving a piece of paper with a resident's medical information exposed could be a HIPAA (law protecting health information aimed to ensure confidentiality) violation. She said the medical information of a resident was confidential and should be protected and not be shared without the permission of the resident or the resident's responsible party. She said she would continually remind them to secure the medical information of the residents.During an interview on 05/30/2026 at 2:11 p.m., the Administrator said the pink slip should be inside the nurse's station and not within view of other residents, staff that did not have anything to do with the resident's care, and visitors what was written on the pink slip was considered confidential medical information. She said the expectation was the health information of the residents remain confidential. She said they were currently correcting the same non-compliance from a visit dated 04/21/2026. Record review of the facility's policy, HIPAA Security Measures P & P Committee implemented December 01, 2025 reflected Policy: It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and /or records that are in electronic format.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, lack of care plan interventions, and physician orders for oxygen administration for four of twelve residents (Residents #2, #3, #4 and #5) reviewed for respiratory care. 1. The facility failed to ensure Resident #2 had her nebulizer mask and nasal cannula bagged when not in use on 04/21/26. 2. The facility failed to ensure Resident #3's nasal cannula, connected to the oxygen concentrator, (medical device that extracts oxygen from room air by filtering out or separating the nitrogen from the oxygen) was properly stored on 04/21/26. 3. The facility failed to ensure Resident #4's nasal cannula, connected to the oxygen concentrator, was properly stored on 04/21/26. 4. The facility failed to ensure Resident #5's nasal cannula, connected to the mobile oxygen tank, attached to his wheelchair, was properly stored on 04/21/26. These failures could place residents at risk of respiratory infection, respiratory complications, and not having their respiratory needs met.Findings include: 1. Record review of Resident #2's face sheet, dated 04/21/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with COPD (breathing difficulty).Record review of Resident #2's Comprehensive MDS Assessment, dated 1/26/26, reflected Resident #2 had a BIMS score of 11, which indicated a moderate cognitive impairment. Resident #2 had an active diagnosis of COPD.Record review of Resident #2's Physician Order, dated 04/21/26, reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml. 1 vial inhale orally via nebulizer every 4 hours as needed for shortness of breath. Oxygen at 2 L every shift for shortness of breath. During an interview and observation on 04/21/26 at 10:48 a.m., the State Surveyor and RN T observed Resident #2's Nebulizer mask sitting on top of her nightstand unbagged and a nasal cannula attached to the oxygen tank, unbagged in a pouch. She stated the items needed to be bagged to avoid contamination. She stated she had bagged the nebulizer mask earlier in the morning and was not sure how it became unbagged.During an interview and observation on 04/21/26 at 1:58 a.m., ADON J was informed by the State Surveyor of Resident #2's Nebulizer mask and nasal cannula unbagged when not in use. He stated the items needed to be bagged to avoid contamination. He stated it was the nursing staff's responsibility to ensure breathing devices were bagged when not in use.During an interview on 04/21/26 at 4:00 p.m., the DON was informed of Resident #2's Nebulizer mask and nasal cannula unbagged when not in use. He stated the items needed to be bagged to avoid contamination. She stated staff should be checking for these items to be bagged when not in use. 2. Record review of Resident #3's face sheet, dated 04/21/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included Chronic Diastolic (congestive) Heart Failure (a chronic, progressive condition in which the heart cannot pump blood efficiently enough to meet the body's needs) and Type 2 Diabetes (High blood sugar).Record review of Resident #3's April 2026 active Physician orders did not reflect any orders for oxygen administration. Record review of Resident #3's active care plan reflected no care plan problem goals, or intervention related to the resident's oxygen administration. During an observation on 04/21/26 at 9:47 a.m. revealed Residents #3's nasal cannula connected to the oxygen concentrator was observed hanging on her concentrator while the resident was in her wheelchair.3. Record review of Resident #4's face sheet, dated 04/21/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had a diagnosis which included Unspecified Diastolic (congestive) Heart Failure (a chronic, progressive condition in which the heart cannot pump blood efficiently enough to meet the body's needs). Record review of Resident #4's April 2026 active Physician orders did not reflect any orders for oxygen administration. Record review of Resident #4's active care plan reflected no care plan problem goals, or intervention related to the resident's oxygen administration.During an observation on 04/21/26 at 9:55 a.m., Resident #4's nasal cannula connected to oxygen concentrator was observed hanging on the head of the bed while the resident was out of the room. 4. Record review of Resident #5's face sheet, dated 04/21/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #5 had a diagnosis which included Chronic Obstructive pulmonary disease (a progressive, long-term lung disease that makes it hard to breathe). Record review of Resident #5's April 2026 active Physician orders did not reflect any orders for oxygen administration.Record review of Resident #5's active care plan reflected no care plan problem goals, or intervention related to the resident's oxygen administration. During an observation and interview on 04/21/26 at 10:00 a.m., Resident #5's nasal cannula, which was connected to his oxygen tank, was observed lying on the floor. The resident was in bed using the nasal cannula connected to his oxygen concentrator. The resident stated he was not aware the nasal cannula should be bagged, he stated he was not given a bag or instructed to bag the nasal cannula when not in use by any staff member. During an interview on 04/21/26 at 3:30 p.m. with CNA A, she stated the nasal cannulas should be stored in a bag and dated, she stated the CNAs and nurses were responsible for making sure they were bagged and dated. She stated if the nasal cannula was not bagged, it would become contaminated and result in an infection to the residents. She stated if she found it not bagged; she should put it in the designated bag.During an interview on 04/21/26 at 3:35 p.m. with CNA B, she stated the nasal cannulas should be stored in a bag and dated, she stated the CNAs and nurses were responsible for making sure they were bagged and dated. She stated if the nasal cannula was not bagged, it would become contaminated and result in an infection to the residents. She stated if she found the nasal cannula on the floor she reported to the nurse to have it changed, if not on the floor she put it back in the bag.During an interview on 04/21/26 at 3:45 p.m. with ADON K, she stated all nasal cannulas and any respiratory apparatus that came in contact with the respiratory system should be bagged and dated and changed weekly according to the facility policy for infection control purposes. She stated the nurses were responsible to change, date and bag the items and the CNAs were responsible for notifying the nurses if they saw it was not bagged and was exposed. She stated the risk of not storing the nasal cannulas would result in an infection. During an interview on 04/21/26 at 3:55 p.m. with LVN C, he stated the nasal cannula should be bagged and attached to the oxygen concentrator when not in use and the bag should be dated. He stated the nurses and CNAs were responsible for making sure the nasal cannulas were bagged, but the nurses should ensure the policy was implemented. He stated the nasal cannula not being bagged could result in contamination and infection and could make the residents sick. During an interview on 04/21/26 at 4:05 p.m. with the DON, she stated the nasal cannula and nebulizer mask should always be bagged when not in use for infection control purposes and it should be dated. She stated it was the responsibility of everyone to notify the nurse if they saw it was not bagged and dated to replace if needed. She stated the risk of not having the nasal cannula and nebulizer mask in a bag could result in them getting dirty, the residents could inhale germs from them and get sick with an infection. Record review of the Facility's Oxygen Concentrator Policy, dated 11/1/2025, reflected: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. Policy Explanation and Compliance Guidelines:1. Staff responsible for the use and care of oxygen concentrators receive training on oxygen safety and the functionality of the device.2. Oxygen is administered under orders of the attending physician, except in the case of an emergency. 4. Use of the Concentrator:a. The nurse shall verify physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula etc.)i. Keep delivery devices covered in plastic bag when not in use.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 6 of 8 (Residents #4, #6, #7, #8, #9, and #10) reviewed for medication storage. 1. The facility failed to ensure Resident #6 did not have a pink paste (moisture barrier cream) inside the room on [DATE]. 2. The facility failed to ensure a white powder (Nystatin) was not inside Resident #7's room on [DATE]. 3. The facility failed to ensure Resident #8 did not have a pink paste (moisture barrier cream) inside the room on [DATE]. 4. The facility failed to ensure Resident #9 did not have a Topical anesthetic spray and pink paste (moisture barrier cream) inside the room on [DATE] 5. The facility failed to ensure Resident #10 did not have Supplements and probiotic bottles inside the room on [DATE]. 6. The facility failed to ensure Resident #4 did not have Biofreeze inside the room on [DATE]. These failures could place residents at risk of accidental overdose, misuse of medications, and possible adverse reactions.Findings include: 1. Record review of Resident #6's Face Sheet, dated [DATE], revealed an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a diagnosis which included Pressure ulcer of right buttock (damage to the skin and underlying tissue, usually over bony areas, caused by prolonged pressure, friction, or shear, restricting blood flow). Record review of Resident #6's Comprehensive Care Plan, dated [DATE], revealed Pressure Ulcer Prevention with interventions of barrier cream and turn and reposition every 2 hours and as needed, keep body in good alignment. The comprehensive care plan revealed Resident #6 had an ADL self-care performance deficit and required assistance from staff. Record review of Resident #6's physician order, dated [DATE], revealed an order for: Wound care to sacrum, cleanse wound with normal saline, pat dry, apply barrier cream and leave open to air. Record review of Resident #6's Comprehensive MDS Assessment, dated [DATE], revealed the resident has Pressure ulcer of the right buttock. During an observation on [DATE] at 9:37 a.m., revealed Resident #6 was in her bed, awake. It was noted a pink barrier cream, in a medication cup was observed on the resident's nightstand. 2. Record review of Resident #7's Face Sheet, dated [DATE], revealed an [AGE] year-old male who was admitted to the facility on [DATE]. The resident has diagnoses which included Pressure ulcer of sacral region (damage to the skin and underlying tissue, usually over bony areas, caused by prolonged pressure, friction, or shear, restricting blood flow) and Dementia (A progressive loss of memory, reasoning and communication skills). Record review of Resident #7's Comprehensive Care Plan, dated [DATE], revealed Pressure Ulcer Prevention with interventions of barrier cream and turn and reposition every 2 hours and as needed, keep body in good alignment. The comprehensive care plan revealed Resident #7 had an ADL self-care performance deficit and required assistance from staff; it revealed the resident has impaired cognitive function/impaired thought process related to dementia. Record review of Resident #7's physician order, dated [DATE], revealed an order for: Nystatin External Powder 100000, apply to groin topically two times a day for Redness. Record review of Resident #7's Comprehensive MDS Assessment, dated [DATE], revealed under skin and ulcer/injury treatments an intervention for Applications of ointments/medications other than to feet. During an observation and interview on [DATE] at 9:40 a.m., revealed Resident #7 was in his bed, awake. Nystatin powder in a medication cup was observed on the residents' nightstand. The resident's representative stated the nursing staff put the powder on the residents' groin area after he was cleaned, she stated it was on the bedside table when she came into the room. 3. Record review of Resident #8's Face Sheet, dated [DATE], revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident has a diagnosis which included Pressure ulcer of the sacral region (damage to the skin and underlying tissue, usually over bony areas, caused by prolonged pressure, friction, or shear, restricting blood flow). Record review of Resident #8's Comprehensive Care Plan, dated [DATE], revealed Pressure Ulcer Prevention with interventions of barrier cream and turn and reposition every 2 hours and as needed, keep body in good alignment. The comprehensive care plan revealed Resident #6 had an ADL self-care performance deficit and was totally dependent on staff. Record review of Resident #8's Comprehensive MDS Assessment, dated [DATE], revealed under skin and ulcer/injury treatments an intervention for Applications of ointments/medications other than to feet. Record review of Resident #8's physician order, dated [DATE], revealed an order for: Skin preventive treatment: Apply house barrier cream to sacral area once daily and leave open to air every day shift for prevention treatment. During an observation on [DATE] at 9:43 a.m., revealed Resident #8 was in her bed, awake. A pink barrier cream in a medication cup was observed on the resident's nightstand. 4. Record review of Resident #9's Face Sheet, dated [DATE], revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident had diagnoses which included Pressure ulcer of multiple areas of the sacral area (damage to the skin and underlying tissue, usually over bony areas, caused by prolonged pressure, friction, or shear, restricting blood flow) and pain. Record review of Resident #9's active physician orders as of [DATE] did not reflect any ordered for barrier cream nor Topical Anesthetic. Record review of Resident #9's Comprehensive Care Plan, dated [DATE], revealed Pressure Ulcer Prevention with interventions of barrier cream and turn and reposition every 2 hours and as needed, keep body in good alignment. The comprehensive care plan revealed Resident #6 had an ADL self-care performance deficit and required assistance from staff. Record review of Resident #9's Comprehensive MDS Assessment, dated [DATE], did not reveal the resident had any Pressure ulcers. During an observation and interview on [DATE] at 9:45 a.m., revealed Resident #9 was in her bed, awake. A pink barrier cream in a medication cup and a bottle of topical anesthetic were observed on the resident's nightstand. The resident stated the cream was used for his abdominal rash and the CNAs' used it after he was cleaned and the topical anesthetic was used for wound dressing on his left arm. He stated the CNA brought in the Barrier cream each morning for when he would be cleaned but the topical anesthetic had always been in his room and the nurses used it when doing his wound dressing on his right hand. 5. Record review of Resident #10's Face Sheet, dated [DATE], revealed an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a diagnosis which included Muscle weakness (a noticeable lack of strength where your muscles do not respond the way they are supposed to). Record review of Resident #10's active physician order as of [DATE] revealed no orders for barrier cream. Record review of Resident #10's Comprehensive Care Plan, dated [DATE], revealed the resident was at risk for pressure Ulcer with interventions of barrier cream. The comprehensive care plan revealed Resident #6 had an ADL self-care performance deficit and required assistance from staff. Record review of Resident #10's Comprehensive MDS Assessment, dated [DATE], did not reveal the resident had any Pressure ulcers. During an observation and interview on [DATE] at 9:50 a.m., revealed Resident #10 was in her bed, awake. The resident had plastic bottles of supplements (daily energy and papaya enzyme supplement digestive aid) on her nightstand. The resident stated her family member brought the supplements in for her, and s he kept them on her nightstand and did not hide them so it's visible to all. She stated she did not inform the nurses but did not keep the medications a secret and anyone who walked into the room should be able to see them. 6. Record review of Resident #4's Face Sheet, dated [DATE], revealed an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a diagnosis which included Muscle weakness (a noticeable lack of strength where your muscles do not respond the way they are supposed to). Record review of Resident #4's active physician order as of [DATE] revealed no orders for barrier cream. Record review of Resident #4's Comprehensive Care Plan, dated [DATE], revealed care plan for pressure ulcer prevention with intervention of barrier cream. Resident #4 had an ADL self-care performance deficit and required assistance from staff. Record review of Resident #4's Comprehensive MDS Assessment, dated [DATE], revealed under skin and ulcer/injury treatments an intervention for Applications of ointments/medications other than to feet. During an observation and interview on [DATE] at 9:55 a.m., revealed Resident #4 was in her bed, awake. A spray bottle of Biofreeze was observed on the resident's nightstand. The resident stated she used it for pain. She stated she did not tell the nurses about it but they were aware she had it in her possession. During an interview with CNA A on [DATE] at 3:30 p.m., she stated the pink barrier cream was given to her by the wound nurse for residents with pressure ulcers and redness. She stated she put the cream in the rooms and applied it to the residents as she performed incontinent care. She stated no medications should not be left in the residents' rooms, she stated if unsupervised it could be very dangerous and harm the residents if used improperly. During an interview with CNA B on [DATE] at 3:35 p.m., she stated no medication should be in the resident's room, she stated she should report any medication found in the resident's room to the charge nurse. She stated the medications brought in from outside could be expired, could be given at the wrong time and wrong does causing an overdose. During an interview with ADON K on [DATE] at 3:45 p.m., she stated no medications were allowed in any resident's room unsupervised. She stated the risk of having residents self-administer medications could lead to over medication or medication interaction. She stated if we didn't know what the resident was taking they could have an adverse effect that would be hard to pinpoint. During an interview with LVN C on [DATE] at 3:45 p.m., he stated no residents should have medications in their room per facility policy. He stated the nurses should monitor medications when administered. He stated the nurses usually informed new residents about the medication policy, that all medications should be administered by the nurse and placed in the medication cart even for over-the-counter medications. He stated the nurses obtained orders from the physician for any medication the family wanted the resident to have. He stated the nursing department was responsible for making sure no medications were left unsupervised. He stated the risk of not having medication supervised could result in overdosing. During an interview with the DON on [DATE] at 4:05 p.m., she stated the pink barrier cream should be placed in the drawer in the residents, out of reach of the resident for use only when the CNA was providing perineal care. She stated they should identify any items which included medications that should not be in the residents room during rounds and had them removed or reported to the charge nurse if found by a CNA. She stated no residents had an assessment to self-administer medications, as of today. She stated the risk of having medication unsupervised in resident rooms could be other residents who should not be taking them could get a hold of the medications and possibly have a reaction and the resident who had them could be overmedicated if they were already getting similar medications from the facility nurse.

Based on observation, interview and record review the facility failed to ensure the resident had the right to personal privacy and confidentiality of his or her personal and medical records for one of five residents (Resident #1) reviewed for privacy and confidentiality.The facility failed to ensure Resident #1's medication prescription was not left on top of the medication cart on 04/21/26. This failure could place residents at risk of not having their personal privacy maintained while care was provided and their personal and medical record exposed to unauthorized individuals.Findings include: Record review of Resident #1's Face Sheet, dated 04/21/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with Glaucoma (eye disease).Record review of Resident #1's Comprehensive MDS Assessment, dated 01/28/2026, reflected the resident had severe cognitive impairment with a BIMS score of 3. The Comprehensive MDS Assessment indicated the resident had moderate impaired vision.Record review of Resident #1's physician orders, dated 04/21/26, reflected Artificial Tears Ophthalmic Solution 1%, instill 1 drop in both eyes two times a day.During an observation on 04/21/26 at 9:40 a.m., a medication cart on the 100-hall had medication with Resident #1's name on it. During an interview and observation on 04/21/26 at 9:42 a.m., ADON J observed the State Surveyor standing near the medication cart on the 100-hall. He removed the medication for Resident #1 which was sitting on top of the medication cart. He stated the medication should be always secured and the medication displaying Resident #1's name was a privacy concern.During an interview on 04/21/26 at 4:00 p.m., the DON was informed of Resident #1 having medication on the medication cart in plain view. She stated the medication should not be out in the open because it was going against HIPAA practice and a right to their privacy.During an interview on 04/21/26 at 1:11 p.m., LVN D stated she was informed by her ADON of Resident #1's medication left on top of the medication cart, and she stated it should have been secured in the medication cart. She stated the resident's name was shown and it was a privacy concern. She stated she had just finished administering the medication to the resident a had to run to the bathroom.Record review of the facility's policy, Resident Rights, dated 02/21, reflected Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;c. be free from abuse, neglect, misappropriation of property, and exploitation;d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptomsRecord review of the facility's policy Medication Labeling and Storage Nursing Services Policy and Procedure Manual for Long-Term Care revised 2023 reflected Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #73) of four residents reviewed for pharmacy services. The facility failed to ensure the medication cart contained accurate narcotic logs for Resident #73. This failure could place residents at risk for medication error and drug diversion. Findings included: Record review of Resident #73's admission MDS assessment, dated 05/01/25, reflected Resident #73 was a [AGE] year-old male. He admitted to the facility on [DATE] with diagnoses including cancer, bone fracture, and Parkinson's disease. Resident #73 had a BIMs score of 14 which indicated he was cognitively intact. Record review of Resident #73's care plan, dated 04/24/25, revealed the resident was on pain medication therapy (morphine) for fracture related to bone cancer. Facility interventions included: Administer pain medications as ordered by physician. Record review of Resident #73's physician order summary, dated May 2025 reflected: 05/13/25 Morphine 15 milligrams, give half a tablet, by mouth three times a day for pain. 04/24/25 Morphine 15 milligrams, give half a tablet, by mouth every 4 hours as needed for pain. Record review of Resident #73's May 2025 Medication Administration Record reflected: 1. Morphine 15 milligrams, (half a tablet) was administered to the resident once on 05/13/25 at 9:00 PM, two times on 05/14/25 at 3:00 PM and 9:00 PM, and three times a day from 05/15/25 - 05/19/25 at 9:00 AM, 3:00 PM, and 9:00 PM, and one time on 05/20/25 at 9:00 AM. 2. Morphine 15 milligrams, (half a tablet) PRN (as needed order) was administered to the resident once on 05/14/25 at 4:00 AM. The total doses documented as administered was 19. Record review of Resident #73's Narcotic Record reflected the resident was ordered to receive Morphine 15 milligrams three times a day. The resident received the following doses of Morphine: 15 milligrams on 05/13/25 at 9:00 AM 7.5 milligrams on 05/14/25 at 12:00 AM and 9:00 PM 7.5 milligrams on 05/15/25 at 12:30 PM and 9:00 PM 7.5 milligrams on 05/16/25 at 9:30 AM and 9:00 PM 7.5 milligrams on 05/17/25 at 04:33 AM, 7:00 AM, and 9:00 PM 7.5 milligrams on 05/18/25 at 7:00 AM and 9:00 AM 7.5 milligrams on 05/19/25 at 9:00 AM, 11:22 AM, 1:00 PM, and 9:00 PM 7.5 milligrams on 05/20/25 at 9:00 AM The total doses signed out as administered was 17. Review of Resident #73's Morphine card that contained the morphine pills reflected the count was correct. Record reviews of the MAs competency checks reflected: MA E - competency check completed on 01/08/24 and signed by ADON F. MA D - competency check completed on 02/25/21 and signed by ADON F. MA C - competency check completed on 01/08/25 and signed by ADON F. An interview and observation on 05/21/25 at 2:48 PM revealed Resident #73 was lying in bed. The resident said he was not aware that he missed 2 doses of Morphine between 05/13/25 - 05/20/25. He said it did not affect his pain level. The resident said his current pain level was a 6 on a [NAME] of 1-10 and was told that he was about to receive a dose of Morphine. An interview on 05/21/25 at 12:26 PM with LVN A revealed she completed a narcotic count of Resident #73's Morphine. LVN A said the Morphine Card showed the resident was supposed to receive Morphine 15 milligrams three times a day. The Narcotic Count Sheet reflected the same dose. LVN A said prior to 05/13/25, the resident was ordered to receive 15 milligrams of Morphine three times a day. LVN A said the order was changed to 7.5 milligrams three times a day on 05/13/25. LVN A said the nurse would cut the dose in half and destroy it with the MA as a witness. An interview on 05/21/25 at approximately 12:40 PM with ADON B revealed there were missing signatures from the narcotic record indicating there was not a witness to the half tab (7.5 milligrams) being wasted. ADON B said she did not know why there were missing signatures on the narcotic record. An interview on 05/22/25 at 11:18 AM with MA C revealed she worked the 6:00 AM - 2:00 PM shift with Resident #73. She said she administered a 7.5 milligram of dose to the resident at 12:30 PM on 05/15/25 instead of 9:00 AM because he did not want the dose at 9:00 AM. She said she documented in the medication administration record that she administered the dose at 9:00 AM even though she did not. She said if a dose was not given, then she was supposed to notify the nurse and document the dose as not given. An interview on 05/22/25 at 12:51 PM with MA D revealed he worked double shifts on the weekend on 05/17/25 and 05/18/25. He said he documented on the medication administration record that he gave the doses at 9:00 AM, 3:00 PM, and 9:00 PM on those days. On the narcotic record he administered a dose at 7:00 AM and 9:00 PM on 05/17/25 and 7:00 AM and 9:00 AM on 05/18/25. He said he did not know why the narcotic record and the medication administration record showed different times, but that he gave all the doses as ordered on 05/17/25 and 05/18/25. He said he saved the half table of Morphine 7.5 milligrams and left the doses in a cup in the medication cart. He said the risk to the resident was a tough question because he gave all the doses. An observation and interview on 05/21/25 at 3:23 PM revealed MA D wasted 7.5 milligrams of morphine with unknown nurse in the drug buster in the cart. MA D then administered 7.5 milligrams of Morphine to Resident #73. MA D said she worked the 2:00 PM-10:00 pm shift on 05/13/25 - 05/16/25 and 05/19/25. She said that on those days she did not administer the 3:00 PM doses of Morphine because the resident told her he already received it. The Narcotic Record reflected the 3:00 PM doses were not administered on 05/13/25 - 05/16/25. MA D said she thought that maybe the nurse had already administered the dose, so she just documented on the medication administration record that she administered the dose. She said the risk to the resident was overdose. A follow-up interview on 05/21/25 at 1:38 PM with ADON B for Resident #73 revealed the half tab (7.5 milligrams) of Morphine was being saved. ADON B said she found out the MAs and nurses were saving the half tab on 05/19/25. She said she instructed the staff that the half tab had to be destroyed with a witness on 05/19/25. ADON B said the facility could not change the narcotic record and Morphine card to the correct dose of 7.5 milligrams, but that a correction sticker could have been placed on the record and card. ADON B said the nurse did not do that. ADON B said they could not send the morphine pills back to the pharmacy and they were supposed to be destroyed. ADON B said she told staff to call on 05/19/25 to get the correct dose card and correct narcotic record. ADON B said she did not know why staff had documented that they gave doses on the Medication Administration Record that were not actually given. ADON B said the MA was administering the scheduled doses and the nurse was supposed to waste the other half dose that was left over. Interviews on 05/21/25 at 2:08 PM, 05/22/25 at 12:48 PM, and 05/22/25 2:10 PM with the DON for Resident #73 revealed 2 staff were supposed to witness a drug's destruction. The dose was to be placed in the Drug Buster that was kept on the medication cart. The DON said she found out on 05/19/25 that the staff had been saving the half tab and not destroying it. The DON said staff should have contacted the doctor and the pharmacy to get the correct dose on the Morphine card and narcotic record. The DON said she spoke to LVN A and was told the doctor said it was ok to use the Morphine 15 milligrams and split the tablets in half. The DON said Resident #73 was scheduled to receive Morphine 7.5 milligrams three times a day. The DON said she did not know staff were signing in the Medication Administration Record that they were administering doses that they did not administer. The DON said to ensure the MAs were competent, the facility did competency checks, and the pharmacy consultant would pick someone to watch monthly to do medication pass. She said the MAs were not trained at the facility, but they were trained and had a certification. The facility said they did competency checks before they were assigned to pass medications. The DON said the MAs worked under the nurse's license, the DON's license, and the Administrator's license. She said the resident was at risk of pain and not receiving the correct dose due to not receiving the doses of Morphine. Record review of the facility policy titled Pharmacy Services Overview, revised April 2019, reflected: 1. Pharmaceutical services consists of: a. the processes of receiving and interpreting prescriber's orders; acquiring, receiving, storing, controlling, reconciling, compounding (e.g., intravenous antibiotics), dispensing, packaging, labeling, distributing, administering, monitoring responses to, using and/or disposing of all medications, biologicals, chemicals; b. the provision of medication-related information to health care professionals and residents; c. the process of identifying, evaluating and addressing medication-related issues including the prevention and reporting of medication errors; and d. the provision, monitoring and/or the use of medication-related devices . Record review of the facility policy titled Management of Controlled Medications, dated January 2024, reflected: POLICY The Facility staff will follow the method of accounting for controlled medications through receiving, administration, storage, and destruction, which meets the requirements of state and federal narcotic enforcement agencies. PROCEDURE Receipt from Pharmacy 1. Upon receipt of a controlled medication, the charge nurse will verify/initial the receipt of and validate the quantity received with a second nurse/courier using the Controlled Drug Receipt/Record/Disposition Form. 2. Upon receipt, controlled medications will be logged on a Controlled Drug Receipt/Record/Disposition Form if the form did not come from pharmacy. 3. Controlled medications will immediately be placed under double lock, in the appropriate medication cart. Shift-to-Shift Count: 1. Controlled medications will be counted every shift change (scheduled or incidental) by an authorized staff member (RN/LVN/CMA) reporting on duty with an authorized staff member reporting off duty. a. Scheduled shift change = routine shift changes (8, 12, or 16 hours) b. Incidental shift change = interrupted routine shift due to any circumstances (staff illness, reassignments, partial shift work etc) 2. At the end of every shift the authorized staff member reporting on duty and the authorized staff member reporting off duty meet at the designated medication cart or storage area to count controlled medications. 3. The authorized staff member reporting off duty reads all Controlled Drug Receipt/Record/Disposition Form one sheet at a time, announcing the Patient's name, the medication, and dose. 4. The authorized staff member reporting on duty counts the amount of remaining controlled medications (bubble pack or bottle) and announces the number out loud. 5. Steps 3 and 4 are repeated for each controlled medication and/or Controlled Drug Receipt/Record/Disposition Form. 6. Both the authorized staff member reporting off duty and the authorized staff member reporting on duty verify that the count of all controlled medications and Controlled Drug Receipt/Record/Disposition Form(s) are correct and sign the Controlled Medication Count Sheet. 7. In counting controlled medications, the authorized staff member reporting on duty is alert for any evidence of a substitution. a. Inspect tablets and solutions closely. Note any defects in medication container. b. Immediately report any suspicion of substitution or tampering with controlled medications to the Director of Nursing. Generate the appropriate incident reports. c. If a controlled medication is discontinued or the Patient expires, the controlled medication must remain in the scheduled and/or incidental count until the Director of Nursing (DON) picks up the controlled medication for destruction. When picking up the controlled medication the DON and authorized staff member in control of the keys will both sign and date below the number of controlled medications remaining on each Controlled Drug Receipt/Record/Disposition Form. 8. The DON will log the discontinued controlled medications on the Destruction Log and place them under double lock in the designated controlled medication destruction bin until the pharmacist returns for drug destruction. 9. During the drug destruction, all narcotics will be removed from their container, placed in the biohazard bag/box and destroyed by applying liquids over them. If a discrepancy is found: a. Check the Patient's order sheets, administration records and nurse's notes in the chart to see if a controlled medication has been administered and not recorded. b. Check previous recordings on the Controlled Drug Receipt/Record/ Disposition Form for mistakes in arithmetic or error in transferring numbers from one sheet to the next. c. If the cause of the discrepancy cannot be located and/or the count does not balance, report the matter to the Director of Nursing/designee IMMEDIATELY. d. The authorized staff member reporting off duty must remain in the Facility during the investigation. e. Generate the appropriate incident statements. f. The Director of Nursing/designee will then contact the Administrator. The Administrator will determine if the incident is reportable (internal/external). The Consultant Pharmacist will be notified .

Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for one (Resident #73) of four residents reviewed for medication errors. The facility failed to ensure morphine (pain medicine) was administered to Resident #73 as ordered from 05/11/25 until 05/18/25 and 05/20/25. (9 days). This failure could place residents at risk for not receiving medications as ordered by their physician and not receiving the intended therapeutic benefit of the medications. Findings included: Record review of Resident #73's admission MDS assessment dated [DATE] reflected Resident #73 was a [AGE] year-old male. He admitted to the facility on [DATE] with diagnoses including cancer, bone fracture, and Parkinson's disease. Resident #73 had a BIMs score of 14 which indicated he was cognitively intact. Record review of Resident #73's care plan, dated 04/24/25, revealed the resident was on pain medication therapy (morphine) for fracture related to bone cancer. Facility interventions included: Administer pain medications as ordered by physician. Record review of Resident #73's physician order summary, dated May 2025 reflected: 05/13/25 Morphine 15 milligrams, give half a tablet by mouth three times a day for pain. 04/24/25 Morphine 15 milligrams, give half a tablet by mouth every 4 hours as needed for pain. Record review of Resident #73's May 2025 Medication Administration Record reflected: 1. Morphine 15 milligrams, (half a tablet) was administered to the resident once on 05/13/25 at 9:00 PM, two times on 05/14/25 at 3:00 PM and 9:00 PM, and three times a day from 05/15/25 - 05/19/25 at 9:00 AM, 3:00 PM, and 9:00 PM, and one time on 05/20/25 at 9:00 AM. 2. Morphine 15 milligrams, (half a tablet) PRN (as needed order) was administered to the resident once on 05/14/25 at 4:00 AM. The total doses documented as administered was 19. Record review of Resident #73's Narcotic Record reflected the resident was ordered to receive Morphine 15 milligrams three times a day. The resident received the following doses of Morphine: 15 milligrams on 05/13/25 at 9:00 AM 7.5 milligrams on 05/14/25 at 12:00 AM and 9:00 PM 7.5 milligrams on 05/15/25 at 12:30 PM and 9:00 PM 7.5 milligrams on 05/16/25 at 9:30 AM and 9:00 PM 7.5 milligrams on 05/17/25 at 04:33 AM, 7:00 AM, and 9:00 PM 7.5 milligrams on 05/18/25 at 7:00 AM and 9:00 AM 7.5 milligrams on 05/19/25 at 9:00 AM, 11:22 AM, 1:00 PM, and 9:00 PM 7.5 milligrams on 05/20/25 at 9:00 AM The total doses signed out as administered was 17. Review of Resident #73's Morphine card that contained the morphine pills reflected the count was correct. An interview on 05/21/25 at 2:48 PM revealed Resident #73 was lying in bed. The resident said he was not aware that he missed 2 doses of Morphine between 05/13/25 - 05/20/25. He said it did not affect his pain level. The resident said his current pain level was a 6 on a [NAME] of 1-10 and was told that he was about to receive a dose of Morphine. An interview on 05/21/25 at 12:26 PM with LVN A revealed she completed a narcotic count of Resident #73's Morphine. LVN A said the Morphine Card showed the resident was supposed to receive Morphine 15 milligrams three times a day. The Narcotic Count Sheet reflected the same dose. LVN A said prior to 05/13/25, the resident was ordered to receive 15 milligrams of Morphine three times a day. LVN A said the order was changed to 7.5 milligrams three times a day. LVN A said the nurse would cut the dose in half and destroy it with the MA as a witness. An interview on 05/21/25 at approximately 12:40 PM with ADON B revealed there were missing signatures from the narcotic record indicating there was not a witness to the half tab (7.5 milligrams) being wasted. ADON B said she did not know why there were missing signatures on the narcotic record. An interview on 05/22/25 at 11:18 AM with MA C revealed she worked the 6:00 AM - 2:00 PM shift with Resident #73. She said she administered a 7.5 milligram of dose to the resident at 12:30 PM on 05/15/25 instead of 9:00 AM because he did not want the dose at 9:00 AM. She said she documented in the medication administration record that she administered the dose at 9:00 AM even though she did not. She said if a dose was not given, then she was supposed to notify the nurse and document the dose as not given. An interview on 05/22/25 at 12:51 PM with MA D revealed he worked double shifts on the weekend on 05/17/25 and 05/18/25. He said he documented on the medication administration record that he gave the doses at 9:00 AM, 3:00 PM, and 9:00 PM on those days but on the narcotic record he only administered a dose at 7:00 AM and 9:00 PM on 05/17/25 and 7:00 AM and 9:00 AM on 05/18/25. He said he did not know why the narcotic record and the medication administration record showed different times, but that he gave all the doses as ordered on 05/17/25 and 05/18/25. He said he saved the half table of Morphine 7.5 milligrams and left the doses in a cup in the medication cart. He said the risk to the resident was a tough question because he gave all the doses. An observation and interview on 05/21/25 at 3:23 PM revealed MA D wasted 7.5 milligrams of morphine with unknown nurse in the drug buster in the cart. MA D then administered 7.5 milligrams of Morphine to Resident #73. MA D said she worked the 2:00 PM-10:00 pm shift on 05/13/25 - 05/16/25 and 05/19/25. She said that on those days she did not administer the 3:00 PM doses of Morphine because the resident told her he already received it. The Narcotic Record reflected the 3:00 PM doses were not administered on 05/13/25 - 05/16/25. MA D said she thought that maybe the nurse had already administered the dose, so she just documented on the medication administration record that she administered the dose. She said the risk to the resident was overdose. A follow-up interview on 05/21/25 at 1:38 PM with ADON B for Resident #73 revealed the half tab (7.5 milligrams) of Morphine was being saved. ADON B said she found out the MAs and nurses were saving the half tab on 05/19/25. She said she instructed the staff that the half tab had to be destroyed with a witness on 05/19/25. ADON B said the facility could not change the narcotic record and Morphine card to the correct dose of 7.5 milligrams, but that a correction sticker could have been placed on the record and card. ADON B said the nurse did not do that. ADON B said they could not send the morphine pills back to the pharmacy and they were supposed to be destroyed. ADON B said she told staff to call on 05/19/25 to get the correct dose card and correct narcotic record. ADON B said she did not know why staff had documented that they gave doses on the Medication Administration Record that were not actually given. ADON B said the MA was administering the scheduled doses and the nurse was supposed to waste the other half dose that was left over. An interview on 05/21/25 at 2:08 PM and 05/22/25 at 12:48 PM with the DON for Resident #73 revealed 2 staff were supposed to witness a drug's destruction. The dose was to be placed in the Drug Buster that was kept on the medication cart. The DON said she found out on 05/19/25 that the staff had been saving the half tab and not destroying it. The DON said staff should have contacted the doctor and the pharmacy to get the correct dose on the Morphine card and narcotic record. The DON said she spoke to LVN A and was told the doctor said it was ok to use the Morphine 15 milligrams and split the tablets in half. The DON said Resident #73 was scheduled to receive Morphine 7.5 milligrams three times a day. The DON said she did not know staff were signing in the Medication Administration Record that they were administering doses that they did not administer. She said the resident was at risk of pain and not receiving the correct dose due to not receiving the doses of Morphine. Record review of the facility policy titled Medications, dated November 2017, reflected: Upon admission (including readmission) of each Patient/Resident, the physician's orders for the Patient/Resident must be reviewed and reconciled by the Charge Nurse and the Director of Nursing or his/her designee for accuracy in the Electronic Medical Record . Record review of the facility policy titled Management of Controlled Medications, dated January 2024, reflected: POLICY The Facility staff will follow the method of accounting for controlled medications through receiving, administration, storage, and destruction, which meets the requirements of state and federal narcotic enforcement agencies. PROCEDURE Receipt from Pharmacy 1. Upon receipt of a controlled medication, the charge nurse will verify/initial the receipt of and validate the quantity received with a second nurse/courier using the Controlled Drug Receipt/Record/Disposition Form. 2. Upon receipt, controlled medications will be logged on a Controlled Drug Receipt/Record/Disposition Form if the form did not come from pharmacy. 3. Controlled medications will immediately be placed under double lock, in the appropriate medication cart. Shift-to-Shift Count: 1. Controlled medications will be counted every shift change (scheduled or incidental) by an authorized staff member (RN/LVN/CMA) reporting on duty with an authorized staff member reporting off duty. a. Scheduled shift change = routine shift changes (8, 12, or 16 hours) b. Incidental shift change = interrupted routine shift due to any circumstances (staff illness, reassignments, partial shift work etc) 2. At the end of every shift the authorized staff member reporting on duty and the authorized staff member reporting off duty meet at the designated medication cart or storage area to count controlled medications. 3. The authorized staff member reporting off duty reads all Controlled Drug Receipt/Record/Disposition Form one sheet at a time, announcing the Patient's name, the medication, and dose. 4. The authorized staff member reporting on duty counts the amount of remaining controlled medications (bubble pack or bottle) and announces the number out loud. 5. Steps 3 and 4 are repeated for each controlled medication and/or Controlled Drug Receipt/Record/Disposition Form. 6. Both the authorized staff member reporting off duty and the authorized staff member reporting on duty verify that the count of all controlled medications and Controlled Drug Receipt/Record/Disposition Form(s) are correct and sign the Controlled Medication Count Sheet. 7. In counting controlled medications, the authorized staff member reporting on duty is alert for any evidence of a substitution. a. Inspect tablets and solutions closely. Note any defects in medication container. b. Immediately report any suspicion of substitution or tampering with controlled medications to the Director of Nursing. Generate the appropriate incident reports. c. If a controlled medication is discontinued or the Patient expires, the controlled medication must remain in the scheduled and/or incidental count until the Director of Nursing (DON) picks up the controlled medication for destruction. When picking up the controlled medication the DON and authorized staff member in control of the keys will both sign and date below the number of controlled medications remaining on each Controlled Drug Receipt/Record/Disposition Form. 8. The DON will log the discontinued controlled medications on the Destruction Log and place them under double lock in the designated controlled medication destruction bin until the pharmacist returns for drug destruction. 9. During the drug destruction, all narcotics will be removed from their container, placed in the biohazard bag/box and destroyed by applying liquids over them. If a discrepancy is found: a. Check the Patient's order sheets, administration records and nurse's notes in the chart to see if a controlled medication has been administered and not recorded. b. Check previous recordings on the Controlled Drug Receipt/Record/ Disposition Form for mistakes in arithmetic or error in transferring numbers from one sheet to the next. c. If the cause of the discrepancy cannot be located and/or the count does not balance, report the matter to the Director of Nursing/designee IMMEDIATELY. d. The authorized staff member reporting off duty must remain in the Facility during the investigation. e. Generate the appropriate incident statements. f. The Director of Nursing/designee will then contact the Administrator. The Administrator will determine if the incident is reportable (internal/external). The Consultant Pharmacist will be notified .

Based on observations, interviews, and record review, the facility failed to ensure they offered a therapeutic diet when there was a nutritional problem and the health care provider ordered a therapeutic diet for 1 of 3 residents (Resident #27) reviewed for nutritional status. The facility failed to ensure Resident #27 received the therapeutic diet that was ordered for her during the lunch hour on 05/20/25. This failure could result in residents not receiving their ordered therapeutic meal which could lead to malnutrition and/or choking. The findings included: Record review of Resident #27's admission MDS assessment dated [DATE], revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Her BIMs score was 7 indicating she was cognitively impaired. Her diagnoses included stroke, diabetes, non-Alzheimer's disease, and malnutrition. The resident required supervision while eating. The resident was on a therapeutic diet. Record review of Resident #27's Physician Order Summary report reflected: 04/14/25 Regular diet, ground texture, regular/thin consistency. 02/04/25 Magic Cup (supplement) two times a day for malnutrition. Record review of Resident #27's Care Plan reflected: Date initiated: 03/19/25 with revision on: 04/09/25. The resident had a swallowing problem. Facility interventions included: All staff to be informed of resident's special dietary and safety needs. Instruct resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly. Keep head of bed elevated 45 degrees during meal and thirty minutes afterwards. Resident to eat only with supervision. Record review of Resident #27's Hospice Note, dated 03/18/25, reflected: RN Comprehensive Visit Mechanical diet Assistance required with meals Notes: Pt [patient] tolerating mechanical soft. Pt continues to refused to eat, consuming mostly fluids . An observation on 05/20/25 at 1:18 PM of Resident #27 revealed the resident was lying in bed at a 30-degree angle. Her tray was raised up and to the right of the resident. The resident could not reach all the food on the tray. The resident was trying to feed herself a magic cup and drink milk. The resident was served a whole ham or turkey sliced sandwich with a slice of tomato on it. The tray also had broccoli florets and macaroni. The Surveyor stepped into the hall and requested staff to assist the resident to sit-up and have access to her tray. An interview and observation with LVN I on 05/20/25 at approximately 1:22 PM she said she did not know how Resident #27 was supposed to eat with her tray far away from her. LVN I said she would get assistance to pull her up. LVN J entered the room with LVN I. Both nurses washed their hands and pulled the resident up in bed. LVN I said the resident was supposed to have assistance to eat, but said the resident would not let staff feed her, because she liked to feed herself. LVN I said she thought the resident was on a regular diet but would check. LVN I left the room and ADON F entered the room. ADON F said the resident was ordered to be on a regular, ground diet and that she was not supposed to be served a whole sandwich. ADON F said the resident was at risk for choking. An interview on 05/20/25 at 2:21 PM with CNA G revealed she delivered the wrong tray to Resident #27 on 05/20/25. She said she did not check the tray and just looked at the tray card for the name. CNA G said she was supposed to check the tray, sit up the resident, make sure the food was the right portion, and ask the resident if she needed anything else. CNA G said she did not check the tray for Resident #27 on 05/20/25 because she was rushing to help. CNA G said the resident was at risk of choking if she was not assisted to sit up and was at risk of having an allergy if she received the wrong diet tray. CNA G said sometimes the resident received a puree' diet and sometimes she received a regular diet . An interview on 05/20/25 at 2:26 PM with the Dietician for Resident #27 revealed the resident was supposed to be on a ground diet. The Dietician said the macaroni and cheese was the proper texture and the broccoli was the appropriate texture. The Dietician said the staff returned Resident 27's whole sandwich and the resident received a tuna fish sandwich instead. The Dietician said the resident did not have any choking incidents. The Dietician she was on a ground diet to optimize her oral intake. The Dietician said she did not know if the resident had dysphagia but had a care plan for trouble swallowing. The Dietician said the kitchen staff and nursing staff were responsible for checking the resident's tray. An interview on 05/20/25 at 3:07 PM with the DON revealed she did not know what happened with Resident #27's tray. She said dietary and nursing were responsible for checking the trays. The DON said she was told the resident was delivered a thinly sliced turkey sandwich. The DON said she did not know why the resident did not have supervision to eat and staff were supposed to make sure that she was in the right position to eat. The DON said the resident was at risk for choking if she was served the wrong diet. Record review of the facility policy, Regular Ground Diet, dated 07/26/22, reflected: Policy It is the policy of this facility that the Dining Services Department shall provide a Regular Ground diet when ordered by a physician that is nutritionally adequate and texturally appropriate for the Patient. Responsibility: All Dining Services Staff Procedure: 1. All Dining Services staff must follow the Regular Ground Diet as written on the modified diet spreadsheets. 2. The Regular Ground Diet shall be served according to the guidelines listed in the Diet Rationale from the menu company, unless otherwise indicated. 3. All meats must be ground on all meal trays. 4. Any Patients requiring a different meat texture modification shall have a different diet order indicating that difference. For example, Patients able to tolerate a whole piece of bacon may obtain a physician order; May have a whole piece of bacon. 5. The Dining Services Director and/or designee shall interview the Patient upon admission, readmission and as needed to determine the tolerance of certain foods allowed on the Regular Ground Diet. Any intolerances shall be listed on the tray ticket system. 6. Patients with several food intolerances may be referred to Speech Therapy for a screen.

Based on interview and record review, the facility failed to complete a discharge summary that included but was not limited to, (i) A recapitulation of the resident's stay that includes, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; (ii) A final summary of the resident's status; (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) for 1 of (Resident #71) of 3 residents reviewed for discharge planning. The facility failed to complete a recapitulation of stay for Resident #71, who discharged to another facility on 05/06/25. This failure could place residents at risk of a recapitulation of their stay being unavailable to help ensure continuity of care once they discharged from the facility. Findings included: Review of Resident #71's Face Sheet, dated 05/21/25, reflected she was an [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including urinary tract infection (an infection in any part of the urinary system), type 2 diabetes mellitus with hyperglycemia (a chronic condition that happens when you have persistently high blood sugar levels), and unspecified injury of head (a head injury where the specific type or severity of the injury is not clearly defined or known). Resident #71 discharged from the facility on 05/06/25. Review of Resident #71's Recapitulation of Stay, dated 05/07/25, reflected the document was not completed nor signed. The areas of Social Services, Nursing Services, Activities, Dietary Services, and Rehabilitation Services were all missing required information. During an interview with the Director of Nursing on 05/21/25 at 1:00PM, she stated it was expected for each department to complete their appropriate section of a resident's Recapitulation of Stay. She stated she was not sure why Resident #71's Recapitulation of Stay had not been completed. She stated she did not believe a risk was posed to a resident if/when their Recapitulation of Stay was not completed, as the facility still sent all medical paperwork with the resident and/or to the receiving facility upon discharge. A policy related to the completion of recapitulation of stays was requested on 05/21/25 at 1:11PM. The Administrator stated the facility did not have a written policy related to this area, but the facility was expected to go by State guidelines.

Based on interview and record review, the facility failed to ensure residents were free from chemical restraints that were not required to treat the residents' medical symptoms for 1 (Resident #89) of 5 residents reviewed for unnecessary medications. The facility failed to ensure Resident #89's PRN prescription of Xanax 0.5mg (a medication used to treat the symptoms of anxiety) was discontinued after 14 days. The facility did not document a rationale for the continued provision of the medication. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications. Findings included: Review of Resident #89's Face Sheet, dated 05/21/25, reflected he was a [AGE] year-old male, who admitted to the facility on [DATE], with diagnoses including nontraumatic intracerebral hemorrhage (bleeding within the brain tissue itself, not due to a head injury), quadriplegia (the paralysis of both arms and legs, and often the torso, resulting from damage to the cervical (neck) portion of the spinal cord), and restlessness and agitation (a general feeling of unease, nervousness, and difficulty remaining still). Review of Resident #89's MDS Assessment, dated 05/02/25, reflected he was taking a prescribed antianxiety medication which had an indication for use. Review of Resident #89's Care Plan, dated 05/19/25, reflected he was taking a prescribed antianxiety medication (Xanax) due to anxiety disorder. Goals included for Resident #93 to be free from discomfort or adverse reactions related to antianxiety therapy. Review of Resident #89's Physician's Orders, dated 05/21/25, reflected he was prescribed Xanax Oral Tablet 0.5mg (Alprazolam). The orders specified for staff to give 1 tablet via g-tube every 8 hours as needed for anxiety. The start date was 04/26/25. There was no specified end date. Review of Resident #89's Medication Administration Record, from April 2025 to May 2025, reflected Resident #89 received his prescription of Xanax Oral Tablet 0.5mg (Alprazolam) on 04/29/25, 05/01/25, 05/08/25, 05/11/25, and 05/14/25. During an interview with the Director of Nursing on 05/21/25 at 1:00PM, she stated the expectation for PRN psychotropic medications was for the medication not to be prescribed for more than 14 days. She stated she was not sure why Resident #89's PRN prescription medication of Xanax Oral Tablet 0.5mg (Alprazolam) had been prescribed for more than 14 days. She stated she did not know what type of risk this could pose to the resident. A policy related to PRN antianxiety/psychotropic medication use was requested on 05/21/25 at 1:11PM. The Administrator stated the facility did not have a written policy related to this area, but the facility was expected to go by State guidelines.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #57 and Resident #84) of eight residents, reviewed for infection control. 1. The facility failed to ensure CNA G performed hand hygiene during incontinence care and did not soil the wipes container with soiled gloves for Resident #57. 2. The facility failed to ensure CNA H did not soil the wipes container with soiled gloves for Resident #84. This failure placed residents at risk for healthcare associated cross contamination and infections. Findings included: 1. Review of Resident 57's Quarterly MDS Assessment, dated 03/28/25, reflected the resident had a BIMs score of 13 and was cognitively intact. She was a [AGE] year-old female admitted to the facility on [DATE]. The resident had diagnoses which included fall with fracture. The resident was occasionally incontinent of bladder and was always incontinent of bowel. The resident required partial assistance with toileting. Review of Resident #57's Comprehensive Care Plan, dated 05/22/25, reflected the resident had an activities of daily living self-care performance deficit. Facility interventions included: Toilet use: The resident requires assistance of one or two staff for toileting. An observation on 05/20/25 at 10:55 AM of Resident #57 revealed CNA G was preparing to perform incontinence Care. CNA G washed her hands, put on gloves, positioned the resident in bed on her back, folded down the brief, and cleaned the vaginal area. The brief was soiled with bowel movement. CNA G turned the resident to her right side and wiped her buttocks. CNA G grabbed clean wipes out of the wipes container with soiled gloves. CNA G changed her gloves but did not perform hand hygiene. CNA G put a clean brief on the resident. An interview on 05/20/25 at 11:12 AM with CNA G revealed she was supposed to perform hand hygiene after removing her soiled gloves. She also said she was not supposed to touch the container of wipes with soiled gloves. CNA G said she did not perform hand hygiene and touched the wipes container with soiled gloves because she was stressed. CNA G said the risk to the resident was infection. 2. Review of Resident 84's Quarterly MDS Assessment, dated 04/15/25, reflected the resident had a BIMs score of 6 and was cognitively impaired. She was an [AGE] year-old female admitted to the facility on [DATE]. The resident had diagnoses which included cancer. The resident was always incontinent of bladder and bowel. The resident required partial assistance with toileting. Review of Resident #84's Comprehensive Care Plan, dated 05/04/25, reflected the resident had an activities of daily living self-care performance deficit. Facility interventions included: Toilet use: The resident requires assistance of one or two staff for toileting. An observation on 05/20/25 at 12:25 PM of Resident #84 revealed CNA G and CNA H were preparing to perform incontinence care. Both CNAs washed their hands and put on gloves. The resident was positioned on her back. CNA H folded down the resident's brief and it was soaked with urine. The resident was lying on a dry bed pad, but the resident's bottom sheet had a large urine stain on it. The brief also contained bowel movement. CNA H began cleansing the buttocks and picked up clean wipes with soiled gloves. CNA H placed the soiled wipes container on the bedside table. The CNAs changed their gloves and washed their hands. CNA H put a clean brief on the resident but did not change the soiled sheet. CNA H said she would change the sheet later. An interview on 05/20/25 at 12:30 PM with CNA H revealed she was not supposed to touch and move the wipes container with soiled gloves on the bedside table. She said she was also not supposed to leave soiled linen on the bed. CNA H said she did it this time because she was in a hurry and the risk to the resident was contamination. An interview on 05/21/25 at 4:12 PM with ADON B revealed staff were supposed to change gloves and perform hand hygiene when going from a dirty area to a clean area. ADON B also said it was not ok for staff to stick soiled, gloved, hands into the wipe's container and pull out wipes. ADON B said the risk to the resident was infection. An interview with the DON on 05/22/25 at 12:42 PM revealed staff were supposed to change gloves and perform hand hygiene when going from a dirty area to a clean area. The DON also said it was not ok for staff to stick soiled, gloved, hands into the wipe's container. The DON said the risk to the resident was infection and contamination. Record review of the facility policy, Infection Control, dated November 2017, reflected: 1. The facility must establish an infection prevention and control program (IPCP) that must include: a. A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all Patients, staff, volunteers, visitors, and other individuals . Record review of the facility policy, Handwashing, dated August 2012, reflected: GUIDELINES Standards of Practice/Hand washing Hand washing is the single most important means of preventing the spread of infection. The principle of good hand washing is that of using friction to mechanically remove micro-organisms. After Patient contact - Wash hands with soap and running water - Rinse hands with running water - Dry hands well with paper towel - Use paper towel to turn off faucet. All manually controlled faucets are considered contaminated. - Dispose of single use or linen towels in appropriate receptacle. - May use Hand sanitizing gel in place of soap and water.

Based on observation, interviews, and record review, the facility failed to ensure the right to be free from abuse was provided for 1 (Resident #1) of 6 residents reviewed for abuse and neglect. The facility failed to protect Resident #1 from abuse when CNA A was witnessed being verbally and physically abusive to Resident #1, resulting in Resident #1 becoming fearful of CNA A. The noncompliance was identified as PNC. The noncompliance began on 12/23/24 and ended on 12/27/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for abuse and neglect. Findings included: Review of Resident #1's Annual Minimum Data Set (MDS ), dated 01/26/2025, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including depression (a mood disorder that causes persistent feelings of sadness, emptiness, and loss of joy, fibromyalgia (a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and trouble sleeping, it occurs in the absence of an identifiable physical or physiological cause). Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, reflecting mild cognitive impairment. The MDS also revealed Resident #1 required extensive assistance with Activities of Daily Living (ADL). During an interview and observation of Resident #1 on 01/30/2025 at 10:05 a.m., Resident #1 reported an incident in early December involving CNA A and CNA B. While CNA A was providing incontinent care, Resident #1 asked CNA A to stop rolling her over due to pain, but CNA A continued despite protest from both Resident #1 and CNA B. Resident #1 stated CNA A was verbally abusive during the interaction, though she could not recall the exact words used. The physical handling caused Resident #1 pain, and she became fearful that CNA A would harm or kill her. Resident #1 reported the incident to multiple staff members but was initially told no one matching CNA A's description or name worked at the facility. Weeks later, Resident #1 recognized CNA A during an activity and confronted her, learning that CNA A had provided a false name during the incident. Resident #1 reported this to the ADON and the DON. Resident #1 stated she had only seen CNA A one time since the initial occurrence and CNA A did not provide her care before that incident nor after. Resident #1 stated she feels safe living in the facility and receiving care. During an interview on 01/30/2025 at 1:10 PM with LVN A, she reported she worked the 6 a.m. to 2 p.m. shift on Resident #1's hall. The LVN reported Resident #1 reported that she was abused by a CNA. The LVN stated she immediately reported the alleged abuse to the Administrator and the DON. During an interview on 01/30/2025 at 2:45 with Resident #1's FM. FM stated Resident #1 told him when CNA A was rolling her over to her side to change her, Resident #1 said she did it a little aggressively. FM stated he had not heard about the incident from the facility, which is why family installed a camera in Resident #1's room, for added security. He expressed frustration that the facility initially dismissed Resident #1's claims, suggesting she might be fabricating the story, as they did not have a staff member by the name Resident #1 was saying. FM stated soon after this incident he received another call from the facility stating they were going to have his Resident #1 tested by psychology. He stated he thought this was odd because Resident #1's mind is on point. During an interview on 01/30/2025 at 2:30 PM with RN A, the Weekend Supervisor, RN A confirmed Resident #1's account and began conducting interviews of weekend staff. During his interviews, RN A learned from CNA B that she witnessed CNA A abusing Resident #1 and did not report the incident. RN A stated he educated CNA B that if she saw abuse or was unsure if it was abuse that she witnessed, CNA B should have reported the incident. RN A stated he had worked with CNA A before and never had any issues reported to him. RN A stated in speaking with Resident #1, she was unable to provide a date of when the incident occurred, she denied being in pain, and Resident #1 stated that the CNA A providing Resident #1 the wrong name upset her. RN A stated he had called the DON and the Administrator once he became aware of the allegation and that CNA B was suspended but CNA A was not on duty. RN A stated that the following Monday, (12/23/24) CNA A was suspended. RN A stated he was educated on abuse, neglect and reporting allegations of abuse to the abuse coordinator the Administrator, immediately. During an interview on 01/30/2025 at 12:50 PM, CNA B reported she was in the room with CNA A when the incident happened. CNA B said CNA A told Resident #1 to move onto her side for incontinent care and Resident #1 was refusing. She stated Resident #1 was resisting while CNA A was pushing on Resident #1's back to place her onto her side. CNA B said she told CNA A to leave the room numerous times, but she wouldn't. CNA B said CNA A also witnessed CNA B saying to Resident #1 that her FM does not love her and left her here. CNA B said she did not report this incident to management or the abuse coordinator after it happened. CNA B said she made an emotional decision on not to report the abuse. CNA B stated she knew abuse and neglect was supposed to be reported to the Abuse Coordinator, the Administrator immediately but CNA A's living conditions at the time made her hesitant to say anything as she felt bad about CNA A's situation. During an interview on 01/30/2025 at 3:50 PM, the DON stated she learned about the incident on between Resident #1 and CNA A from RN A. DON stated RN A called on Saturday or Sunday unsure date her to state Resident#1 had a camera put in her room, when DON asked why RN A reported that Resident #1 said she was verbally assaulted but did not state by who. DON stated she immediately called the Administrator and started an investigation. DON stated she directed RN A to talk to as many staff to find out what occurred and that was when CNA B reported she witnessed CNA A be abusive to Resident #1. DON stated prior (unknown date) Resident #1 told her a CNA was rude to her and turned her over too fast to reposition. DON stated around 12/09/24 a grievance was filed related to the information. The DON reported that Resident #1 gave her a name, but they did not have anyone by that name that worked at the facility or fit the physical description of any of their employees. The DON stated a few weeks later Resident #1 said she recognized the CNA that was abuse to her as CNA A and reported this to staff. The DON stated she completed a mental assessment and a physical assessment for injuries and non were found. DON stated that the MD referred Resident #1 to psych service. DON stated CNA A was suspended. She stated CNA B was also suspended for not reporting the abuse. DON stated she spoke to staff who all denied that anything occurred between CNA A and Resident #1. DON stated when talked to Resident #1 the first time Resident #1 said she was not abuse but the second time they spoke Resident #1 expressed she felt abused, and Resident #1 was providing conflicting information. During an interview on 01/30/2025 at 3:15 PM, the ADON reported she was made aware of the alleged abuse by Resident #1 who reported she was abused by a CNA while being provided care. The ADON stated that she and the DON went to interview Resident #1 who gave a description of a person who did not match any of the employed staff. ADON stated that Resident #1 stated the aide was being rude. ADON stated that Resident #1 had reported to RN A a week or two later that an aide had been abusive towards her. ADON stated that while RN A was interviewing, CNA B stated she had witnessed the event between Resident #1 and CNA A. ADON stated that Resident #1 did not express she was in pain during the incident. ADON stated once CNA A was identified as the perpetrator, she was suspended and later terminated from employment. ADON stated she was educated on abuse, neglect and reporting allegations of abuse to the abuse coordinator the Administrator, immediately. During an interview on 01/30/2025 at 4:00 PM, the Administrator stated she learned about the alleged abuse on 12/22/2024 when she reported it. She stated she was contacted by the DON who told her Resident #1 had reported she was abused by a CNA. The Administrator stated a couple of weeks prior to this, Resident #1 reported a CNA was rude to her and the description provided by Resident #1 did not match anyone that worked there. The Administrator stated that she did not feel like Resident #1 was abused. Administrator stated that CNA A was suspended pending the investigation and was then fired. She reported CNA B was fired for not reporting the alleged abuse. The Administrator reported she did not report the alleged abuse on 12/09/2024 because Resident #1 stated she did not feel like the abuse was intentional. Administrator stated that Resident #1 is always reporting abuse and is confused. Administrator stated as a result of the 12/22/24 incident the facility completed in-services on abuse and neglect, when and who to report allegations of abuse to with all staff. Safe surveys were completed, an assessment of Resident #1 was completed for injuries, both aides were terminated from employment. During a follow-up interview on 01/30/25 at 6:17 PM Regional Nurse Consultant, DON and Administrator stated that the facility completed safe surveys on residents, in-serviced all staff on abuse, neglect and when to report allegations of abuse and to whom, the abuse coordinator. Regional Nurse Consultant, DON and Administrator stated that they felt like CNA B stated she was there as there when CNA A abused Resident #1 as there was tension between staff. Review of the facility Provider Investigation Report dated 12/27/24, reflected the following: CNA B stated that she witnessed CNA A being unkind and rude to [Resident #1] stated this happened a few weeks ago but did not give a date Resident [#1] had no physical injuries noted, resident stated she felt okay however employee did make her upset . Treatment was not provided. Provider Response: ED notified RDO/RCS/ Executive Director reported Abuse Allegation to HHSC at 11:02 PM on 12/22/24, employee statements collected, Physician, Ombudsman and Family notified. Staff was re-in serviced on Abuse and Neglect and Injuries of Unknown Origin, Staff was re-tested for Abuse and Neglect, Resident Safe Surveys conducted. CNA were suspended. Investigation Summary: the investigation concluded that this claim was inconclusive due to inconsistencies in description and time and place from resident .Facility did terminate both CNA's due to statements by the resident and due to the CNA failing to report to administration. Please see investigation summary for detailed investigation report. Review of Facility External/Internal Investigation Summary dated 12/27/24 reflected the following: incident CNA B stated that she witnessed CNA A being unkind and rude to miss. She stated this happened a few weeks ago but did not give an exact date. Timeline 12/09/24 Resident #1 stated to DON that CNA by the name of [NAME] was rude to her period DON stated that we did not have an employee by that name and asked if she could describe the person. She stated she was tall black and that she had four blonde cornrows on top of her head . DON asked her if she knew what date and times occurred, Resident #1 was unsure of date or time. [DON] asked her if she felt unsafe or that it was verbally abusive Resident #1 stated she felt safe and that she felt the aid was just having a bad day, but it was not verbally abusive. [DON] informed [Resident #1] that we did not have an aide by that name or a nurse by that name and we did not have anyone who fit the description she stated she would let us know if she saw the person again. Family member was notified. [FM] stated [Resident #1] had told him something similar but also knows [Resident #1] has a history of confusion Grievance report was done, and staff interviewed no one knew of incident or employee that matched description. 12/22/24 [DON] received a phone call from the weekend supervisor [RN A] regarding Resident #1 now having a camera in her room . [Resident #1] told the supervisor it was because of aide that was rude and required. [Resident #1] stated the aids name was [the same as CNA A]. [RN A] informed [DON] that [CNA B] had just informed him that she was in the room with [CNA A] when she was being rude to [Resident #1] [CNA B] stated that [CNA A] stated that [Resident #1's] [FM] left her at the facility because they did not love her and did not want to take care of her. [CNA B] also stated that [CNA A] stated that she made a comment that she should be happy someone is there to wipe her ass these statements were never stated to [DON] prior by [Resident #1] . When administrator and [DON] inquired if she had informed anybody of the allegations prior, she stated she had not. Administrator informed her [CNA B] that she was required to inform about any type of abuse or neglect witness suspected or reported. [CNA B] has completed training on abuse neglect prior to this incident stated she did know she should have reported to us. [CNA B] was suspended while investigation was ongoing due to not reporting directly to administrator and timely manner. Facility reported to HHS allegation of verbal abuse .CNA A was informed that she was suspended by pending investigation . Resident Safe Surveys Conducted, Employee interviews conducted, ombudsman and physician notified. 12/23/24 [DON] and [ADON] spoke with [Resident #1] in the morning regarding [CNA A]. [Resident #1] stated she did see the aide she was talking about two week prior going to a Christmas Caroling evening and she had asked the aide who was taking her what her name was, and she informed her that her name was [CNA A] .All staff training and tests on abuse and neglect .12/27/24 CNA A was terminated from employment. CNA B was terminated from employment for failing to report in a timely manner, despite prior training . Actions taken by facility: ED notified RDO/RCS. [ED] reported abuse allegation to HHSC at 11:02 PM on 12/22/24, employment statements were collected, physician, ombudsman and family notified, staff was in serviced on abuse and neglect and injuries of unknown origin .retested on abuse and neglect. Safe surveys were conducted, CNA A and B were suspended. Review of facility in-service titled Abuse and Neglect dated 12/23/24 was presented by the DON, the contents included abuse in reporting guidelines; If you witness or suspect any type of abuse, you must report it immediately. Failure to report abuse is grounds for corrective action and or termination. Revealed 59 staff members (RN, LVN, ADON, PTA, Cook, DOR, Nutritional Aide, PT, DOR, MA, Concierge, HR, DOM, SW, Hskping Supervisor, Laundry Aide) had taken the in-service. Review of facility Review Discussion Form with a creation date of 12/22/24 initiated by DON reflected that CNA A was suspended pending investigation. Review of facility Personnel Action Form with an effective date of 12/27/24, for CNA B reflected: Employee status TERMINATED. Date last worked: 12/21/24. Review of facility Personnel Action Form with an effective date of 12/27/24, for CNA A reflected: Manager Comments: Misconduct/Violation of rules and policies. Failure to report allegations Employee status TERMINATED . Date last worked: 12/21/24. Review of facility Resident Safe Surveys dated 12/22/24 reflected all residents felt safe in the facility and had no concerns. Review of facility [Facility Name] Abuse Protocol Test reflected 89 staff had taken the tests between 12/23/24 through 12/27/24. Interview on 01/30/24 from 9:30 AM to 4:00 PM revealed that 5 LVN (1 PRN), 1 RN, ADON, 3 CNAs had been educated by the DON on abuse neglect exploitation, including when and who to report abuse to. All staff confirmed that they had taken a post test on the abuse policy. An Abuse Prevention and Reporting Policy dated April 2029 indicated .our facility will not condone patient abuse, neglect, mistreatment, or misappropriation of patient property and exploitation (collectively Patient Abuse) by anyone, including staff members, other patient, consultants, volunteers, staff of other agencies serving the patient, family members, legal guardians, sponsors, friends, or other individuals.Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.Verbal abuse is defined as any use of oral, written or gestured language that includes disparaging and derogatory terms to patient or their families, or within their hearing distance, or describe patient, regardless of their age, ability to comprehend, or disability.

Based on observation, interview and record review, the facility failed to ensure that residents received routine and 24-hour emergency dental services for one of (Residents #2) of three residents reviewed for the provision of routine/emergency dental services. The facility failed to ensure Resident #2 received routine dental care. This failure could affect residents by placing them at risk of pain, weight loss, infection, difficulty eating and a decline in their quality of life due to unmet dental needs. Findings included: Review of Resident #2's annual MDS Resident assessment dated [DATE] revealed she was a [AGE] year old female who admitted to the facility on [DATE]. Her diagnoses included heart failure, hypertension, gastroesophageal reflux disease, hyperkalemia, hyperlipidemia, Alzheimer's disease, multiple sclerosis, and seizure disorder. Her functional abilities section reflected she was dependent on staff regarding personal hygiene. Interview with RP on 01/30/25 at 11:24 am revealed she had requested dental services for Resident #2 multiple times. She stated Resident #2 had not been seen by the dentist. She stated Resident #2 needed to be seen by the dentist because her top denture kept falling out. Observation and interview with Resident #2 on 01/30/25 at 12:35 PM revealed her top denture was not secured to her gum. Her top denture kept sliding down. Resident #2's entire top denture was visible while she talked. She stated she did not remember receiving dental services. She appeared to be confused. Review of Resident #2's progress notes on 01/30/25 dated 05/13/24 and 05/22/24 reflected the RP had requested dental services for Resident #2 and a referral was sent to the dental company. There was no documentation reflecting Resident #2 was seen by the dentist. Review of the dental company visit summary dated 11/06/24 reflected Resident #2 was not seen by the dentist. Interview with the social worker on 01/30/25 at 4:49 pm revealed she was responsible for ensuring Resident #2 received dental services. She stated the previous social worker had submitted Resident #2 dental referral to the dental company. She stated she did not know if Resident #2 received dental services. She stated Resident #2 was not her dental list. She stated there was no reason Resident #2 should not have received dental services. She stated the dentist or dental hygienist saw residents monthly at the facility. The purpose of Resident #2 receiving dental services was maintain good hygiene and dental care. Record review of the facility policy titled Dental Services, dated December 2016, revealed Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.

Based on interviews and record review, the facility failed to ensure all alleged violations involving abuse and neglect were immediately reported, including injuries of unknown origin, but not later than 2 hours after the allegation was made if the events that caused the allegation involved abuse or resulted in serious bodily injury 24 hours after the allegations were made, to the State Survey Agency for one (Resident #1) of six residents reviewed for abuse. 1. Facility staff (CNA B) failed to notify the Abuse Coordinator/ADM of witnessed abuse of Resident #1 by CNA A. 2. The Abuse Coordinator failed to report to the State Survey Agency alleged abuse when Resident #1 reported abuse to facility staff on 12/09/2024. This failure could place residents at risk of injuries, abuse, and/or neglect. Findings Include: Review of Resident #1's Annual Minimum Data Set (MDS ), dated 01/26/2025, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including depression (a mood disorder that causes persistent feelings of sadness, emptiness, and loss of joy, fibromyalgia (a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and trouble sleeping, it occurs in the absence of an identifiable physical or physiological cause). Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, reflecting mild cognitive impairment. The MDS also revealed Resident #1 required extensive assistance with Activities of Daily Living (ADL). During an interview and observation of Resident #1 on 01/30/2025 at 10:05 a.m., Resident #1 reported an incident in early December involving CNA A and CNA B. While CNA A was providing incontinent care, Resident #1 asked CNA A to stop rolling her over due to pain, but CNA A continued despite protest from both Resident #1 and CNA B. Resident #1 stated CNA A was verbally abusive during the interaction, though she could not recall the exact words used. The physical handling caused Resident #1 pain, and she became fearful that CNA A would harm or kill her. Resident #1 reported the incident to multiple staff members but was initially told no one matching CNA A's description or name worked at the facility. Weeks later, Resident #1 recognized CNA A during an activity and confronted her, learning that CNA A had provided a false name during the incident. Resident #1 reported this to the ADON and the DON. Resident #1 stated she had only seen CNA A one time since the initial occurrence and CNA A did not provide her care before that incident nor after. Resident #1 stated she feels safe living in the facility and receiving care. During an interview on 01/30/2025 at 1:10 PM with LVN A, she reported she worked the 6 a.m. to 2 p.m. shift on Resident #1's hall. The LVN reported Resident #1 reported that she was abused by a CNA. The LVN stated she immediately reported the alleged abuse to the Administrator and the DON. During an interview on 01/30/2025 at 2:45 with Resident #1's FM. FM stated Resident #1 told him when CNA A was rolling her over to her side to change her, Resident #1 said she did it a little aggressively. FM stated he had not heard about the incident from the facility, which is why family installed a camera in Resident #1's room, for added security. He expressed frustration that the facility initially dismissed Resident #1's claims, suggesting she might be fabricating the story, as they did not have a staff member by the name Resident #1 was saying. FM stated soon after this incident he received another call from the facility stating they were going to have his Resident #1 tested by psychology. He stated he thought this was odd because Resident #1's mind is on point. During an interview on 01/30/2025 at 2:30 PM with RN A, the Weekend Supervisor, RN A confirmed Resident #1's account and began conducting interviews of weekend staff. During his interviews, RN A learned from CNA B that she witnessed CNA A abusing Resident #1 and did not report the incident. RN A stated he educated CNA B that if she saw abuse or was unsure if it was abuse that she witnessed, CNA B should have reported the incident. RN A stated he had worked with CNA A before and never had any issues reported to him. RN A stated in speaking with Resident #1, she was unable to provide a date of when the incident occurred, she denied being in pain, and Resident #1 stated that the CNA A providing Resident #1 the wrong name upset her. RN A stated he had called the DON and the Administrator once he became aware of the allegation and that CNA B was suspended but CNA A was not on duty. RN A stated that the following Monday, (12/23/24) CNA A was suspended. RN A stated he was educated on abuse, neglect and reporting allegations of abuse to the abuse coordinator the Administrator, immediately. During an interview on 01/30/2025 at 12:50 PM, CNA B reported she was in the room with CNA A when the incident happened. CNA B said CNA A told Resident #1 to move onto her side for incontinent care and Resident #1 was refusing. She stated Resident #1 was resisting while CNA A was pushing on Resident #1's back to place her onto her side. CNA B said she told CNA A to leave the room numerous times, but she wouldn't. CNA B said CNA A also witnessed CNA B saying to Resident #1 that her FM does not love her and left her here. CNA B said she did not report this incident to management or the abuse coordinator after it happened. CNA B said she made an emotional decision on not to report the abuse. CNA B stated she knew abuse and neglect was supposed to be reported to the Abuse Coordinator, the Administrator immediately but CNA A's living conditions at the time made her hesitant to say anything as she felt bad about CNA A's situation. During an interview on 01/30/2025 at 3:50 PM, the DON stated she learned about the incident on between Resident #1 and CNA A from RN A. DON stated RN A called on Saturday or Sunday unsure date her to state Resident#1 had a camera put in her room, when DON asked why RN A reported that Resident #1 said she was verbally assaulted but did not state by who. DON stated she immediately called the Administrator and started an investigation. DON stated she directed RN A to talk to as many staff to find out what occurred and that was when CNA B reported she witnessed CNA A be abusive to Resident #1. DON stated prior (unknown date) Resident #1 told her a CNA was rude to her and turned her over too fast to reposition. DON stated around 12/09/24 a grievance was filed related to the information. The DON reported that Resident #1 gave her a name, but they did not have anyone by that name that worked at the facility or fit the physical description of any of their employees. The DON stated a few weeks later Resident #1 said she recognized the CNA that was abuse to her as CNA A and reported this to staff. The DON stated she completed a mental assessment and a physical assessment for injuries and non were found. DON stated that the MD referred Resident #1 to psych service. DON stated CNA A was suspended. She stated CNA B was also suspended for not reporting the abuse. DON stated she spoke to staff who all denied that anything occurred between CNA A and Resident #1. DON stated when talked to Resident #1 the first time Resident #1 said she was not abuse but the second time they spoke Resident #1 expressed she felt abused, and Resident #1 was providing conflicting information. During an interview on 01/30/2025 at 3:15 PM, the ADON reported she was made aware of the alleged abuse by Resident #1 who reported she was abused by a CNA while being provided care. The ADON stated that she and the DON went to interview Resident #1 who gave a description of a person who did not match any of the employed staff. ADON stated that Resident #1 stated the aide was being rude. ADON stated that Resident #1 had reported to RN A a week or two later that an aide had been abusive towards her. ADON stated that while RN A was interviewing, CNA B stated she had witnessed the event between Resident #1 and CNA A. ADON stated that Resident #1 did not express she was in pain during the incident. ADON stated once CNA A was identified as the perpetrator, she was suspended and later terminated from employment. ADON stated she was educated on abuse, neglect and reporting allegations of abuse to the abuse coordinator the Administrator, immediately. During an interview on 01/30/2025 at 4:00 PM, the Administrator stated she learned about the alleged abuse on 12/22/2024 when she reported it. She stated she was contacted by the DON who told her Resident #1 had reported she was abused by a CNA. The Administrator stated a couple of weeks prior to this, Resident #1 reported a CNA was rude to her and the description provided by Resident #1 did not match anyone that worked there. The Administrator stated that she did not feel like Resident #1 was abused. Administrator stated that CNA A was suspended pending the investigation and was then fired. She reported CNA B was fired for not reporting the alleged abuse. The Administrator reported she did not report the alleged abuse on 12/09/2024 because Resident #1 stated she did not feel like the abuse was intentional. Administrator stated that Resident #1 is always reporting abuse and is confused. Administrator stated as a result of the 12/22/24 incident the facility completed in-services on abuse and neglect, when and who to report allegations of abuse to with all staff. Safe surveys were completed, an assessment of Resident #1 was completed for injuries, both aides were terminated from employment. During a follow-up interview on 01/30/25 at 6:17 PM Regional Nurse Consultant, DON and Administrator stated that the facility completed safe surveys on residents, in-serviced all staff on abuse, neglect and when to report allegations of abuse and to whom, the abuse coordinator. Regional Nurse Consultant, DON and Administrator stated that they felt like CNA B stated she was there as there when CNA A abused Resident #1 as there was tension between staff. Review of the facility Provider Investigation Report dated 12/27/24, reflected the following: CNA B stated that she witnessed CNA A being unkind and rude to [Resident #1] stated this happened a few weeks ago but did not give a date Resident [#1] had no physical injuries noted, resident stated she felt okay however employee did make her upset . Treatment was not provided. Provider Response: ED notified RDO/RCS/ Executive Director reported Abuse Allegation to HHSC at 11:02 PM on 12/22/24, employee statements collected, Physician, Ombudsman and Family notified. Staff was re-in serviced on Abuse and Neglect and Injuries of Unknown Origin, Staff was re-tested for Abuse and Neglect, Resident Safe Surveys conducted. CNA were suspended. Investigation Summary: the investigation concluded that this claim was inconclusive due to inconsistencies in description and time and place from resident .Facility did terminate both CNA's due to statements by the resident and due to the CNA failing to report to administration. Please see investigation summary for detailed investigation report. Review of Facility External/Internal Investigation Summary dated 12/27/24 reflected the following: incident CNA B stated that she witnessed CNA A being unkind and rude to miss. She stated this happened a few weeks ago but did not give an exact date. Timeline 12/09/24 Resident #1 stated to DON that CNA by the name of [NAME] was rude to her period DON stated that we did not have an employee by that name and asked if she could describe the person. She stated she was tall black and that she had four blonde cornrows on top of her head . DON asked her if she knew what date and times occurred, Resident #1 was unsure of date or time. [DON] asked her if she felt unsafe or that it was verbally abusive Resident #1 stated she felt safe and that she felt the aid was just having a bad day, but it was not verbally abusive. [DON] informed [Resident #1] that we did not have an aide by that name or a nurse by that name and we did not have anyone who fit the description she stated she would let us know if she saw the person again. Family member was notified. [FM] stated [Resident #1] had told him something similar but also knows [Resident #1] has a history of confusion Grievance report was done, and staff interviewed no one knew of incident or employee that matched description. 12/22/24 [DON] received a phone call from the weekend supervisor [RN A] regarding Resident #1 now having a camera in her room . [Resident #1] told the supervisor it was because of aide that was rude and required. [Resident #1] stated the aids name was [the same as CNA A]. [RN A] informed [DON] that [CNA B] had just informed him that she was in the room with [CNA A] when she was being rude to [Resident #1] [CNA B] stated that [CNA A] stated that [Resident #1's] [FM] left her at the facility because they did not love her and did not want to take care of her. [CNA B] also stated that [CNA A] stated that she made a comment that she should be happy someone is there to wipe her ass these statements were never stated to [DON] prior by [Resident #1] . When administrator and [DON] inquired if she had informed anybody of the allegations prior, she stated she had not. Administrator informed her [CNA B] that she was required to inform about any type of abuse or neglect witness suspected or reported. [CNA B] has completed training on abuse neglect prior to this incident stated she did know she should have reported to us. [CNA B] was suspended while investigation was ongoing due to not reporting directly to administrator and timely manner. Facility reported to HHS allegation of verbal abuse .CNA A was informed that she was suspended by pending investigation . Resident Safe Surveys Conducted, Employee interviews conducted, ombudsman and physician notified. 12/23/24 [DON] and [ADON] spoke with [Resident #1] in the morning regarding [CNA A]. [Resident #1] stated she did see the aide she was talking about two week prior going to a Christmas Caroling evening and she had asked the aide who was taking her what her name was, and she informed her that her name was [CNA A] .All staff training and tests on abuse and neglect .12/27/24 CNA A was terminated from employment. CNA B was terminated from employment for failing to report in a timely manner, despite prior training . Actions taken by facility: ED notified RDO/RCS. [ED] reported abuse allegation to HHSC at 11:02 PM on 12/22/24, employment statements were collected, physician, ombudsman and family notified, staff was in serviced on abuse and neglect and injuries of unknown origin .retested on abuse and neglect. Safe surveys were conducted, CNA A and B were suspended. Review of facility in-service titled Abuse and Neglect dated 12/23/24 was presented by the DON, the contents included abuse in reporting guidelines; If you witness or suspect any type of abuse, you must report it immediately. Failure to report abuse is grounds for corrective action and or termination. Revealed 59 staff members (RN, LVN, ADON, PTA, Cook, DOR, Nutritional Aide, PT, DOR, MA, Concierge, HR, DOM, SW, Hskping Supervisor, Laundry Aide) had taken the in-service. Review of facility Review Discussion Form with a creation date of 12/22/24 initiated by DON reflected that CNA A was suspended pending investigation. Review of facility Personnel Action Form with an effective date of 12/27/24, for CNA B reflected: Employee status TERMINATED. Date last worked: 12/21/24. Review of facility Personnel Action Form with an effective date of 12/27/24, for CNA A reflected: Manager Comments: Misconduct/Violation of rules and policies. Failure to report allegations Employee status TERMINATED . Date last worked: 12/21/24. Review of facility Resident Safe Surveys dated 12/22/24 reflected all residents felt safe in the facility and had no concerns. Review of facility [Facility Name] Abuse Protocol Test reflected 89 staff had taken the tests between 12/23/24 through 12/27/24. Interview on 01/30/24 from 9:30 AM to 4:00 PM revealed that 5 LVN (1 PRN), 1 RN, ADON, 3 CNAs had been educated by the DON on abuse neglect exploitation, including when and who to report abuse to. All staff confirmed that they had taken a post test on the abuse policy. An Abuse Prevention and Reporting Policy dated April 2029 indicated .our facility will not condone patient abuse, neglect, mistreatment, or misappropriation of patient property and exploitation (collectively Patient Abuse) by anyone, including staff members, other patient, consultants, volunteers, staff of other agencies serving the patient, family members, legal guardians, sponsors, friends, or other individuals.Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.Verbal abuse is defined as any use of oral, written or gestured language that includes disparaging and derogatory terms to patient or their families, or within their hearing distance, or describe patient, regardless of their age, ability to comprehend, or disability.