Every finding on record at The Heights of Alamo

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving neglect, were reported immediately to the State Survey Agency, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, for 3 of 3 residents (Resident #11, Resident #21, and Resident #120) reviewed for abuse or neglect. 1. The facility failed to report Resident #11's unwitnessed fall with major injury on [DATE] which resulted in a right hip fracture that required hospitalization and surgery. 2.The facility failed to report Resident #21's unwitnessed fall with major injury on [DATE] at 06:45 p.m., where Resident #21 sustained a left femur (thigh bone) fracture and an L1 compression fracture (a partial collapse or wedge-shaped break in the first lumbar vertebra, located at the transition point between the mid-back and lower back) that required hospitalization and surgery. 3.The facility failed to report Resident #120's unwitnessed fall with major injury on [DATE] at 6:45 p.m. where Resident #120 sustained a hematoma and a left femur fracture (broken thigh bone). This failure could place all residents at increased risk for potential abuse due to not having allegations reported as required.The findings included: 1. Record review of Resident #11's Face Sheet, dated [DATE], reflected an [AGE] year-old resident with an admission date of [DATE] and diagnoses included dementia (a decline in mental ability severe enough to interfere with daily life), osteoporosis (a systemic bone disease where bone mineral density and mass decrease, and bone tissue structure deteriorates), osteoarthritis (a degenerative joint disease characterized by the breakdown of articular cartilage and underlying bone, leading to pain, stiffness, and reduced mobility), history of falling, and muscle weakness. Record review of Resident #11's Discharge MDS assessment dated [DATE] reflected Resident #11 had a severely impaired mental status. Resident #11 required setup or clean-up for eating and was dependent on all other self-care. Resident #11 had a fall with major injury. Record review of Resident #11's Care Plan with a printed date of [DATE] reflected Resident # 11 was at risk for falls r/t impaired mobility, history of falls, attempt to get out of wheelchair without assistance at times, attempt to get out of WC without assistance to try to ambulate, and sustained a fall on [DATE] Date Initiated: [DATE] Bed Alarm Date Initiated: [DATE] Bed to wall. Date Initiated: [DATE] Fall mat Date Initiated: [DATE] Fall Risk: *Anticipate & meet needs & keep call bell within reach as indicated. Date Initiated: [DATE] Fall Risk: *Assist resident to toilet before going to bed at night and/or during night. Date Initiated: [DATE] Revision on: [DATE] Fall Risk: *Keep commonly used items close to resident for easy access. Date Initiated: [DATE] Fall Risk: *Low bed for safety. Date Initiated: [DATE].Record review of progress notes for Resident #11 reflected:On [DATE] at 1:13 A.M. Was notified by CNA that resident was found on the floor next to bed. Resident noted laying on her right side on top of safety floor mat at bedside, bed at lowest position. Head to toe assessment done, vital signs taken, WNL, neuro-checks initiated, prn Tylenol given and NP made aware of fall. Received orders for RT shoulder, humerus, elbow, femur, knee, tibia-fibula, and RT hip x-rays. RP notified. Documented by LVN EOn [DATE] 7:29 A.M. X-ray dated [DATE] relayed to NP and gave orders to have Resident sent out to a free standing ER for further eval and treatment. RP aware and agreed with orders above. Report called in to ER, EMS in facility to transfer resident out to ER for further eval & tx. Documented by LVNEOn [DATE] 10:56 P.M. spoke to freestanding ER, resident would be transferred to hospital ER DX fx to right femur. Notified DON Documented by LVN [NAME] [DATE] 6:03 P.M. pt returned from hosp post rt hip fx noted dressing to rt hip it was not to be removed until seen by ortho pt also had knee immobilizer noted large bruise to left forearm daughter states from blood draws also noted redness to bil. heels and sacrum tx orders obtained np made aware of pt arrival cont hosp medlist and new medication was added. Documented by LVN MRecord review of the facility's Incident report dated [DATE] reflected that Resident #11 was found on the floor next to bed. Resident #11 was noted laying on her right side on top of safety floor mat at bedside, bed at lowest position. When staff asked Resident #11 what happened, if she was going anywhere? Resident #11 stated, Me cai senorita, me cai. (I fell miss, I fell). Head to toe assessment was done, vital signs taken, WNL, neuro-checks initiated, and prn Tylenol given. Staff received orders for right shoulder, humerus, elbow, femur, knee, tibia-fibula, and right hip x-rays. RP was notified. Resident #11 was oriented to place and person. No injuries observed post incident. Statements were obtained from staff involved with incident. RP and NP were notified. Notes indicated Resident #11 was confused and had poor safety awareness. All safety measures were in place. Resident was last checked at approximately 10:30 pm and then found less than 2 hours later, on the floor. Resident stated that she wanted to go home. Resident stated she had fallen. Record review of the state reporting system on [DATE] reflected the incident and injury for Resident #11 on [DATE] was not reported to the State Survey Agency.In an interview and observation on [DATE] at 9:50 a.m. with Resident # 11, resident was observed up in wheelchair with family member by her side. Resident #11 was groomed and dressed appropriately. No injury was visibly noted on Resident #11. Resident #11 was able to greet surveyor and said she was doing fine but used short unclear sentences and only answered simple questions. Resident #11 did not appear in distress. The family member said Resident # 11 could talk and voiced her needs, but her memory was not very good anymore. As per family member, Resident # 11 had a fall with hip fracture about 5 months ago. Family member said Resident # 11's RP was notified at 1:30 in the morning and resident's RP informed her around 7:00 in the morning the next day. The family member said the facility sent Resident #11 to the hospital, x-rays were done and then was admitted to the hospital due to a hip fracture and had surgery. The family member said she spends most of the day at the facility and the staff check on Resident #11 frequently. The family member said family were always kept up to date and informed of any changes with the resident. The family member said she had no concerns with the fall or staff not providing appropriate care or not providing privacy or dignity for Resident #11. In an interview on [DATE] at 11:06 a.m., LVN E said during the night shift Resident #11 slept throughout the night. LVN E said at times Resident #11 would wake up close to 5:00 a.m., so they get resident up in wheelchair and taken to the nurse's station to be monitored. LVN E said each time staff passed by Resident #11's room they checked on her to make sure she was in bed. LVN E said on the night of Resident #11's fall, the CNA started her round and when checked on Resident # 11, she was on the floor mat. The CNA immediately notified LVN E. LVN E said when she arrived at the room, Resident # 11 was on her side on the floor mat, the bed was at lowest position, there was a mat on the floor and the bed had bolsters. LVN E asked Resident # 11 what happened. LVN E said Resident #11 replied, me [NAME] senorita, me [NAME]. LVN E said Resident # 11 did not voice any pain. LVN E said upon assessment, she did not observe any abnormalities, such as redness or skin tears and Resident # 11's vitals were normal. LVN E said with the help of the CNAs they placed Resident # 11 back in bed and she did not complain of pain. After Resident #11 was situated in bed she noticed resident appeared in a little discomfort, so to be on the safe side, LVN E called the NP and got the order for the x-rays. LVN E said she did give Resident #11 something for pain. LVN E said Resident # 11 was sent out to the hospital. LVN E said she felt the facility did everything they needed to ensure the fall was not due to abuse or neglect. LVN E said she did not feel Resident # 11's fall was due to abuse or neglect. LVN E said she knew both her CNAs did their rounds. One CNA had checked on Resident #11 a couple of hours prior, and she was in bed, then the next round, another CNA checked on her and found her on the floor mat. LVN E said the CNAs got to her immediately and they started their process.LVN E said the resident did tell her right away she fell and repeated it. LVN E said Resident # 11 can normally voice her needs like if she needs to be changed or wants water. LVN E said if a resident had a fall, she must report immediately to whoever was on call and the DON. LVN E said she would get orders to rule out injury or fractures. LVN E said for falls they must assess the resident, complete a head-to-toe assessment, check vitals, contact family and NP/MD, and notify whoever was on call or the DON. LVN E said if the fall was unwitnessed, they must conduct neuro checks even if the Resident said they did not hit their head. In an interview on [DATE] at 10:55 a.m. with the DON, she said on [DATE] Resident # 11 had a fall. The DON said Resident # 11 was found next to her bed, on the floor mat, lying on her side by a CNA while she completed her rounds. The DON said the nurse at the time assessed Resident #11 and the resident verbalized to the nurse she wanted to go home. The nurse and the CNAs placed Resident #11 back in her bed and then the nurse observed she was in pain, so she called and got orders for an x-ray. The DON said Resident #11 was then taken to hospital and she thinks they did x-rays there again. The DON said they learned Resident #11 suffered a hip fracture and was taken for surgery. The DON said Resident # 11 returned to the facility after her surgery. The DON said she did not recall the specific dates, but she did complete an investigation/incident report. The DON said she interviewed the staff that assisted the resident post fall. The DON said the resident verbalized she fell by saying, me [NAME] senorita. (I fell miss). The DON said she reviewed the camera footage and saw the last round done around 10:30 pm then the next round was around 1:00 a.m. (not sure of exact times) when resident was found on the floor. The DON said there were no other people seen going in and out of the resident's room when she checked the video footage. The DON said even with the residents' BIMS of 06, she was able to tell staff her immediate needs and what happened at the time. The DON said it was a fall with major injury, but since the resident verbalized and told them it was a fall and her investigation/interviews did not indicate any suspicions of abuse or neglect, she was not required to report it to the state. In an interview on [DATE] at 11:30 a.m., the Administrator said based on Resident # 11's ability to verbalize she had a fall, me [NAME] senorita, me [NAME], (I fell miss, I fell) and the reviewed video showed only the CNAs going in and out of the room a couple of hours apart, there was no indications of abuse or neglect. The Administrator said with Resident # 11's BIMS of 6, she was still able to verbalize if she needed something or something that happened at that time. The Administrator said when patients were able to verbalize their needs or what happened, like someone pushed her or she fell, we would take their word. The Administrator said they did an overall investigation which was why they looked at the camera footage. The Administrator said he felt everything was done appropriately for this fall. The Administrator said as per HHSC provider letter, the facility did not need to report an injury that was not suspicious or of unknown origin or the source of the injury could not be explained by the resident. The Administrator said nothing in the provider letter stated the resident must have a certain BIMS. 2. Record review of Resident #21's admission record dated [DATE], revealed she was a [AGE] year-old female with an admission date of [DATE]. Diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) with anxiety, Alzheimer's Disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple tasks), and fracture of unspecified part of neck of the left femur (hip fracture). Record review of Resident #21's Quarterly MDS on [DATE] revealed a BIMS score of 07 which indicated severe cognitive impairment. Resident #21 required partial/moderate assistance (the helper did less than half the effort. The helper lifted, held, or supported the resident's trunk or limbs, but provided less than half the effort.) with toileting, showers, and personal hygiene. Resident #21 had not had any falls since admission/entry or reentry or prior assessment. Record review of Resident #21's Care Plan dated [DATE], revealed the fall on [DATE] was not care planned. Record review of Resident #21's Risk Management note dated [DATE] at 08:45 PM, written by LVN K revealed, Record review of Resident #21's SBAR Summary for Providers on [DATE] at 07:14 PM, written by LVN K revealed, Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Falls. Primary Care Provider responded with the following feedback: A. Recommendations: Send out for eval. [sic]Record review of Resident #21's hospital record dated [DATE] revealed, CNA was taking a resident to common area and found resident on the floor in her room. CNA notified nurse and nurse went to assess resident. Resident stated 'I do not remember why I was trying to get up but ended up falling.' Resident was assessed for pain resident stated she had pain to the left hip on scale of 3 out of 10. Resident was assisted back to bed and educated on the use of the call light for assistance. MD and RP notified. [sic] MD requested resident be sent out to hospital for further evaluation. [sic] [AGE] year-old female admitted on [DATE] after a ground level fall resulting in a left femur fracture (hip fracture) and an L1 compression fracture. Record review of Resident #21's operative report on [DATE] at 11:38 AM, revealed surgery on Resident #21's left hip fracture. During an interview on [DATE] at 06:15 p.m., the DON stated Resident #21 had an unwitnessed fall with a fracture (on [DATE]). She said Resident #21 was able to tell them she fell. She said she did not think the fall should have been reported. She said Resident #21 said she was trying to get up and she fell. The DON stated even with the major injury and the unwitnessed fall, she did not believe it needed to be reported. She said all falls were reviewed during their morning meeting. During an interview on [DATE] at 07:05 p.m., the Administrator stated a reportable was abuse, neglect or unwitnessed injuries of unknown origin. He said when there was an unwitnessed fall, he would look at the guidelines to see if it needed to be reported to State. He said serious bodily injury would be if someone fell who had a major injury. He said Resident #21's unwitnessed fall on [DATE] where she had a hip fracture and L1 complression fracture was a major injury, but resident said she fell, but did not know why she was getting up. He said she told them she fell. The Administrator stated he had been notified of Resident #21's unwitnessed fall. He stated she had a fracture from her fall. He said he had checked the cameras and no one had gone into her room. 3.Record review of Resident #120' s admission sheet revealed an [AGE] year-old female with an admission date of [DATE]. Her relevant diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities, which interfere with daily life), abnormalities of gait and mobility (any deviations from typing walking pattern, often indicating underlying neurological, musculoskeletal, or other medical conditions), lack of coordination, cognitive communication deficit (affects a person's ability to communicate effectively), need for assistance with personal care, and insomnia (difficulty falling asleep or staying asleep). Record review of Resident #120's admission MDS assessment dated [DATE] revealed the BIMS assessment was not completed. The admission MDS assessment also revealed Resident #120 had one fall since admission with a major injury. The MDS assessment described a major injury as a bone fracture (a break or crack in a bone), joint dislocation (when two or more bones are forced out of their normal matching positions), closed head injuries with altered consciousness (the skull is intact, but the brain suffered a jolt causing confusion, dazed feelings, or a blackout), or a subdural hematoma (a serious medical condition where blood gathers between the skull and the surface of the brain). Record review of Resident #120's Initial Care Plan dated [DATE] revealed Resident #120 was at risk for fall related to advanced age, impaired mobility, and disease process. The interventions included Anticipate and meet needs and keep call bell within reach as indicated, bed at appropriate height when unattended, encourage/remind on importance of wearing non-slippery shoes when standing, walking or moving about in wheelchair and keep commonly used items close to resident for easy access. Record review on [DATE] of Resident #120's Post Fall review dated [DATE] authored by LVN A revealed the following findings: A. General Information 1.Date and Time of Fall:[DATE] at 6:45 p.m. 2. Was the fall observed? No. 6. Ask the following question to the resident immediately after the fall: WHY DO YOU THNK YOU FELL? Patient was unable to answer questions, alert and oriented x1 (The patient recognizes their identity but lacks awareness of their surroundings or time) with confusion. B. Patient Evaluation 1. Physical evaluation included; localized pain, redness/swelling/bruise, skin tear, tremors 1a. Details: Patient noted with bump to left side of forehead and open skin tear to bump. Patient noted grabbing left leg and crying. E. Interventions/Recommendations Post Fall 1a. Patient to be send to [hospital] for evaluation and treatment Record review on [DATE] of Resident #120's progress note dated [DATE] at 2:53 a.m. authored by LVN J revealed Called [Hospital] spoke to [Nurse], resident was admitted to ICU, post fall and will have surgery in the am (morning) [DATE]. Record review on [DATE] of Texas Unified Licensure Information Portal ((TULIP) an online portal used by nursing facilities in Texas for mandatory incident reporting) revealed that no self-reported incidents regarding allegations of neglect were reported for Resident #120 for a date of [DATE]. Record review on [DATE] of Resident #120's [Hospital] emergency department report dated [DATE] revealed resident's admitting diagnosis was traumatic intracranial hemorrhage (bleeding inside the skull caused by a head injury). The emergency department report also revealed that Resident #120 also had a left femur fracture. Surgery was planned for the left femur fracture. On [DATE], Resident #120 was not observed nor interviewed. Resident #120 was no longer at the facility during the time of the investigation. In an interview on [DATE] at 10:44 a.m. Resident #120's RP stated Resident #120 had sustained a fall on [DATE] at around 6:45 p.m. The RP stated Resident #120 sustained a brain bleed and a left leg fracture. The RP stated surgery to fix the fracture was done on [DATE]. In an interview on [DATE] at 10:12 a.m., LVN J stated she received a message from ADON B to remind her to call [Hospital] to get a follow up on Resident #120. LVN J stated ADON B told her to verify if Resident #120 had sustained a fracture so it could be reported to the state immediately. LVN J stated she called the hospital on [DATE] during her shift, could not recall the exact time, and was told by the hospital nurse that Resident #120 was going to be admitted into the ICU and was going to have surgery later that morning of [DATE]. LVN J stated she could not recall at this time if she was told by the hospital nurse if Resident #120 had a fracture. LVN J stated she notified ADON B of what the hospital nurse had told her. In an interview on [DATE] at 10:52 a.m., ADON B stated she could not recall if she asked LVN J to follow up with Resident #120 in the hospital. ADON B stated she kind of remembered that LVN J had called her, and she called the DON. ADON B stated, We already knew she had a fracture and was going into ICU. ADON B stated she did not report it to State because the Administrator was in charge of reporting the incident. ADON B stated this incident required it to be reported to the State. In an interview on [DATE] at 11:04 a.m., the Administrator stated he did not report Resident #120's fall to State because it did not meet the criteria for reporting it under Injury of unknown origin, since they knew how she fell. The administrator stated a CNA was in the hall, near Resident 120's door and had heard a sound coming from the resident's room. The CNA went into the room and found the resident on the floor. The administrator stated Resident #120 sustained a hematoma but could not recall if Resident #120 sustained any other injuries. In an interview on [DATE] at 11:19 a.m., the DON stated she did the investigation for Resident #120's fall. The DON stated that Resident #120 was sent out to the hospital because of pain in the leg and a bump on her head. The DON stated she could not remember the reason for Resident #120 getting surgery. The DON stated she did not report Resident #120's fall to state because the fall did not fall under the reportable guidelines such as abuse or neglect. The DON stated she was not aware Resident #120 had sustained a fracture. In an interview on [DATE] at 2:33 p.m., LVN A stated she was notified that Resident #120 had sustained a fall. LVN A stated that when she went into Resident #120's room to assess the resident, Resident #120 was on the floor laying on her left side. LVN A stated Resident #120 was confused and complained of pain to her left leg, to the point that she was crying. LVN A stated she noticed Resident #120 had a hematoma on her head. LVN A stated Resident #120 could not recall how she got on the floor. Record review of the facility's Abuse Guidance: Preventing, Identifying and Reporting policy date revised [DATE], reflected, Compliance Guidelines:Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.Seven Elements of ANE: . Reporting/Response- All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities are individuals as may be required by law and per the current state/federal reporting requirements. Reporting Allegations or Suspicions of AbuseAllegations of, incidents of or suspicions of abuse or neglect are reportable to state authorities in accordance with HHSC's PL 19-17. A community owner, operator or team member who has knowledge of an allegation of or cause to believe that abuse, neglect, or exploitation has been allegedly occurred should report the suspicion or allegation of abuse, neglect, or exploitation to state authorities and may also be reported to local authorities as indicated. Report alleged or suspicions of abuse to HHSC by email reporting or via TULIP reporting within the designated time frames in accordance with HHSC's PL 19-17 (Replaces PL 17-18). are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, State authorities should be notified of reports of abuse described above which alleges that: 1. A resident's health or safety is in imminent danger. 2. A resident has recently died because of conduct alleged in the report of abuse or neglect or other complaint. 3. A resident has been hospitalized or treated in an emergency room because of conduct alleged in the report of abuse or neglect. 4. A resident has been a victim of any act or attempted act of abuse or neglect. 5. A resident has suffered bodily injury, because of alleged or suspicion of abuse or neglect.

Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for 1 of 1 freezer reviewed for food safety. The facility failed to ensure food items (diced carrots, beef patties, chicken breasts, and chicken chimichangas) in the freezer were sealed properly as the packaging was open, and the food items were exposed to the air and other elements. This failure could place residents at risk of complications from food contamination.Findings included: Observations during the initial tour of the kitchen, on 08/03/26 at 8:30 AM, revealed the freezer had boxes of raw beef patties, chicken breasts, chicken chimichangas, and diced carrots that were open and exposed to the air. During an interview, on 08/03/26 at 8:55 AM, the DM stated all items in the freezer should have been sealed correctly to prevent freezer burn and to prevent contamination that could affect the residents. The DM stated it was the responsibility of all kitchen staff to ensure food was sealed correctly as it was a team effort to ensure foods were stored and dated properly. During an interview, on 08/04/26 at 4:00 PM, the DA stated she cooked food for the residents and obtained food from the refrigerators and freezer. The DA stated she ensured that foods were sealed and dated if she took food out. The DA stated she was in-serviced on ensuring to properly seal and date the food, or else the food could get contaminated and they would need to throw it away. During an interview, on 08/04/26 at 4:10 PM, the DM stated she went through the freezer and ensured everything was sealed and dated. The DM stated she in-serviced staff on ensuring foods were sealed/dated about monthly and she would complete another in-service with kitchen staff on this topic. Record review of the facility's Food Storage policy, dated 06/04/26, reflected - Policy: to ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal, and US food code and guidelines.3.e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident # 57) residents out of 6 that were reviewed for safe environment.The facility failed to ensure a wall in Resident # 57's bedroom was in good condition.This failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. The findings Included:Record review of Resident #57's electronic face sheet dated 8/5/26 reflected an [AGE] year-old resident admitted to the facility on [DATE] diagnoses included Alzheimer's (progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple tasks), dementia (loss of cognitive functioning, such as thinking, remembering and reasoning to such an extent that it interferes with a person's daily life and activities), depression (a common and serious mood disorder that causes persistent feeling of sadness, emptiness, and a loss of interest or pleasure in activities), and muscle weakness. Record review of Resident #57's undated comprehensive person-centered care plan reflected Resident #57:Had an impaired cognitive function/dementia or impaired thought process r/t dementiaDate Initiated: 12/09/2025 Revision on: 12/11/2025required anti-depressant medication r/t Dx: Depression, anxiety/agitation/insomnia Date Initiated: 12/11/2025 Revision on: 06/03/2026Record review of Resident #57's Quarterly MDS Assessment, dated 7/17/26, reflected Resident #70 had a BIMS of 04 which indicated a severe impairment of mental status. Resident #57 was dependent on all self-care except for eating, which required substantial/maximal assistance. During an observation on 8/3/26 at 9:04 a.m., the wall on the left side of the bed in Resident # 57's room, had a large area where paint and the upper layer of the dry wall were peeled off. When asked Resident #57 how long her wall had the paint peeled off, Resident 57 kept saying she did not know what surveyor was talking about. In an interview on 8/4/16 at 3:45 p.m., RN F said she was aware of the peeling on the wall to Resident # 57's wall and it was due to the bed scraping against the wall. RN F said she was not sure how long the wall had been like that, but it was less than a month. RN F said if she saw a wall with damage to it, she must report that to the maintenance department. RN F said any issue, such as paint peeling off the wall, must be reported upon first noticing it. RN F said she was informed about the issue during the 24-hour report, but she could not be sure if issue was reported to maintenance by the person who informed her of the issue. RN F could not recall who the person who informed her. In an observation and interview on 8/5/26 at 9:00 a.m., the Maintenance Director said the wall in Resident # 57's room was already fixed. The Maintenance Director walked the surveyor to Resident # 57's room and showed the repaired wall. The Maintenance Director said the wall damage was only there a few days after he received the work order. The Maintenance Director provided a copy of the work order which showed the date created was on 8/1/26 and the due date added on 8/4/26, set to 8/6/26.In an interview on 8/5/26 at 10:00 a.m., CNA G said he worked at the facility for about a month and he noticed the scratches on the wall of Resident # 57's room for at least 2 weeks. CNA G said he was not aware of any requirements to report those issues. In an interview on 8/5/26 at 11:30 a.m., the Administrator said he was made aware by leadership that there were some scratches that need to be taken care of. The Administrator said they had placed a ticket on Thursday or Friday of last week (7/30/26 or 7/31/26 and placed in progress because they had to get a vendor to look at the damage and give them a quote. The Administrator said the wall was fixed this morning. When the Administrator was asked if he believed keeping the wall scratched created a comfortable homelike environment, he would not answer the question. The Administrator said he had not seen or heard about the damage before from any staff. The Administrator said there was no penetration that could have caused a hazard or bug infested environment, but they could get it corrected. The Administrator said if they had been advised about the scratches previously, they would have fixed it right away. The Administrator said team members were instructed about TELS. He sated staff goes into PCC and submits the issue, then it comes to them, and then it gets completed. The Administrator said the issue could be paint, call lights, light fixtures, etc. The Administrator said he looked at their resident rights and environment policy and there was no information on comfortable/homelike environment located on those policies. The Administrator said he asked their regional office and they did not have a policy on homelike environment. Review of the facility's Statement of Resident Rights policy revised January 2023 reflected, Compliance Guidelines: The community should educate, encourage, and honor the rights of those we serve. Further, the community should assist a resident/patient to fully exercise their rights as applicable. Residents/Patients do not give up their rights when entering .Resident/Patient Rights include:To safe, decent and clean conditions .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #70) of 7 residents reviewed for infection control practices. The facility failed to ensure CNA H performed proper incontinent care for Resident #70. CNA H did not dispose of the wipe after each use. This deficient practice could place residents at-risk for infection due to improper hand sanitizing and incontinent care practices.The findings included: Record review of Resident #70's electronic face sheet dated 8/4/26 reflected a [AGE] year-old resident admitted to the facility on [DATE] diagnosis included dementia (loss of cognitive functioning, such as thinking, remembering and reasoning to such an extent that it interferes with a person's daily life and activities), need for assistance with personal care, muscle weakness, Alzheimer's (progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple tasks), and personal history of urinary (tract) infections. Record review of Resident #70's undated comprehensive person-centered care plan reflected Resident #70 had a Self-Care deficit r/t dementia, AD, advanced age, Date Initiated: 07/02/2024 Revision on: 02/04/2026 Personal Hygiene: X 1 person assist. Date Initiated: 07/02/2024Revision on: 07/23/2026 Toileting hygiene/Incontinent care: x 1 person assistanceDate Initiated: 08/15/2025 Revision on: 07/23/2026.Record review of Resident #70's Quarterly MDS Assessment, dated 7/3/26, reflected Resident #70 had a BIMS of 12 which indicated a moderate impairment of mental status. Resident #70 was dependent on self-care for toileting hygiene. During an incontinent care observation on 8/4/26 9:10 a.m., CNA H and CNA I performed incontinent care on Resident #70. During observation of the buttocks, CNA H grabbed 2 wipes, wiped between the center of the buttocks, and disposed of the wipes. CNA H grabbed 2 wipes, wiped between the center of the buttocks, and disposed of the wipes. On the third time, CNA H grabbed 2 wipes, wiped between the center of the buttocks, folded the wipes in half, and reused the same wipes before throwing the wipes away. CNA H cleansed the rest of the buttocks without concern.In an interview on 8/4/26 at 9:22 a.m., CNA H said she could recall anything she did incorrectly during care. CNA H said when completing the last wipe between the buttocks, she wiped with 2 wipes, folded them in half, then wiped again using same wipes. CNA H said they were only supposed to wipe once then dispose of the wipes. CNA H said if used wipes, were folded and reused the wipes were contaminated and residents could get an infection. In an interview on 8/4/26 at 9:25 a.m., CNA I said they usually used a wipe once and threw it away. CNA I said, if they used a wipe, folded it, and used it again, it could cross-contaminate and the resident could get an infection. CNA I said she was not aware of any urinary infections down Resident # 70's hall.In an interview on 8/5/26 at 10:55 a.m., the DON said they provided in-services and skills check-offs for staff on incontinent care upon hire, annually and as needed for any concerns. The DON said staff could use a single wipe, wipe the resident, then discard the wipe or wrap a wipe around their hand and use the palm side once and the back side once, then discard the wipe. The DON said it was not best practice to use a wipe, fold over, and wipe again. The DON said staff were taught to use a wipe, clean with wipe, and throw it in the trash. The DON said since the wipe was reused on the anus, there would not be an adverse effect. The DON said only if the wipes were reused on the anus and wiped towards the vagina, could there be an adverse effect.Record review of the CNA/Caregiver Competency Checklist CNA H dated 2/19/26 indicated she was checked off as skills met on the following: Infection control.PPE donning & doffing.Personal Care.Pericare/Incontinent Female.Record review of facility's Routine Resident Care policy revised January 2024 reflected, Compliance Guidelines: Residents should receive the necessary assistance to maintain good grooming, personal/oral hygiene-and safety.7. Incontinence I catheter care should be offered and provided timely in according to individual needs.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to secure, confidential personal, and medical records for 1 (unknown resident) of 5 residents reviewed for Privacy. The facility failed to ensure the privacy of the unknown resident by not locking the computer screen on a medication cart, leaving the unknown resident's personal and medical information exposed. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons. Findings included: Observation on 08/0426 at 2:23 PM revealed a computer screen on a medication cart in the 100 hallway was left unlocked. The screen displayed the unknown resident's picture, date of birth , and medication information on the screen. The surveyor called an unknown staff member, who was nearby, and asked who the medication cart belonged to. The unknown staff member informed the surveyor that it belonged to LVN A who was in a room providing care to a resident. The unknown staff member stated that LVN A had only been gone for about 2 minutes. In an interview on 08/04/26 at 2:25 PM, LVN A stated she left her medication cart to assist a resident. LVN A stated she was unaware she had left the computer screen unlocked. LVN A stated it was important to lock the computer screen when not in use because the screen displayed unknown resident's private personal and medical information. LVN A stated exposing private personal and medical information was a HIPAA (a law that protects patient medical privacy) violation. LVN A stated she was aware not to leave any resident information exposed but had just failed to do it this time. In an interview on 08/05/2026 at 3:56 PM, the DON stated all staff were in-serviced (teaching) frequently and reminded daily to lock their computer screen. The DON stated that LVN A had left her medication cart to assist a resident and did not verify that the computer screen was locked. The DON stated it was important to lock the computer screen because it contained the unknown resident's patient information; if an unauthorized person saw the screen, that person could have had access to the unknown resident's patient information. Record review of the Facility's Privacy and Security: HIPPA and PHI (is any health information that can identify an individual) revised January 2023 revealed: Compliance Guidelines: PHI must be safeguarded against loss and unauthorized access, use and destruction. Use and disclosure of PHI is a resident right. Record review of the Facility's Statement of Resident Rights Policy revised on January 2023 revealed: Privacy and Confidentiality Residents have the right to personal privacy and confidentiality of their personal and clinical records.

Based on interview and record review, the facility failed to have evidence that all alleged violations involving abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 2 of 12 residents (Resident #13 and Resident #119) reviewed for misappropriation of property. The facility failed to maintain documentation that an alleged violation was thoroughly investigated when Resident #13 alleged misappropriation of property (unauthorized credit card transactions of $509 and $506, and $200 cash missing) on 07/18/26 and when Resident #119 alleged misappropriation of property (unauthorized debit card transactions of $68.81 and $16.03) on 07/15/26. This failure could place residents at increased risk for potential misappropriation of property due to uninvestigated allegations of misappropriation of property. Findings included: 1. Record review of Resident #13's face sheet, dated 08/05/26, reflected a [AGE] year-old male, admitted on [DATE], diagnoses included: encounter for other orthopedic (bones or muscles) aftercare, displaced intertrochanteric fracture of right femur (hip injury), generalized muscle weakness, depression (persistent feelings of sadness and loss of interest), anxiety disorder (uncontrollable worry about everyday issues, affecting daily functioning and quality of life), and post trauma stress disorder (mental health condition triggered by experiencing or witnessing a traumatic event, causing persistent distressing symptoms that affect daily life). Resident #13 was discharged home on [DATE]. Record review of Resident #13's MDS, dated [DATE], reflected a BIMS score of 15, which indicated intact cognition. Record review of Resident #13's care plan, dated 07/15/26, reflected [Resident #13] was at psychosocial risk related to depression, anxiety, PTSD, recent admission, and disease process. Date initiated: 07/13/26. Interventions included: calm and reassure resident is safe and refer to social services as indicated. Record review of PIR for Intake #1105400, dated 07/26/26, reflected the facility was notified of the allegation for Resident #13, of credit card usage (2 transactions of $506 and $509) and cash missing (2 $100 bills), on 07/18/26 at 1:30 PM. The PIR reflected the investigation summary, Resident #13's face sheet, mental capacity assessment and psychosocial evaluations (07/18/26-07/20/26) with no emotional changes or psychosocial distress, resident interviews, staff interviews, and staff in-service. The resident interviews were completed by the SW. The resident interviews reflected questions regarding abuse, neglect, and mistreatment. The resident interviews did not reflect questions or answers regarding missing items, misappropriation of property, or exploitation. 2. Record review of Resident #119's Face Sheet, dated 7/23/26, reflected a [AGE] year-old resident with an admission date of 7/09/26 and diagnosis included dementia (a decline in mental ability severe enough to interfere with daily life), type II diabetes (chronic medical condition where the body develops insulin resistance and cannot use insulin properly causing sugar to build up in the blood), and hypertension (when the force of blood pushing against the artery walls were consistently too high). Record review of PIR for Intake #1104951, dated 07/23/26, reflected the facility was notified of the allegation for Resident #119, of credit card usage (2 transactions of $68.81 and $16.03) on 07/15/26 at 3:30 PM. The PIR reflected the investigation summary, Resident #119's face sheet, mental capacity assessment and psychosocial evaluations (07/15/26-07/17/26) with no emotional changes or psychosocial distress, resident interviews, staff interviews, and staff in-service. The resident interviews were completed by the SW. The resident interviews reflected questions regarding abuse, neglect, and mistreatment. The resident interviews did not reflect questions or answers regarding missing items, misappropriation of property, or exploitation. In an interview on 8/4/26 at 2:37 p.m., the SW said on 7/15/26 he was notified that Resident # 119 misplaced her debit card and she was unsure of the last time she had it. The SW said he conducted staff and resident questionnaires. The SW said the questionnaires for the residents were general questions that asked about abuse and neglect. The SW verbalized he explained to the residents what abuse, neglect and misappropriation was and asked the residents if they had any issues with money or personal items missing and there were no concerns. The SW said he did not document the questions asked about misappropriation or document the resident's responses. During an interview, on 08/04/26 at 4:00 PM, Resident #13 stated FM 2 was on the call with him, and they both provided information about the incident. Resident #13 stated FM 2 visited him at the facility and when they went outside, FM 2 left her purse in the room. Resident #13 stated he did not recall the exact date, but the following day, his bank alerted him of unusual credit card charges of $506 and $509. Resident #13 stated he had not been anywhere and had not bought anything. Resident #13 stated his wallet was in FM 2's purse and FM 2 stated she had not made those transactions. Resident #13 stated they disputed the charges and FM 2 checked her purse which was missing 2 credit cards and $200 cash. Resident #13 stated they notified the facility, the ADON spoke to Resident #13 and FM 2, acted immediately and the police department was notified. Resident #13 stated the police officer investigated quickly, and they were satisfied with how fast everything was resolved. Resident #13 stated they suffered no losses as the bank was aware of the fraud, they were not charged for the transactions, they received new credit cards, and the police recovered the $200. During an interview, on 08/05/26 at 8:55 AM, the SW stated on 07/18/26, he was notified that Resident #13 had unauthorized credit card transactions and cash missing from FM 2's purse. The SW stated he followed up with residents for the investigation regarding Resident #13's allegation of misappropriation of property. The SW stated he used a standard questionnaire about abuse and neglect, how staff interacted with them, mistreatment, and how the staff provided care. The SW stated the questionnaire for the residents did not specifically ask about exploitation or misappropriation of property, but he asked the residents questions about exploitation and misappropriation of property in a way that they understood. During an interview, on 08/05/26 at 11:30 AM, the SW stated he documented the resident interviews in the questionnaire forms that were provided as part of the investigation. The SW stated he did not document the resident interviews or answers anywhere else other than the questionnaire forms. During an interview, on 08/05/26 at 11:35 AM, the Administrator stated he believed everything was done appropriately for the investigation and the allegation of misappropriation of property for Resident #13 on 07/18/26 was thoroughly investigated. The Administrator stated the SW completed interviews with staff and residents for the investigation process to determine any other issues or concerns. The Administrator stated a standard form was used with questions for the resident interviews, but the SW explained the questions in a manner that the residents understood. The Administrator stated the SW asked the residents about missing items and misappropriation of property. The Administrator stated he provided all the documentation available for the investigation. The Administrator stated he did not recall what the abuse, neglect, exploitation, and misappropriation of property policy indicated regarding the investigation and documentation, but he followed up and documented his investigation summary. The Administrator stated he had no other documentation to show that the residents were specifically asked about missing items or misappropriation of property. In an interview on 8/5/26 at 1:30 p.m., the Administrator said when he received the information on 7/15/26 about Resident #119's missing debit card the facility did everything appropriately to complete the investigation. He said the resident questionnaires were standard forms. The Administrator said they did ask the residents if they had been abused, neglected, or exploited and we explain each of those using examples. The Administrator said they would document the questions they asked related to misappropriation if there was a concern voiced, such as they had money or a stolen debit card. The Administrator said at that time they would document the information on a new investigation form. He said they did not have any additional documents for the investigation. The Administrator stated their policy on Abuse, Neglect and Exploitation stated when investigating, they must talk to their residents, investigate what their residents tell them happened, interview team members and other residents, and call law enforcement. The Administrator said they then review all interviews to see if there were any correlations. The Administrator said the facility must follow the steps of their ANE policy. The Administrator said he did not recall off the top of his head if the ANE policy mentions anything about documentation. But they must make sure they conduct interviews and ensure they follow through with interview documentation. The Administrator said he believed the investigation was thoroughly investigated. The Administrator said if during the resident interviews the information asked about misappropriation was not documented, they knew the question was still asked in a way the residents could understand because that was part of their process. When the Administrator was asked how others reviewing the information would know the question was asked if it were not documented, and the Administrator said he would look into revising the resident questionnaire. Record review of the facility's Abuse Guidance: Preventing, Identifying and Reporting policy date revised January 2024, reflected, Compliance Guidelines: Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Investigative Procedures Related to Allegations of Abuse, Neglect or Exploitation 1. The community should immediately take all appropriate steps to remediate the non-compliance and protect the resident from additional abuse. The community should implement a response plan and take corrective action as appropriate. The response plan implemented should address the immediate risk, those identified at risk, systemic response to prevent abuse, neglect, or exploitation from occurring in the future and implement a plan that allow the QAPI team to monitor the results of the interventions in put into place to validate the safety, well-being of the residents served and community's compliance of the response plan. o Conducting a thorough investigation of the alleged violation. 4. The statements described above should be available for inspection by HHSC.

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 7 residents' rooms (Resident #24's room) reviewed for food safety. The facility failed to place a temperature log by the personal refrigerator and failed to place a thermometer in the personal refrigerator located in Resident #24's room; therefore, the staff did not monitor the internal temperature. These failures could place residents at risk of foodborne illnesses.The findings included:Record review of Resident #24's electronic face sheet dated 8/5/26 reflected a [AGE] year-old resident admitted to the facility on [DATE] diagnoses included dementia (loss of cognitive functioning, such as thinking, remembering and reasoning to such an extent that it interferes with a person's daily life and activities), major depression (a common and serious mood disorder that causes persistent feeling of sadness, emptiness, and a loss of interest or pleasure in activities), and morbid obesity (health condition of having a Body Mass Index of 40 or higher, a Body Mass Index of 35 or higher with major health problems, or weighing 100 pounds or more over your ideal body weight). Record review of Resident #24's undated comprehensive person-centered care plan reflected Resident #24:Was at risk for impaired cognitive function or impaired thought process r/t advanced age, dementia, disease process. Date Initiated: 02/23/2024 Revision on: 04/08/2024Was at risk for psycho-social issues: emotional distress or behaviors r/t depression, recent admission, disease process. Date Initiated: 02/23/2024 Revision on: 06/23/2026Record review of Resident #24's Quarterly MDS Assessment, dated 5/31/26, reflected Resident #24 had a BIMS of 07 which indicated a severe impairment of mental status. Resident #24 was independent on all self-care except for eating, which required setup or clean-up assistance. During an observation on 8/3/26 at 9:58 a.m., Resident #24's room was noted to have a personal refrigerator. The refrigerator contained perishable food items such as bottled water. The refrigerator did not contain a thermometer inside and there was not a log present indicating the refrigerator's daily temperatures. In an interview on 8/3/26 at 9:58 a.m., Resident #24 said a family member brought the refrigerator to him on Sunday, 8/2/26. Resident #24 said the SW gave him permission to have the refrigerator in his room. Resident #24 said he only keeps his water in the refrigerator right now. Resident #24 said no one had come to check the temperature of his refrigerator. In an interview on 8/4/16 at 3:45 p.m., RN F said Resident #24 had a personal refrigerator in his room. RN F said she did not know when Resident #24 first brought the refrigerator to his room. RN F said maintenance usually assessed the refrigerator and made sure it was up to standards. The RN F said Nurses/CNAs did not monitor the personal refrigerators in resident's rooms. RN F said if a family brought a refrigerator, she would report to DON, ADON, or maintenance. RN F said she would educate family/resident for risk management if they brought in a refrigerator without the facility knowing.During an observation on 8/4/26 at 8:45 a.m., the refrigerator in Resident #24's room still contained perishable food items such as bottled water. The refrigerator still did not contain a thermometer inside and there was not a log present indicating the refrigerator's daily temperatures.In an interview on 8/4/16 at 3:50 p.m., the SW said he was just made aware this morning by Resident #24 that the personal refrigerator was brought into his room last night, Monday 8/3/26, so this morning he went in and placed a thermometer in the refrigerator and placed a log on the side of the refrigerator to make sure it was working appropriately. The SW said housekeeping would be updating the logs. The SW said he informed Resident #24 and his family they could bring in a personal refrigerator in the past, but he did not find out Resident #24 had the refrigerator in the room until this morning. In an interview on 8/5/26 at 9:00 a.m., the Maintenance Director said they learned of the refrigerator in Resident #24's room yesterday morning, 8/4/26. The Maintenance Director said he knew the refrigerator was in Resident #24's room on Monday morning, 8/3/26 when he arrived at the facility and checked on it, making sure it was functional, and at an appropriate temperature. The Maintenance Director said on Tuesday morning, 8/4/26, the refrigerator still did not have a log or thermometer, but today it did. In an interview on 8/5/26 at 9:45 a.m., the SW came to talk to me and said he called the family of Resident #24, and they told him they brought the personal refrigerator in on Sunday, 8/2/26 and didn't tell staff about it because they had been told previously it was ok that Resident #24 had one. As per the SW, he informed the family previously that the facility must be informed when they bring the refrigerator in so that it was checked to ensure it was in working condition, but the family did not let them know. The SW said as soon as they learned of it, they had maintenance check on it. The SW worker said they placed a thermometer and log and housekeeping would be keeping track of the log.In an interview on 8/5/26 at 11:30 a.m., the Administrator said he learned that the refrigerator was brought in by family Sunday night and placed it in Resident #24's room. The Administrator said he had the SW call the family to find out when it was brought in. The Administrator said no one had noticed the refrigerator and that was the truth. The Administrator said they always enforced placing a thermometer, log, and that maintenance checked personal refrigerators for working condition. The Administrator said as soon as they were aware the refrigerator was there; they put everything in place. The Administrator said staff were informed that items, such as new refrigerators, could be placed on the TELS, so administrators become aware. The Administrator said TELS was consistently reviewed by maintenance due to high demand for items needing to be addressed. The Administrator said the TELS system helped them document and structure environment for the facility. The Administrator said the only policy they had for personal refrigerators, was the policy he provided me titled, Personal Refrigerator policy. Record review of the facility's Personal Refrigerator policy revised January 2023 reflected, Compliance Guidelines: Residents are encouraged to bring personal and familiar belongings to their new home, such as furniture and appliances, i.e. televisions, refrigerators, etc. Guidelines Please check with the community maintenance director prior to bringing in furniture and appliances, i.e.: televisions, refrigerators, etc. to ensure it is in a safe working condition, an allowable item and to ensure there is ample room for the resident to move about in the room. If the resident chooses to have a refrigerator in their room, they can use it for food that is brought into the community for the resident to consume. Community should place a thermometer in the refrigerator and monitor the temps to confirm that the refrigerator is properly working and maintaining food at proper storage temps. Routinely check the refrigerator to identify unsafe for consumption foods and discard any items(s) that appeared to have gone bad or are expired. Honor the manufactured date item that is self-stamped and the best used by date by the manufacturer.

Based on observation, interview and record review, the facility failed to review and revise the comprehensive care plan by the interdisciplinary team, for 1 of 5 residents (Resident #12) reviewed for comprehensive care plan revisions. The facility failed to review and revise Resident #12's care plan to reflect she needed to wear a neck collar starting on 07/11/26 after a laminectomy. This failure could place the residents at risk of not receiving appropriate interventions and care to meet their current needs. Findings included:Record review of Resident #12's face sheet, dated 08/05/26, reflected a [AGE] year-old female, admitted on [DATE], diagnoses included: cervical spondylosis with myelopathy (degenerative changes in the neck and spine that compress the spinal cord), encounter for surgical aftercare following surgery on the nervous system, type 2 diabetes mellitus (insulin resistance and high blood sugar levels), discitis-thoracolumbar region (infection or inflammation of the intervertebral disc at the thoracic-lumbar (middle-lower back) junction), unspecified dementia (decline in cognitive function severe enough to interfere with daily life affecting memory loss, language, problem solving, and other cognitive abilities), end stage renal disease (final stage of kidney failure), dependence on renal dialysis (ongoing dialysis to perform the functions of the kidneys), adult failure to thrive (syndrome of weight loss, decreased appetite, functional decline, and social withdrawal), and depression (persistent feeling of sadness and loss of interest). Record review of Resident #12's MDS, dated [DATE], reflected a BIMS score of 13, which indicated intact cognition. Record review of Resident #12's care plan, dated 08/05/26, reflected [Resident #12] had chronic health conditions that affected physical function related to spondylosis with myelopathy-cervical region and discitis-thoracolumbar region. Date initiated: 02/03/26. Date revised: 07/29/26. Care plan did not reflect soft neck collar. Record review of Resident #12's order summary, dated 08/05/26, reflected physician's order to wear soft collar to neck at all times may remove for bathing every shift for laminectomy (surgical procedure that removes part of a vertebra called the lamina to relieve pressure on the spinal cord or nerves). Start date: 07/11/26 and start date: 07/29/26. Record review of Resident #12's MAR, dated 07/11/26-08/05/26, reflected the soft neck collar was checked off every shift by nursing staff. During an interview and observation, on 08/03/26 at 11:45 AM, Resident #12 stated she was doing well and had returned from dialysis. Resident #12 was observed with a soft neck collar. Resident #12 stated she had a procedure because the doctor found a crack on her neck and she had to wear the collar. Resident #12 stated the crack was not from a fall or incident but rather from her disease that caused her fragile bones. During an interview, on 08/05/26 at 8:40 AM, RN D stated Resident #12 wore the soft neck collar since she had a laminectomy on 07/09/26. RN D stated the nurses had a check off on the MAR to ensure Resident #12 wore the neck collar and there were no concerns with her wearing it appropriately. RN D stated the care plans were updated by the MDS Nurse. During an interview, on 08/05/26 at 9:10 AM, the ADON stated Resident #12 wore the neck collar since she had surgery, laminectomy, but she was not sure on the date. The ADON stated Resident #12 wore the neck collar without issue and the neck collar should have been added to the care plan. The ADON stated the MDS Nurse updated the care plans as needed. The ADON stated there was no negative outcome to Resident #12 as she wore the neck collar. The ADON stated there was no risk of injury for Resident #12 as there was an order that was followed by staff and staff ensured she wore the neck collar. The ADON stated it was important for care plans to be updated and accurate to ensure orders were followed. During an interview, on 08/05/26 at 9:35 AM, the MDS Nurse stated she was responsible for developing and updating care plans as needed. The MDS Nurse stated she added orders, changes, or any new behaviors to the care plans. The MDS Nurse stated Resident #12 had a cervical laminectomy and wore a neck collar after that procedure. The MDS Nurse stated she was not sure what date Resident #12 had the procedure. The MDS Nurse stated she was not informed that Resident #12 was noncompliant with the neck collar and the staff ensured she wore it by documenting on the MAR every shift. The MDS Nurse stated the neck collar should have been added to the care plan, and she was not sure why it was not added. The MDS Nurse stated the purpose of the care plan was to monitor the resident, any changes of condition, any behaviors, and monitor specific needs or devices required. The MDS Nurse stated the care plan informed staff on how to take care of the resident. During an interview, on 08/05/26 at 9:55 AM, the DON stated Resident #12 had a laminectomy regarding a degenerative disease she had a history of. The DON stated she did not recall what date Resident #12 had the laminectomy, but Resident #12 wore a neck collar since the procedure was done. The DON stated the neck collar should have been added to the care plan, and she was not sure if it was care planned. The DON stated the MDS Nurse updated care plans as needed. The DON stated there was no negative outcome for Resident #12 as staff followed the order to ensure she wore the neck collar. The DON stated it was important for the care plan to be updated and accurate to show the current and ongoing care. Record review of the facility's Care Plans policy, dated February 2017, revised January 2024, reflected - Guidelines: The community develops a comprehensive care plan for each resident that includes measurable objectives to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate intervention/interventions in relation to the identified problem or risk. The care plan should be updated and reviewed. Additional updates to the care plan may be done as indicated.

Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 2 (Resident #22 and Resident #76) of 3 residents reviewed for unnecessary medications. 1. The facility failed to have an adequate indication for the use of the medication Rexulti (an antipsychotic) for Resident #22 with a diagnosis of dementia. 2. The facility failed to have an adequate indication for the use of the medication Rexulti for Resident #76 with a diagnosis of Alzheimer's Disease and dementia. This failure could put residents at risk of harm from adverse reactions or harmful side effects. The findings included: 1. Record review of Resident #22's admission record dated 08/04/2026, revealed an [AGE] year-old male with an admission date of 04/17/2026. Resident #22's diagnoses included dementia (a decline in mental ability - such as memory, thinking, and reasoning - severe enough to interfere with daily life) with other behavioral disturbance, hallucinations (a sensory experience - such as seeing, hearing, smelling, tasting, or feeling something - that feels completely real but is created by the mind without any actual external stimulus), unspecified, and psychosis (a collection of symptoms rather than a single illness where a person experiences a loss of contact with reality) not due to a substance or known physiological condition. Record review of Resident #22's Quarterly MDS, dated [DATE], revealed a BIMS score of 04, indicating severe cognitive impairment. Resident #22 had no potential indicators of psychosis such as hallucinations or delusions (a firm, fixed belief that was not true and did not change even when clear facts or proof show it was wrong). Resident #22 received antipsychotics on a routine basis. Record review of Resident #22's care plan, dated 07/10/2026, revealed FOCUS: [Resident #22] require Anti-psychotic medication r/t hallucinations History of failed GDR Date Initiated: 04/18/2026 Created on: 04/18/2026 Revision on: 07/02/2026. [sic] Record review of Resident #22's Physician's order dated 05/08/2026 revealed Rexulti Oral Tablet 0.5 MG (Brexpiprazole)Give 1 tablet by mouth in the morning for dementia with behavioral disturbance. Record review of Resident #22's April 2026 MAR revealed Resident #22 was administered Rexulti 0.5 mg tablet at bedtime for dementia with behavioral disturbance on 04/17/2026, 04/20/2026, 04/22/2026, 04/23/2026 through 04/28/2026, and on 04/30/2026. Record review of Resident #22's Physician's order dated 05/08/2026 revealed Rexulti Oral Tablet 1 MG (Brexpiprazole)Give 1 tablet by mouth in the morning for hallucinations. Record review of Resident #22's May 2026 MAR revealed Resident #22 was administered Rexulti 0.5 mg tablet at bedtime for hallucinations on 05/09/2026 through 05/29/2026. Record review of Resident #22's pharmacy recommendation on 06/12/2026 revealed, This resident has an order for an antipsychotic, Rexulti 1 mg QAM, with an inappropriate diagnosis. Please attempt a gradual dose reduction to Rexulti 0.5 mg QAM with the goal of discontinuing the medication and/or clarifying the diagnosis and make the necessary corrections, which was signed by MH NP. Record review of Resident #22's June 2026 MAR revealed Resident #22 was administered Rexulti 0.5 mg tablet in the morning for hallucinations on 06/01/2026 through 06/10/2026, and 06/12/2026 through 06/30/2026. Record review of Resident #22's Progress Notes dated 07/01/2026 at 11:14 AM written by ADON B revealed, resident presents with increased anxiety , trying to constantly get up from chair, stating he is going home . Un-redirectable, and becomes agitated when re-directed . Placed call to MH NP, informed of above and failed Rexulti GDR, received orders to resume Rexulti 1mg qd. RP aware and consented. [sic] Record review of Resident #22's Progress Note dated 07/08/2026 at 01:42 PM written by ADON B revealed, Resident restless , continuously trying to get out of wheelchair without assistance, stating he needs to pick up his truck then go pick up his wife. Re-directed several times but un-redirectable. Placed call to MH NP, informed of above, and received orders to increase rexulti 1mg to BID. Order carried out, RP aware. [sic] Record review of Resident #22's Progress Note dated 07/08/2026 at 02:56 PM written by LVN A revealed, Pharmacy called to question Rexulti order, Pharmacy recommended 2 tabs at HS as it cannot be given 1 tab BID. As per MH NP, ok to change to 2 tabs at HS. Orders received and carried through. [sic] Record review of Resident #22's Physician's order dated 07/10/2026 revealed Rexulti Oral Tablet 1 MG (Brexpiprazole)Give 2 tablets by mouth in the morning related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION. 1 mg give 2 tabs = 2 mg. Record review of Resident #22's Progress Note dated 07/24/2026 at written by MH NP revealed, Exam: [Resident #22] appears calm, distracted, minimally communicative, normal weight, and slow to respond. Mood presents as normal with no signs of either depression or mood elevation. There are no apparent signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. [sic] Record review of Resident #22's July 2026 MAR revealed, -Resident #22 was administered Rexulti (Brexpiprazole) 1 mg tablet in the morning for hallucinations on 07/02/2026 through 07/08/2026. -Resident #22 was administered 2 - 1 mg Rexulti (Brexpiprazole) tablets by mouth at bedtime for hallucinations on 07/08/2026 and 07/09/2026. -Resident #22 was administered 2 - 1 mg Rexulti (Brexpiprazole) tablets by mouth in the morning for psychosis on 07/11/2026, 07/18/2026, and 07/20/2026 through 07/31/2026. Record review of Resident #22's August 2026 MAR revealed Resident #22 was administered 2 - 1 mg Rexulti (Brexpiprazole) tablets by mouth in the morning for psychosis from 08/01/2026 through 08/05/2026. 2. Record review of Resident #76's admission record dated 08/05/2026, revealed an [AGE] year-old female with an admission date of 05/24/2026. Resident #76's diagnoses included dementia (a decline in mental ability - such as memory, thinking, and reasoning - severe enough to interfere with daily life), unspecified severity, without other behavioral disturbance, psychotic disturbance (a collection of symptoms rather than a single illness where a person experiences a loss of contact with reality), and anxiety, Alzheimer's Disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills), and anxiety disorder (a group of mental health conditions that cause intense, persistent, and excessive fear or worry in non-threatening situations), major depressive disorder (a common and serious mental health condition that lasts for at least two weeks that affects how a person feels, thinks, and handles daily activities), single episode, and unspecified psychosis (a collection of symptoms rather than a single illness where a person experiences a loss of contact with reality) not due to a substance or known physiological condition . Record review of Resident #76's admission MDS, dated [DATE], revealed a BIMS score of 07, indicating severe cognitive impairment. There were no potential indicators for psychosis. Antipsychotics, antidepressants, diuretics, and hypoglycemics (including insulin) were used routinely. Record review of Resident #76's Care Plan dated 05/25/2026 revealed FOCUS: I require Anti-psychotic medication r/t MDD History of GDR Date Initiated: 05/25/2026 Revision on: 08/04/2026. Record review of Resident #76's Psychologist/Psychiatrist Progress Note written by MH NP, dated 07/24/2026 at 12:52 PM revealed Nursing staff reports that he gets anxious and impulsive. He attempts to get up in bed in his own. He is high risk for fall. [sic] There are no apparent signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Associations are intact, thinking is logical, and thought content appears appropriate. Suicidal ideas or intentions are denied. Homicidal ideas or intentions are denied. Insight into problems appears to be poor. There are signs of anxiety. A short attention span is evident. [sic] Record review of Resident #76's Physician's order dated 07/29/2026, revealed Rexulti Oral Tablet 0.5 MG (Brexpiprazole)Give 1 tablet by mouth one time a day related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION until 08/07/2026. Record review of Resident #76's July 2026 MAR revealed Resident #76 was administered Rexulti 0.5 mg one time a day related to psychosis from 07/30/2026 and 07/31/2026. Record review of Resident #76's August 2026 MAR revealed Resident #76 was administered Rexulti 0.5 mg one time a day related to psychosis from 08/01/2026 through 08/04/2026. During an interview on 08/05/2026 at 06:15 PM, the DON stated she was notified of all antipsychotic orders that were given. She said she will talk with the practitioner who ordered the antipsychotic. The DON stated for a resident who had the diagnosis of Alzheimer's Disease or dementia and had an order for an antipsychotic, it would be the practitioner who made the decision for the indication of the medication, and she would clarify the indication. She said they could not just stop giving an antipsychotic. She said they would GDR the antipsychotics. The DON stated if the pharmacy said the antipsychotic had an inappropriate diagnosis, they would notify the doctor, but the doctor is treating a condition where the medication cannot be abruptly stopped. She stated the in-services on antipsychotic medications were scheduled and as needed. She could not remember when the last in-service on antipsychotics was given. Record review of the facility's Psychotropic Medications & Gradual Dose Reduction policy with a revision date of January 2023 reflected: Guideline Statement:Physicians and mid-level providers will use psychotropic medications appropriately working the with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. StandardsThe community is expected to make every effort to comply with state and federal regulations related to the use of psychotropic medications in the community to include diagnosis, targeted behavior or clinical indications for use, prescriber's specified dosage frequency and duration of therapy, consent much be received and noted in the medical record for any use of psychotropic medications. Additionally, the prescriber must provide specific rational for use, clinical indications for use, risks and/or benefits for therapy and informed consent as per defined content in the Texas 3713 form for all antipsychotic or neuroleptic drug therapy.

Based on interviews and record reviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 3 residents (Resident #2) reviewed for accuracy of records. The facility failed to ensure LVN C signed off Bisacodyl 10 mg PRN via rectal 1 dose on 10/03/25 after it was administered to Resident #2.This failure could place residents at risk of not receiving appropriate care through inadequate documentation resulting in deterioration in condition, exacerbation of disease process, overmedication, and increased risk of harm or injury. The Findings included: Record review of Resident #2's admission record dated 11/13/25 reflected a [AGE] year-old female with an admit date of 09/29/25 and an initial admission date of 09/15/25. Her relevant diagnoses included end stage renal disease (the final stage of chronic kidney disease, where the kidneys have severe damage and can no longer function well enough to sustain life), dependence on renal dialysis (patient has permanent kidney failure and relies on dialysis procedure or kidney transplant to sustain life), and constipation (having fewer than three bowel movements a week, with stools that are hard, dry, and difficult to pass). Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS score of 10, which indicated her cognition was moderately impaired. Record review of Resident #2's quarterly care plan dated 09/15/25 reflected a: Focus- I have chronic health conditions & comorbidities conditions that have affected my physical function and may affect my quality of life.constipation Interventions- in part included administer my medications, treatments, respiratory treatment/therapy, and diet as recommended by physician. Provide care as tolerated and needed. Record review of Resident #2's change in condition dated 10/03/25, authored by LVN D reflected: Situation: The change in condition, symptoms, or signs observed and evaluated is/are: constipation or impaction. Things that make the condition or symptom worse are: Resident complaining of constipation and wanting relief. This condition, symptom, or sign has occurred before: yes. Review and notify: primary care clinician notified: yes, date: 10/03/25, time: 11:00 am. Recommendations of Primary Clinicians: administer Bisacodyl PRN via rectal X 1 dose. Record review of Resident #2's eMAR for the month of October 2025 did not reflected an order for bisacodyl PRN via rectal x1 dose therefore, not signed off after being administered on10/03/25. Record review of Resident #2's Bowel Task report for 10/03/25 reflected she had a bowel movement at 1:43 pm. In an interview on 11/12/25 at 9:18 am, LVN D said on 10/03/25, RN E had informed him that Resident #2 had been flagged on their daily reports indicating she had not had a bowel movement in several days. He said he immediately sent CNA H to go check on Resident #2 and asked her if she felt she was constipated or had any discomfort. LVN D said CNA H had later gone back to him and told him that Resident #2 had requested medication for her constipation. LVN D said he called Resident #2's NP and he had prescribed a PRN 1 x medication (Bisacodyl/suppository) for relief. He said he instructed CNA H to accompany him to administer the suppository. LVN D said the medication Bisacodyl was successful and Resident #2 had a bowel movement minutes later. LVN D said as soon as Resident #2's NP ordered the Bisacodyl, he had completed an order and signed it off on her 10/2025 eMAR after it was administered. LVN D there were no negative outcomes to Resident #3 for not inputting an order for Bisacodyl and signing off on it after it was administered because he insisted he had done both. In an interview on 11/12/25 at 10:00 am, RN E said the facility received daily reports on residents that were flagged for not having a bowel movement in three days. RN E said on 10/03/25 while she reviewed those reports she noticed that Resident #2 had been flagged for not having a bowel movement in 3 days and discussed it with LVN D. RN E said as she reviewed Resident #2's eMAR that she did not see an order for the medication Bisacodyl and since there was no order, it did not populate on Resident #2's 10/2025 eMAR. RN E said the facility's protocol would have been that as soon as LVN D received the order for Bisacodyl, he should have inputted an order and then it would have automatically populated on Resident #2's eMAR. RN E said, since LVN D did not create an order for Bisacodyl, it was not populate on Resident #2's eMAR and not alerted to sign off on it. RN E said there were no negative outcomes to Resident #2 not having the medication Bisacodyl listed and signed off on her 10/2025 eMAR because she had confirmed with CNA H and LVN D that it had been administered. She said the medication had been written on Resident #2's Change in Condition. In an interview on 11/12/25 at 11:45 am, the DON said the facility's protocol for a nursing staff would have been that as soon as they receive an order to input it on the resident's electronic medical record. Once it was inputted as an order, it would populate on the resident's eMAR. After the nursing staff had administered the medication, it needed to be signed off on the eMAR. She said if the medication had been inputted and for some reason the nursing staff had forgotten to sign off on it, the system would have generated an alert. She said she had already discovered that on 10/03/25, LVN D had not inputted the medication Bisacodyl as an order and had not signed it off on Resident #2's eMAR. The DON said there were no negative outcomes to Resident #2 not having her medication Bisacodyl listed on her October 2025 eMAR and LVN D not signing off on it. She said the fact that what Resident #2's NP had ordered (Bisacodyl) had been documented on her Change in Condition report was sufficient. The DON said Resident #2's bowel movement task report indicated Resident #2 had a bowel movement on 10/03/25 after the administration of the Bisacodyl. Record review of the facility's Professional Standard of Care policy dated February 2017 and revised in January 2024 reflected: Compliance Guidelines: The community provides services that meet professional standard of quality and are provided by appropriately qualitied persons (e.g., licensed, certified).Compliance with Professional Standards of Care Nursing: Practices-D: When a licensed nurse takes a verbal or telephone order from a medical provider (MD/NP/PA), podiatrist, or dentist, the nurse should sign the order.

Based on observation, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for comprehensive person-centered care plans. The facility failed to develop an individualized comprehensive person-centered care plan for Resident #1 by including a bedtime snack when he was NPO. This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. The Findings include: The Findings include: Record review of Resident #1's admission sheet dated 11/10/25 reflected a [AGE] year-old male with an admit date of 06/16/2025 and an initial admission date of 02/13/2025. His relevant diagnoses included Huntington's disease (a progressive, fatal genetic disorder that causes the breakdown of nerve cells in the brain, leading to motor, cognitive, and emotional symptoms that worsen over time), diabetes (chronic disease where the body cannot properly regulate its blood glucose levels), muscle wasting/atrophy, muscle weakness, abnormalities of gait/mobility, lack of coordination, hypoxia (shortness of breath, rapid breathing, and a fast heart rate) and aphasia (a language disorder that impairs a person's ability to communicate, affecting their reading, writings, speaking, and understanding of others). Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score was left blank, which indicated his cognition was severely impaired. His MDS also reflected he had unclear speech (slurred or mumbled word), he rarely/never made himself understood, and rarely/never understood others.Record review of Resident #1's quarterly care plan dated 08/25/25 reflected a:Focus: I am at risk for nutritional deficits and/or dehydration risk r/t NPO-unable to eat or drink by mouth, requires enteral (the delivery of nutrition directly into the gastrointestinal tract through a tube) feedings for nutrition/hydration supportInterventions: in part included tube feeding Record review of Resident #1's Kardex (a desktop file system that gives a brief overview of each resident and is updated every shift) dated 11/10/25 reflected: Eating/Nutrition: NPO-nothing by mouth-see nurse for questions, I require enteral feeding support. Eating: bedtime snack In an observation on 11/10/25 at 1:43 pm, Resident #1 was observed lying in bed awake. He was on O2 via nasal cannula at 3 lpm (as ordered) and had a feeding tube with continuous feeding. RP G was at his bedside. In an interview on 11/10/25 at 1:45 pm, RP G said Resident #1 had been admitted to the facility with a feeding tube. She said Resident #1 cannot eat or drink anything by mouth. She said Resident #1 had never been fed anything by mouth while at the facility.In an interview on 11/10/25 at 4:00 pm, CNA A said she had cared for Resident #1 for five months and knew he was not able to eat or drink anything by mouth because he was fed via feeding tube. She said if she had a question regarding his plan of care, she would ask the charge nurse. She said CNAs were not allowed to touch a resident's feeding tube or to feed them via their feeding tube. She said that task belonged to nursing staff.In an interview on 11/10/25 at 4:18 pm, LVN D said Resident #1 had a feeding tube and was not allowed to eat or drink anything by mouth. He said if a CNA had any questions regarding his plan of care they would ask a charge nurse. He said CNAs were not allowed to touch a resident's feeding tube, he said that tasked belonged to nursing staff only.In an interview on 11/12/25 at 9:00 am, MDS/RN F, said it was her responsibility to ensure a resident's care plan (Kardex), and MDS were individualized and accurate. She said Resident #1 had a feeding tube and was not able to eat or drink anything by mouth. She said Resident #1's Kardex included a bedtime snack which was not an appropriate task for him because he had a feeding tube. She said the task of bedtime snack auto populated on all resident's Kardex, she said it was her responsibility to remove it for residents that were not allowed to have one. She said she failed to remove the task of bedtime snack for Resident #1 when she completed his most recent care plan. She was observed as she checked Resident #1's task of bedtime snack for the past 30 days and said the CNAs had documented NA for bedtime snack which indicated a snack was not given. MDS/RN F said there were no negative outcomes to Resident #1 having that task of a bedtime snack on his Kardex because he had not been given one. In an interview on 11/12/25 at 11:00, the DON said Resident #1 had been admitted with a feeding tube. She was observed as she checked Resident #1's Kardex and said a bedtime snack was a task that automatically populated but for him, it should have been removed because he was NPO. The DON said there were no negative outcomes to Resident #1 having his Kardex show a bedtime snack because he had not been given one. She said CNAs were trained to no give any food or drink to residents who were on continuous feed via a feeding tube and if they had any questions regarding a resident's plan of care to ask their charge nurse.Record review of the facility's Care Plans policy dated February 2017 and revised January 2024 reflected:Care Plans: The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate intervention/interventions in relation to the identified problem or risk, outcome objective, and the resident's ability, needs, medical condition, preventative measures. The care plan may also include the expressed preferences. The care plan in conjunction with the plan of care throughout the medical record is developed and or recommended to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 1 resident (Resident#49) reviewed for indwelling catheters. The facility failed to prevent Resident#49's urinary catheter bag/tubing from touching the floor. This failure could place residents at risk of cross contamination and urinary tract infections. Findings included: Record review of Resident #49 ' s face sheet dated 06/03/25 revealed a [AGE] year-old male admitted on [DATE]. Resident #49 had primary diagnoses of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (cognitive disorders characterized by progressive decline in memory, thinking, reasoning, and other mental abilities that interfere with daily life and activities), and obstructive and reflex uropathy (two conditions affecting the urinary tract, obstructive uropathy is a blockage prevents urine from draining properly and reflux is where urine flows backward from the blader into the ureters and kidneys instead of draining properly). Record review of Resident #49 ' s Physician ' s Order Summary as of 06/03/25 revealed Foley Catheter 16 FR 30 cc, change monthly and PRN every night shift starting on the 15th and ending on the 15th every month related to Obstructive and Reflux Uropathy, unspecified. Record review of Resident #49 ' s Quarterly MDS dated [DATE] revealed he had clear speech, was able to understand others and was understood by others, had a BIMS of 06 which indicated he had severe cognitive impairment and had an indwelling catheter. Record review of Resident #49 ' s comprehensive care plan initiated on 11/22/24 and revised on 01/31/25 revealed he had an indwelling catheter relating to obstructive uropathy with interventions for catheter care every shift and as indicated, change catheter per physician ' s orders and check for tubing kinks each shift and during care encounters and monitor for s/sx of discomfort and abnormalities report those findings to MD as indicated. Observation on 06/03/25 at 9:56 a.m. revealed Resident #49 lying on a low bed, on his back, catheter bag hanging from the bottom rail of the bed and the catheter bag was resting on the floor. Interview on 06/03/25 at 9:57 a.m. revealed Resident #49 was unaware catheter bag was on the floor. Resident #49 was able to answer simple questions but could not provide information of how long the catheter bag was on the floor. Resident #49 said he did not have any concerns with the care provided. In an interview on 06/03/25 at 10:00 a.m., CNA E was informed and shown the catheter bag touching the floor. CNA E said the catheter bag should not touch the floor. CNA E said she did not know who hung the catheter bag on the bottom rail of the bed. CNA E said she had just started her round and had not gotten to Resident #49 ' s room yet. In a follow-up interview on 06/03/25 at 11:34 a.m. CNA E said she was supposed to hang the catheter bag low at the side of the bed but not too low it touches the floor. CNA E said when she lowers the bed, she must be sure the catheter bag was not touching the floor. CNA E said the catheter bag should not touch the floor because the floor was dirty, and it could get contaminated. If the catheter bag got contaminated, it could cause an infection. CNA E said she was trained in how to provide catheter care. In an interview on 06/04/25 at 3:42 p.m., CNA F said the CNAs were responsible to hang the catheter bags at the side of the bed. CNA F said when she lowers the bed, she must check that the bag was not touching the floor. CNA F said the nurses check to see if the resident has the leg band and the CNAs check to make sure the bag is not on the floor. CNA F said every time they did a round; they checked that the catheter bag was not on the floor. CNA F said the catheter bag should not touch the floor because it could lead to an infection. In an interview on 06/04/25 at 3:55 p.m., LVN C said the nurses were responsible to check the catheter bags were placed correctly. The LVN C said he checked on the catheter bags every shift. LVN C said the catheter bag should not touch the floor. LVN C said it should not touch the floor because the floor has bacteria and if the catheter bag touched the floor, it would travel up the bag and could lead to an infection. LVN said he is constantly monitoring the CNAs on the floor. In an interview on 06/05/25 at 10:53 a.m., the ADON said it was the nurse ' s responsibility to check the catheters were appropriately placed but all staff could check them and report if a catheter was not placed correctly. The staff should check on the catheters every shift, but they should check them frequently because some residents were very mobile, and the CNAs do incontinent care and drain the catheter bags. The ADON said the catheter should never be lifted above the bladder and should not touch the floor. The catheter should not be above the bladder because the urine could flow back into the bladder and residents would not be able to urinate. The catheter should not touch the floor due to infection. Bacteria could travel up the tubing and cause infection. ADON said the DON, ADON and nurses did spot checks on the CNAs to make sure they were doing their tasks and doing them correctly. In an interview on 06/05/25 at 3:16 p.m., the DON said direct staff were responsible for checking that the catheter placement was correct. The catheter bag should not be on the floor to reduce the chance of pathogens getting onto the catheter bag and tubing and reduce the chance of infection. The DON said she does rounds and would go into different halls to check on staff to make sure they are doing their tasks. The DON said they do annual performance reviews for CNAs. Record review of the facility ' s CNA/Caregiver Competency Checklist blank form under the section for Personal Care revealed Catheter tubing/Bag not touching floor/tubing not above bladder/privacy. Record review of the facility ' s policy on Incontinence and Catheterization Assessment and Evaluation revised in January 2024 did not address the proper placement of a catheter bag at the bedside.

Based on observation, interview 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 resident's goals and preferences for 2 of 6 (Resident #68, Resident #67) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #68's oxygen was administered at the correct setting of 2 liters per minute on 06/03/2025 as ordered by the physician. 2. The facility failed to ensure Resident #67's oxygen was administered at the correct setting of 2 liters per minute on 06/03/2025 as ordered by the physician. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: 1.Record review of Resident #68's admission record dated 06/03/2025 reflected a [AGE] year-old male with an admission date of 05/16/2025 and with an initial admit date of 09/30/2022. Pertinent diagnoses included Shortness of Breath, Paraplegia (paralysis that affects your legs, but not your arms), Heart Failure, Chronic Kidney Disease, Muscle Wasting and Atrophy (loss of muscle tissue), Type 2 Diabetes Mellitus, Dysphagia (difficulty swallowing), and Hypertension (high blood pressure). Record review of Resident #68's Quarterly MDS assessment, dated 05/21/2025 revealed oxygen therapy. Resident #68's BIMS score of 15, indicated he was cognitively intact. Record review of Resident #68's physician order dated 05/19/2025, revealed oxygen at 2 LPM via nasal cannula for SOB or saturation less than 92 as needed every shift. Record review of Resident #68's person-centered care plan, initiated date 10/21/2023 reflected Resident #68 used oxygen therapy related to shortness of breath. Intervention included Administer O2 as per MD orders. During an observation of Resident #68 on 06/03/2025 at 11:15 a.m. the oxygen level on the oxygen concentration machine was at 4LPM via nasal cannula. Observed Resident #68 in bed with head of the bed slightly elevated. No signs of respiratory distress noted. In an interview on 06/03/2025 at 11:18 a.m. with Resident #68, stated that the nurse checked his saturation this morning. He stated that he does not touch the oxygen machine. In an interview on 06/03/2025 at 11:25 a.m. LVN J, stated she was the nurse for Resident #68. LVN J agreed that the O2 setting was set at 4LPM. She stated the oxygen setting was supposed to be at 2 LPM per physician orders. She stated that she checked the setting yesterday when she replaced the water and tubing when Resident #68 returned from dialysis. She was not sure who might have moved it. LVN J stated that she checked Resident #68's oxygen tubing and saturation this morning. She stated that she usually checks the oxygen twice a day when she goes in to check his colostomy bag. LVN J stated that the negative outcome to keeping Resident# 68's oxygen setting at a of 4 LPM was that too much oxygen can hurt his lungs. In an interview on 06/03/25 at 4:39 p.m. with the ADON stated that the nurse was responsible for checking O2 setting. She stated the nurse was supposed to check it every shift, whenever the patient comes back from doctors' appointments, and as needed. The ADON stated the nurse was to follow the physician order for the oxygen setting. She stated the negative outcome of keeping it at a high setting would be that the patient would have expanded lungs and will get hyperoxia (high levels of oxygen). In an interview on 06/03/2025 at 4:46 p.m. with MDS D stated that she was responsible for supervising Resident #68's hall. She rounds once or twice a day. She checks that the O2 setting was at 2-4 liters depending on the physician order. That the resident was breathing ok and not in any distress. MDS D stated that she only checked Resident #68's tubing today and did not check the setting. She stated that the negative outcome would be that Resident #68 could hyperventilate if he continues that high rate. In an interview on 06/03/2025 at 4:56 p.m. with the DON, stated that the nurses assigned to that hall were responsible for checking the O2 setting. She stated that the nurses were to check the setting once per shift. The DON stated they were to follow oxygen settings on physician orders. The DON stated that they called the doctor and he said there was no negative outcome. She stated there were administrative nurses that oversee different wings. MDS D was the administrator responsible for overseeing Resident #68's hall. The DON stated that there was no negative outcome. 2. Record review of Resident #67's admission record dated 06/03/2025 revealed he was a [AGE] year-old female admitted on [DATE]. Her relevant diagnoses included kidney failure (a condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis (relying on a process to filter waste and excess fluid from the blood, as the kidneys were no longer functioning properly), and congestive heart failure ( a chronic condition in which the heart doesn't pump blood as well as it should). Record review of Resident #67's admission MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated her cognition was intact. Further review reflected; Resident #67 was on oxygen therapy on admission. Record review of Resident #67's care plan dated 04/09/25 reflected a focus of oxygen therapy related to CHF (date initiated: 04/10/25). Her interventions in part included administering O2 as per MD orders (date initiated: 04/10/25). Record review on 06/03/25 at 11:43 a.m., of Resident #67's order summary dated 06/03/25 reflected an active order of continuous oxygen, 2 liters per n/c every shift for SOB effective 04/10/25. During an observation on 06/03/25 11:35 a.m., Resident #67 was observed sitting in her wheelchair watching television in her room. She said she had been admitted to facility short-term to get physical therapy. She said she required continuous oxygen at 2 lpm. She said she had not experienced any shortness of breath or was under any respiratory distress. During an observation on 06/03/25 11:40 am, Resident #67's oxygen concentrator revealed it was set at 2.5 LPM. During an observation and interview on 06/03/25 at 11:45 a.m., LVN B was observed as he reviewed Resident #67's electronic medical record and said she had an active order of 2 lpm continuous oxygen. He then was observed as he checked Resident #67's oxygen concentrator and said her O2 was set at 2.5 lpm. He said there was no negative outcome to Resident #67 because she had not experienced any respiratory distress. He said the nursing staff were responsible to ensure a resident's oxygen setting was set as ordered during every shift. He said his shift started at 6 a.m. and had already checked on Resident #67 several times but had not checked her oxygen setting. LVN B said he had been in-serviced on oxygen administration regularly. In an interview on 06/03/25 at 11:53 a.m., the ADON, said Resident #67 had an active oxygen for at 2 lpm continuous via n/c. She said she had just gone into Resident #67's room and had changed her oxygen setting back to 2 lpm. She said, it was slightly above the ordered amount. The ADON said it was the nurse's responsibility to ensure a resident's oxygen concentrator was as ordered. She said the nursing staff were supposed to check the concentrators at least once every shift. The ADON said there were no negative outcome to Resident #67 not having her oxygen setting at 2 lpm because she had not experienced respiratory distress. In an interview on 06/04/25 at 9:12 AM, the DON said Resident #67 had an oxygen order of 2 lpm continuous via n/c. She said the nursing staff were responsible to ensure a resident's oxygen settings were set as ordered at least once every shift. She said the nursing staff completed skills competencies online as part of their in-service on oxygen administration. The DON said Resident #67 had no negative outcome due to not having her oxygen settings at 2 LPM as ordered. She said she had called her NP, and he too agreed that Resident #67 had not sustained any negative outcome and had not given any new orders. Record review of the facility's policy subject titled, Oxygen Administration, dated revised January 2023, revealed, Compliance Guidelines: A resident receives oxygen therapy when there is an order by a physician. Procedure: 3. Obtain physician orders for oxygen administration. Orders should include the following: c. flow rate of delivery

Based on interview, and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, for 1 resident (Resident #9) of 24 residents whose care plans were reviewed. 1) The facility failed to ensure Resident #9's comprehensive care plan was updated after the code status was changed from full code to DNR on 05/21/25. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and the implementation of personalized plan of care developed to address their specific needs. The findings include: Record review of Resident #9's face sheet dated 06/04/25 reflected an [AGE] year-old-female with an original admission date of 01/29/25. Diagnoses included Dementia (general decline in cognitive abilities that affects a person's ability to perform everyday tasks) and Hypertension (high blood pressure). Record review of Resident #9's care plan initiated on 02/02/25 reflected: Resident/Family/RP does not have advance directives and elects Full Code Record review of Resident #9's physician orders dated 05/21/25 reflected DNR status. In an interview on 06/04/25 at 09:16 AM, the DON stated Resident #9's care plan reflects full code and should reflect her current DNR status. The DON stated Resident #9 was a full code and was changed to a DNR on 5/21/25 and the full code status was discontinued. The DON stated the care plan should have been revised. The DON stated that the SW and the MDS Coordinators are the ones responsible for updating care plans. The DON stated care plans are reviewed when a resident has a change in condition or any significant changes. The DON stated she does not know why the care plan was not updated. The DON stated in case of an emergency, the nurses would go based off the physician's orders to honor the residents code status. In an interview on 06/04/25 at 09:34 AM, the SW stated he and the MDS Coordinators are responsible for care plan revisions. The SW stated he usually takes charge when there is a code status change, but there is no specific person in charge of making sure the code status is revised. The SW stated he does try to audit care plans every quarter along with quarterly care plan meetings but could not state why the care plan was not revised. The SW stated Resident #9's care plan should have been revised, but the nurses know to go by the physician's orders. In an interview on 06/04/25 at 09:58 AM, the MDS Coordinator stated it was a team effort, but MDS Coordinators, nursing, and the SW were responsible for making sure the care plans are updated. The MDS Coordinator stated she oversaw the 100 and 200 hall resident care plans. The MDS Coordinator stated she had no reason why Resident #9's care plan was not updated and as she usually checked the residents' care plans that are in her halls every morning. The MDS Coordinator stated she was surprised to find out Resident #9's care plan was not updated. The MDS stated she was responsible for making sure Resident #9 ' s care plan was accurate. The MDS Coordinator stated that resident care plans are reviewed every three months, and she was responsible for ensuring accuracy. The MDS Coordinator stated there was no negative impact to Resident #9 since the code status was correct in the orders. In an interview on 06/04/25 at 04:13 PM, LVN C stated the residents had a tab on their chart that states if they are a full code or DNR. LVN C stated if the care plan had a conflicting code status, he would follow what the physician orders state. LVN C stated there was also a list of DNR residents in a binder at the nurse's station but in an emergency, he would follow the physician's orders. Record review of the facility's Care Plans policy dated January 2023 reflected: Guidelines: Care Plans The care plan should be initiated upon admission, continued to be developed during the initial 48-72 hrs., throughout the completion of the admission comprehensive assessment. The care plan should be updated and reviewed at least quarterly thereafter, then annually and with significant changes in conditions as defined in the RAI (Resident Assessment Instrument) manual. Additional updates to the care plan may be done as indicated. The care plan should be considered a part of the medical record and should be utilized in conjunction with the complete medical record. The care plan should serve as a guide, which should direct care needs, care choices and care preferences. However, the care plan in not an all-inclusive reflection of prescribed or recommended care by the IDT.

Based on interviews and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #45) of 8 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #45 was coded in the MDS for Dialysis. This failure could place residents at risk for receiving inadequate care and services based on an inaccurate assessment. The findings included: Record review of Resident #45's face sheet dated 06/05/2025 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with an initial admit date of 09/27/2024. Pertinent diagnoses included: End of Stage Renal Disease (final stage of kidney disease, where kidneys can no longer function on their own), Dependence on Renal Dialysis, Cerebrovascular Disease (conditions that affect blood flow to the brain), Unspecified Dementia, Type 2 Diabetes (high levels of sugar in blood), Hypertension (high blood pressure), Gastrostomy Status (opening in the stomach to insert a tube for nutritional support), Hemiplegia and Hemiparesis (paralysis and weakness that affects only one side of the body). Record review of Resident #45's Quarterly MDS assessment dated [DATE] revealed: BIMS score of 06 indicating Resident #45 was severe cognitively impaired. Section O0110 - Special treatments, procedures, and programs - section J1 Dialysis was not marked. Record review of Resident #45's comprehensive care plan initiated on 01/10/2025 revealed Resident #45 had End Stage Kidney Disease and require Dialysis treatment with interventions Dialysis treatment as recommended / ordered by physician and Dialysis treatments at Davita [NAME] Meadows as indicated. In an interview on 06/05/2025 at 1:18 p.m. with MDS Coordinator, she stated that she and MDS D are responsible for completing the MDS assessments. She stated that she was assigned the 100 and 200 halls. MDS D was assigned the 300 and 400 halls. She stated that she signs off on the MDS assessments that MDS D completes because MDS D was an LVN and the MDS assessments need to be signed off by an RN. She confirmed that MDS D completed the quarterly MDS assessment for Resident #45 dated 05/06/2025. P. The MDS Coordinator verified that Dialysis was not marked on Resident #45's MDS assessment. She stated that she checked Resident #45 MDS assessment and that she missed it too, it was an oversight. She stated the negative outcome was that it will not show that the care was provided even though Resident #45 goes to dialysis and reimbursement would be affected. In an interview on 06/05/25 at 1:25 p.m. with MDS D, she stated that she and the MDS Coordinator are responsible for completing the MDS assessments. They divide the workload. She stated that the MDS Coordinator verifies the information and then signs off on it. MDS D confirmed that she was the one that completed the MDS assessment for Resident #45 dated 05/06/2025. She verified that Dialysis was not marked on the MDS assessment. MDS D stated that it was an oversight. She stated the negative outcome was that it would affect the reimbursement and it will show that the resident did not receive dialysis. In an interview on 06/05/25 at 3:32 p.m. with the DON, she stated both the MDS Coordinator and MDS D are responsible for completing the MDS assessments. They divide the facility; they each take 2 halls. The DON stated the MDS Coordinator signs off on the MDS assessments for MDS D due to MDS D was an LVN and they needed to be signed by an RN. There was no system in place that oversees that they are accurately completed. She stated that she had seen that Dialysis was not marked on Resident #45 MDS assessment dated [DATE]. The DON stated that it was an oversight. She stated the negative outcome for not completing them accurately was none for patient, but it would affect the facility payment. Record review of the facility's Comprehensive Assessments Policy dated January 2024 revealed - Comprehensive resident assessment: The community uses the Resident Assessment Instrument (RAI) to develop the comprehensive resident assessment. It identifies the care, services, and treatments that each resident needs to attain or maintain his or her highest practicable mental and physical functional status. Accuracy of Assessment: Each resident receives an accurate team member assessment of relevant care areas that provide team members with knowledge of each residents status, needs, strength, and areas of decline. Record review of CMS's RAI version 1.19.1 dated October 2024 revealed section: O0110: Special Treatments, Procedures, and Programs a. On admission b. while a resident c. at discharge J1: Dialysis Code peritoneal or renal dialysis which occurs at the nursing home or at another facility, record treatments or hemofiltration, Slow Continuous Ultrafiltration, Continuous Arteriovenous Hemofiltration, and Continuous Ambulatory Peritoneal Dialysis in this item.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #19, Resident #69) of 8 residents reviewed for infection control practices, in that: 1) The facility failed to ensure the WCN performed hand hygiene for at least 20 seconds prior to and after performing Resident #19's wound care. 2) The facility failed to ensure the CNA A performed hand hygiene for at least 20 seconds prior to and after assisting the WCN with Resident #19's wound care. 3) The facility failed to ensure LVN K followed enhanced barrier precautions while providing gastrostomy site care for Resident #69. These failures could place residents at risk for healthcare associated cross-contamination and infections. Findings include: 1) Record review of Resident #19's face sheet dated 06/04/25 reflected a [AGE] year-old-male with an initial admission date of 03/11/25. Diagnoses included acute kidney failure, stage 4 (deep wounds that may impact muscle, tendons, ligaments, and bone) pressure ulcer of the sacral region (bottom of the spine and lies between the fifth segment of the lumbar spine (L5) and the coccyx (tailbone), above the knee right and left leg amputation, and type 2 diabetes (insufficient insulin production in the body). During an observation of wound care on 06/04/25 at 10:31 AM, the WCN performed hand hygiene prior to Resident #19's wound care for approximately 15 seconds. CNA A was observed performing hand hygiene for approximately 13 seconds prior to assisting the WCN with Resident #19's wound care. After wound care, the WCN removed her gloves and performed hand hygiene for approximately 5 seconds. CNA A also removed her gloves after assisting with Resident #19's wound care and performed hand hygiene for approximately 6 seconds. In an interview on 06/04/25 at 10:53 AM, the WCN stated handwashing should be 20 seconds or more. The WCN stated she was nervous, and she did count 20 seconds while washing her hands but guessed she was counting fast. The WCN stated it was important to wash hands properly to keep hands clean and to remove any bacteria. The WCN stated Resident #19 could get an infection, or the wound could become worse if the resident came in contact with any bacteria. The WCN stated she does not recall the last hands-on handwashing or infection control in-service, but stated staff did get in-serviced on infection control regularly. In an interview on 06/04/25 at 10:53 AM, CNA A stated hand washing should be at least 20 seconds or more. CNA A stated she was nervous, and it was important to wash hands properly to stop the spread of infection. CNA A stated she could not recall when the last handwashing in-service was but was maybe about a month ago. In an interview on 06/04/25 at 11:04 AM, the DON stated staff should wash their hands for more than 20 seconds because that was the recommended time to remove pathogens from the hands according to CDC. The DON stated if staff were not wearing gloves, they could carry pathogens on their hands and possibly expose pathogens to a resident. The DON stated depending on the patient, there could be bacterial growth and could affect the wound and could develop an infection. The DON stated staff do get hands on training for handwashing but was unsure when the last one was. In an interview on 06/04/25 at 11:10 AM, the ICP stated staff should lather their hands with soap and water for at least 20 seconds. The ICP stated it was important to get rid of bacteria on the hands and nails to prevent cross contamination and prevent infection or possible sepsis. The ICP stated the last in-service for hand washing was about a week ago with all staff and was done quarterly as well as computer-based training. 3) Record review of Resident #69's face sheet dated 06/04/2025 reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] with an initial admit date of 11/06/2023. Pertinent diagnoses included: Gastrostomy Status (opening in the stomach to insert a tube for nutritional support), Dysphagia (difficulty swallowing), Unspecified Dementia, Type 2 Diabetes Mellitus (high levels of sugar in blood), Muscle Weakness, and Cerebrovascular Disease (conditions that affect blood flow to the brain). Record review of Resident #69's Quarterly MDS assessment, dated 04/20/2025 revealed her BIMS score of 0, indicated she had severe cognitive impairment. Further review revealed nutritional status were feeding tube (PEG). Record review of Resident #69's physician order dated 03/12/2025, revealed cleanse gastrostomy site with normal saline, pat dry with 4x4 gauze and leave open to air every shift and EBP (Enhanced Barrier Precautions): Practice EBP as indicated when in contact with Gastrostomy Tube every shift dated 03/25/2025. Record review of Resident #69's Comprehensive Care Plan, revision date 03/25/2025, revealed Resident #69 was at risk for infection or recurrent/chronic infection r/t compromised medical condition. Interventions: EBP (Enhanced Barrier Precautions) r/t: gastrostomy tube. During an observation on 06/04/2025 at 3:15 p.m. revealed LVN K applied gloves but did not wear a PPE gown when she provided gastrostomy site care on Resident #69. In an interview on 06/04/25 at 3:45p.m. with LVN K, she stated that EBP was indicated for residents who have gastrostomy tubes, foley catheters, wounds, or who have an infection. EBP requires the use of a gown and gloves during high contact patient care. LVN K stated that a PPE gown was supposed to be put on before going into the patient's room who were identified with EBP. She stated she did not put on the gown because she got nervous. LVN K stated that it was important to wear the required PPE when providing care to EBP patients to prevent the spread of germs and to protect themselves. In an interview on 06/04/2025 at 4:00 p.m. with the ICP, she stated EBP was to be used on high contact care for patients with Gtubes, PICC line, Foleys, and wounds. She stated that PPE includes gloves and a gown. The ICP stated that it was important to use proper PPE on EBP patients to not cross contaminate and to prevent the spread of infection. In an interview on 06/04/2025 at 4:14 p.m. the DON stated for EBP the staff needed to wear gowns, gloves and face shields if the patient has a trach or was coughing. She stated that EBP patients were identified as anyone who has gtube, indwelling catheters, wounds, and with certain MDROs. The DON stated that PPE for EBP patients was important because they were susceptible to receive bacteria. Record review of the facility's Infection Prevention and Control policy dated 3/13/19 reflected: Gloves and Handwashing Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. In addition to isolation practices, Enhanced Barrier Precautions (EBP) maybe implemented as an infection control intervention designed to reduce transmission of resistant organisms. The use of PPE, such as gown and gloves use during high contact resident care activities. EBP may be indicated as a recommendation by the CDC (when Contact Precautions do not otherwise apply) for residents with the following: -Wounds or indwelling medical devices, regardless of MDRO colonization status. EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Use of eye protection may be necessary when splash or spray may occur but was not necessary in other situations. Record review of the facility's Handwashing/Hand Hygiene policy dated January 2023 reflected: Guideline This facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for situations such as this (including but not limited to): Between glove changes/After removing gloves; The following resource was found on the CDC website at https://www.cdc.gov/clean-hands/about/index.html reflected: The CDC handwashing guidelines recommend the following steps for effective handwashing: 1. Wet your hands with clean, running water (warm or cold), and turn off the tap. 2. Apply soap and lather your hands by rubbing them together, including the backs of your hands, between your fingers, and under your nails. 3. Scrub your hands for at least 20 seconds. 4. Rinse your hands well under clean, running water. 5. Dry your hands using a clean towel or air dry them. Use hand sanitizer when you can't use soap and water.

Based on observations, interviews and record review, the facility failed to ensure residents have the right to request, refuse, and or discontinue treatment and to formulate an advance directive for 1 (R#82) of 6 residents whose records were reviewed for OOH-DNR Order forms: The facility failed to have Resident #82's Out-of-Hospital Do Not Resuscitate (OOH DNR) on admission or in a timely manner. This failure could place residents at risk for not having their end of life wishes honored. The findings included: Record review of Resident #82's admission record dated 06/05/2025 revealed he was a [AGE] year-old male admitted on [DATE]. His relevant diagnoses included kidney failure (a condition in which the kidneys lose the ability to remove waste and balance fluids), chronic obstructive pulmonary (a group of lung diseases that block airflow and make it difficult to breathe), and lack of coordination( a neurological condition that causes difficulty controlling muscle movements and balance). Record review of Resident #82's admission/5-day MDS assessment was still in progress. Record review of Resident #82's care plan dated 05/19/25 reflected a focus of DNR code status, his interventions in part included to honor his advanced directives, care wishes, and code status would be respected and honored as indicted (date initiated 05/20/25). Record review of Resident #82's order summary dated 06/05/25 reflected an active DNR order effective 05/19/25. In an interview and observation on 06/04/25 at 10:15 a.m., the SW said it was his responsibility to ensure that a resident whose code status was DNR had a completed OOH-DNR form in their medical electronic record. The SW was observed as he reviewed Resident #82's medical electronic record and said the OOH-DNR form had not been uploaded. The SW said he had audited Resident #82's medical electronic record on 06/03/25 and had discovered he had failed to initiate the process of obtaining an OOH-DNR form. The SW said there were no negative outcome to Resident #82 because he had a DNR order, his profile and care plan indicated he was a DNR. He said if Resident #82 had coded, he would be considered a DNR. In an interview on 06/04/25 at 10:30 a.m., the DON said it was the responsibility of the facility's SW to ensure an OOH-DNR form was obtained and correctly completed for each DNR resident. She said as long as there was an active DNR order, the code status of DNR would be entered on the resident's medical electronic record (profile and care plan). She said if a resident coded, nursing staff would immediately check the resident's electronic medical record to check their code status under their profile and ensure there was an active DNR order. She said as long as their profile and order matched, the resident would be considered a DNR. The DON said she had instructed the nursing staff that if they had any doubt about a resident's code status to immediately call the resident's representative. The DON said, whatever is active as an order is what would be most current. The DON said the topic of advanced directives were part of the nurse's skill check offs which were done yearly or as needed. In an interview on 06/04/25 at 3:15 p.m., LVN C, said if a resident coded, he would immediately check their electronic medical record to check their code status under their profile and physician's order. He said if the resident had a code status of DNR, she would also check under the miscellaneous tab to ensure the OOH-DNR form had been uploaded and had all required signatures. He said if the OOH-DNR form had not been uploaded or completed correctly, he would immediately contact the resident's representative for clarification. He said he had never experienced a situation in which a resident coded and their OOH-DNR form had not been uploaded. In an interview on 06/04/25 at 4:30 p.m., LVN G, said if a resident coded, she would immediately check the resident's electronic medical record to check for their code status under their profile and would also ensure there was an active DNR physician order. She said she would also check under the miscellaneous tab to ensure the OOH-DNR form was completed correctly. She said if the OOH-DNR form had not been uploaded or was missing signatures, she would consider the resident a full code. She said she had never experienced a situation in which a resident coded and their OOH-DNR form had not been uploaded. In an interview on 06/04/25 at 4:54 p.m., LVN H, said if a resident coded, she would immediately check their electronic medical record to check their code status under their profile and physician's order. She said if the resident had a code status of DNR, she would also check under the miscellaneous tab to ensure the OOH-DNR form had been uploaded and had all required signatures. LVN H said ultimately, as long as the resident's profile had them coded as a DNR and there was an active DNR order, she would consider the resident a DNR. She said she had never experienced a situation in which a resident coded and their OOH-DNR form had not been uploaded. An interview on 06/04/25 at 5:04 p.m., LVN I said if a resident coded, he would immediately check their electronic medical record to check their code status under their profile and physician's order. He said if the resident had a code status of DNR, he would also check under the miscellaneous tab to ensure the OOH-DNR form had been uploaded and had all required signatures. LVN I said as long as the resident's profile had them coded as a DNR and there was an active DNR order, he would consider the resident a DNR. He said she had never experienced a situation in which a resident coded and their OOH-DNR form had not been uploaded. Record review of the facility's Advanced Directives policy dated February 2017 and revised in January 2023 reflected: Compliance Guidelines: Every resident has the right to formulate an advance directive and to refuse treatment. The community will determine the existence of an advance directive at the time of admission .A copy of the advance directive and subsequent revisions will be included in the resident's medical record. Advanced directive implementation: The IDT will notify the medical provider of the resident's/representative's care decisions made to include expressed advanced directive, such as DNR code status. The nurse should then obtain a physician's order for appropriate care decision in order to initiate and implement the preferred treatment wishes expressed. IDT should initiate the Out of Hospital-Do Not Resuscitate (OOH-DNR) form and should obtain the medical provider/physician's signature as per the OOH-DNR form instructions. The Medical record and resident plan of care should reflect the resident's wishes as well as the physician orders in order to meet the directives described.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: The facility failed to ensure that 1 of 2 juice nozzles was clean. This failure could place residents at risk of foodborne illnesses. The findings included: During the initial observation of the kitchen on 06/03/2025 at 10:30 a.m., revealed the juicer's nozzle dispenser had red and white slimy substance in the middle and a brown slimy substance on the outer part. In an interview on 06/03/25 at 10:35 a.m., the DM said his staff had a hard time removing the juicer nozzle but ensured it was cleaned daily. She said she did not know what the slimy substances were. She said she kept a weekly cleaning schedule which included the juice machine. The DM was not able to say what negative outcome to the residents was for having the juicer ' s nozzle with slimy substances. Record review of the kitchen' s weekly cleaning schedule from 06/01/25 to 06/04/25 reflected the juice machine/nozzles had been cleaned. Record review of the facility's General Kitchen Sanitation policy dated 01/2024 and revised 01/2025 reflected: Policy: The facility recognizes that foodborne illness has the potential to harm elderly and frail residents. All Nutrition & Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and foodborne illness. Procedure: 1. Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment. After each use, clean and sanitize all tableware, kitchenware, and food contact surfaces of equipment, except cooking surfaces of equipment and pots and pans that are not used to hold or store food and are used solely for cooking purposes.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #3) reviewed for accidents and supervision, in that: The facility failed to ensure Resident #3 received adequate supervision to prevent him from falling off the bed fracturing his right distal femur on 07/30/2024. An Immediate Jeopardy was identified on 05/02/2025. The Immediate Jeopardy template was provided to the facility on [DATE] at 06:55 PM. The Immediate Jeopardy was removed on 05/04/2025 at 05:00 PM. The IJ was lowered to isolated with no actual harm with a potential for more than minimal harm. This deficient practice placed all resident as risk of injuries, such as falls, fractures, and death due to improper supervision. The findings included: Record review of Resident #3's admission record dated 05/02/2025 reflected a [AGE] year-old male originally admitted to the facility on [DATE]. His diagnoses included paraplegia (a condition characterized by partial or complete paralysis of both lower limbs, typically affecting the legs, feet, and hips caused by damage to the spinal cord in the thoracic or lumbar regions), chronic kidney disease, Stage 5, dependence on renal dialysis, heart failure, hypertension (high blood pressure), and type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Record review of Resident #3's quarterly MDS dated [DATE] reflected a BIMS score of 15, indicating Resident #3 was cognitively intact. Resident #3 had adequate hearing, understood others, was understood by others, was always incontinent of bladder, continence of bowel was not rated due to the ileostomy (a surgical procedure where the end of the last part of the small intestine was brought out through an opening in the abdomen, creating an artificial opening). The MDS Section GG reflected, Toilet hygiene: Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity Or, the assistance of 2 or more helpers is required for the resident to complete the activity). Record review of Resident #3's 05/20/2024 Care Plan revealed: FOCUS: o I have a Self Care deficit r/t impaired mobility, multiple comorbidities, disease process. At times I require more staff support than others based on comorbidities Date Initiated: 01/08/2024 Created on: 05/25/2022 Revision on: 01/08/2024 GOAL: o I will maintain or improve my ability to participate in my care with ADLs through my next review date. Date Initiated: 05/25/2022 Created on: 05/25/2022 Revision on: 10/10/2022 Target Date: 05/20/2024 INTERVENTIONS/TASKS: . o Toileting/Incontinent Care x 2 person assistance Date Initiated: 05/25/2022 Created on: 05/25/2022 NSG CNA . Record review of Resident #3's Progress Notes written by RN D, dated 07/30/24 at 02:56 AM, CNA notified SN that resident had witnessed fall sliding off bed legs first upon performing perineal care. I grabbed the side rail as they were changing and i just started sliding off, maybe I must have grabbed it too fast. Upon entering room resident was at bedside floor bed was at lowest position, resident was seated in seated position slated to his left side. Resident was assessed for any injuries skin intact. Resident denied experiencing any pain prior to having nursing personnel pick him up from ground. Stating I'm fine mija, just put me back in bed. Record review of Resident #3's Progress Notes dated 08/07/2024 at 11:39 AM written by LVN C revealed, resident has swelling, redness, warm to the touch, and pain to the right knee. NP notified. Orders given for x-ray to right knee. Record review of Resident #3's x-ray results of right knee, dated 08/07/24 at 01:57 PM, revealed an acute-appearing fracture of the distal shaft of the right femur (a bone break due to a sudden traumatic event of the lower thigh bone above the knee). Impression: There is an acute-appearing fracture as described above. -There is osteopenia (a loss of bone density that occurs when the body does not make new bone as quickly as it reabsorbs old bone). Record review of Resident #3's Progress Notes written by NP E, dated 08/07/2024 at 03:04 PM, Resident #3 states he is feeling well, but does c/o some discomfort to right knee. Xray of right knee shows acute distal fx of femur. Xray shows osteopenia. New order to send to ER to eval and tx. Record review of Resident #3's Progress Notes written by RN F, dated 08/07/2024 at 04:32 PM, SBAR Summary for Providers Situation : The Change In Condition/s reported on this CIC Evaluation are/were: Trauma (fall related or other). With response from NP E to send out to ER. Record review of Resident #3's Preliminary Hospital Report dated 08/08/24, revealed Resident #3 was brought to the ER from the nursing facility with right lower extremity pain and edema (swelling), after sustaining a fall from bed. X-ray showed mildly displaced right distal femur fracture, with small joint effusion (when excess fluid builds up I or around a joint, causing swelling) and intermuscular hematomas (a bruise between muscle layers) at fracture site. Orthopedics was consulted and took patient for surgery today (08/08/24). Patient is being admitted for further evaluation and treatment. Record review of facility's reported incident report dated 08/08/25 revealed, Resident #3's fractured right distal femur was reported as Injury of Unknown Origin. In an interview on 05/01/25 at 03:40 PM, Resident #3 stated he fractured his leg last August (2024) and he remembered it. Resident #3 stated he slipped from the bed when the CNA was changing his diaper. He said he knew he was falling but could not stop it. He said the nurse went in to check him and his hips and back were hurting. Resident #3 stated that his knee started hurting a day later. He said he was given something for pain. In an interview on 05/02/25 at 10:20 AM, Resident #3 stated one CNA was doing the diaper change when he fell and fractured his right knee last July (2024). Resident stated the CNA turned him and pushed too far and he could not stay in the bed. He said he fell even though he grabbed the side rail and tried to stay in the bed. Resident #3 said the next day he told the nurse that he had pain to his right knee. Resident #3 stated he did not think the CNA meant for him to fall. In an interview on 05/02/25 at 10:37 AM, The DON stated Resident #3 was now coded a 2 person assist, but back when the fall happened, he was coded a 1-2 person assist. She said he was now a 2 person assist due to safety reasons. The DON stated CNA B was the CNA performing care at the time of Resident #3's fall from the bed. This was verified with the July 2024 schedule. The DON stated CNA B no longer worked at the facility. In an attempted telephone interview on 05/02/25 at 12:23 PM, with CNA B, the call would not go through. The telephone number had been disconnected. Surveyor was unable to leave voicemail. In an interview on 05/02/25 at 12:52 PM, LVN C stated she notified NP E of x-ray results of Resident #3 on 08/07/24. LVN C stated Resident #3 fell during night shift (07/30/24) and she reported the x-ray results to the NP. LVN C stated she was not the one who had completed the initial assessment on Resident #3 after his fall last year. LVN C stated she had completed the assessment on Resident #3 when his leg was red and warm to touch about a week after the fall (08/07/24). She said Resident #3 was a paraplegic and had no feeling to his legs so he would not have felt pain. LVN C stated she could not remember much about it because it was so long ago. LVN C stated they all could check the care plan to find out how many are needed to assist a resident for ADLs. She said the CNAs could look on their tablets (Kardex) to find the information. LVN C stated they have been in-serviced all the time on abuse/neglect. She said the last in-service they had on abuse/neglect was a couple days ago. In an interview on 05/02/25 at 01:14 PM, RN D stated she had assessed Resident #3 after his fall on 07/30/24. RN D stated CNA B had been working on Resident #3's hall on 07/30/24 and was with him when he fell out of bed. RN D stated CNA B was changing Resident #3. RN D stated CNA B and the Resident #3 told her he grabbed the rail too fast and fell . RN D stated later in the shift, she notified the doctor the resident was having lower back discomfort and x-rays were ordered. RN D stated she assumed discomfort because the resident had no feeling to the lower part of his body. RN D stated Resident #3 had not complained of knee or leg pain, but he was a paraplegic and could not feel his legs. RN D stated she reported the fall to the DON, NP E, and RP. She said when she assessed Resident #3 at the time of the fall, there was no redness or swelling to the lower extremities. RN D stated abuse/neglect in-services occurred all the time. She said the last one was two days ago (04/30/25). She said the charge nurse was to monitor CNAs and she was a charge nurse. She said she had not seen CNA B go into Resident #3's room that night to do incontinent care. RN D stated it was right after shift change and she was still in report when CNA B went into Resident #3's room. RN D stated they could find whether a resident was a one- or a two-person assist by reading the admission assessment. RN D stated she was not sure whether Resident #3 was a 1- or a 2-person assist. In an interview on 05/02/25 at 05:10 PM, the Administrator stated the DON was notified of Resident #3's fall on 07/30/24, but he was not notified until after the fracture was found (08/08/24) by x-ray. He said at the time of the fall, staff were in-serviced on A/N and the DON had added bordered mattress with cover to the care plan for an intervention after the fall. Observation of incontinent care on 05/04/25 at 04:20 PM for Resident #2 (Resident #2 was a 2-person assist for incontinent care per Care Plan and MDS). CNA G and CNA H performed incontinent care on Resident #2. CNA G reviewed Kardex for level of care prior to entering Resident #2's room. No deficiencies noted for incontinent care. Record review of the facility's Falls Prevention Guideline policy dated March 28, 2022 Revised 1/2024, revealed: Purpose: To establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls. This was determined to be an IJ and the Administrator was provided the IJ template on 05/03/25 at 06:55 PM. The following Plan of Removal submitted by the facility was accepted on 05/03/25 at 01:45 PM. POR reflected: -QAPI / IDT meeting to be held in regard to IJ; -Random audit by facility of 6 CNAs performing incontinent care; -Incontinent Care observation; - Audit of ADLs care/appropriate level of care; -Interviews, by facility, with staff and interviewable residents completed on A/N; -Audit of all 2-person assist resident's care plan/Kardex and MDS for incontinent care were showing 2-person assist. -In-services to be conducted with staff on Abuse/Neglect, fall prevention, Kardex/Care Plan; Topic: Plan of Care/Kardex - Staff were educated on the CNA to confirm with charge nurse at the beginning of shift any changes in ADL level of assistance and validate by viewing the Kardex. CNA and charge nurse to communicate changes with incoming shift during end of shift report to ensure that the staff member understands the level of care to be provided and adhered to. Topic: Abuse/Neglect Preventing, Identifying, and Reporting - Staff were educated on abuse/neglect preventing, identifying, and reporting all suspicions or allegations immediately to the administrator. Topic: Preventing Accidents/Incidents and Fall Prevention - Staff to ensure care was provided in a safe manner in accordance with the plan of care/Kardex. Staff to respond to a fall urgently, assessing, and notifying. Immediate Corrective Action Response: Record review of QAPI / IDT meeting held with signatures for IJ. Date completed 05/03/25. Record review on 05/03/25 at 02:45 PM of random audit by facility of 6 CNAs performing incontinent care with all 6 CNAs using correct level of assistance. Date completed 05/03/25. Record review on 05/03/25 at 02:50 PM of incontinent Care observation by facility with CNA I completed by facility. Date completed 05/03/25. Record review on 05/03/25 at 03:02 PM of ADLs care/appropriate level of care audit completed by facility on 05/02/25 - 05/03/25 for all residents by facility was completed and verified. Date completed 05/03/25. Record review on 05/02/25 - 05/03/25 of interviews, by facility, with staff and interviewable residents completed on A/N. No resident or staff reported abuse or neglect. Date completed 05/03/25. Record review on 05/03/25 at 03:10 PM surveyor audited all 2-person assist resident's care plan/Kardex and MDS for incontinent care were showing 2-person assist. 36 / 36 residents verified for correctness. Record review of facility's in-services revealed the following in-services were conducted with staff: Topic: Plan of Care/Kardex - Staff were educated on the CNA to confirm with charge nurse at the beginning of shift any changes in ADL level of assistance and validate by viewing the Kardex. CNA and charge nurse to communicate changes with incoming shift during end of shift report to ensure that the staff member understands the level of care to be provided and adhered to. Topic: Abuse/Neglect Preventing, Identifying, and Reporting - Staff were educated on abuse/neglect preventing, identifying, and reporting all suspicions or allegations immediately to the administrator. Topic: Preventing Accidents/Incidents and Fall Prevention - Staff to ensure care was provided in a safe manner in accordance with the plan of care/Kardex. Staff to respond to a fall urgently, assessing, and notifying. During interviews on 05/03/2025 at 04:00 PM through 05/04/25 at 03:23 PM CNAs G, H, I, J, K, L, O, P, R, V, X, Y, Z, CC, GG, II, KK, and three NAs in Training L, Q, and JJ said they had been in-serviced on the topics of the Plan of Care/Kardex, Abuse/Neglect Preventing, Identifying, and Reporting, and Preventing Accidents/Incidents and Fall Prevention. During interviews on 05/03/2025 at 04:00 PM through 05/04/25 at 03:23 PM LVNs M, N, S, T, U, W, AA, BB, DD, EE, FF, and HH said they had been in-serviced on the topics of the Plan of Care/Kardex, Abuse/Neglect Preventing, Identifying, and Reporting, and Preventing Accidents/Incidents and Fall Prevention. During interviews on 05/03/2025 at 04:00 PM through 05/04/25 at 03:23 PM RN F, DON, and Administrator said they had been in-serviced on the topics of the Plan of Care/Kardex, Abuse/Neglect Preventing, Identifying, and Reporting, and Preventing Accidents/Incidents and Fall Prevention. The Administrator was notified on 05/04/2025 at 5:00 PM that the IJ had been removed. While the IJ was removed, the facility remained out of compliance at a level of no actual harm that was not immediate jeopardy at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure residents had the right to be free of misappropriation of property and exploitation for 2 of 2 residents (Resident #1 and Resident #2) reviewed for misappropriation and exploitation, in that: 1. The facility failed to ensure the BOM asked Resident #1 and Resident #2 RP's for permission to use their spending account card. 2. The facility failed to ensure the BOM gave the AD permission to use Resident #1 and Resident #2's spending account card for other residents. 3. The facility failed to ensure the AD did not use Resident #1 and Resident #2's spending account card for unauthorized transactions on 4 occasions. As a result, Resident #1 lost $318.64, and Resident #2 lost $313.72 from their spending account card. These failures could affect residents and their responsible party by preventing them from having access to their funds. The findings included: 1.Record review of Resident #1's admission record, dated 04/30/25, reflected a [AGE] year-old female admitted on [DATE], an initial admitted [DATE], and an original admitted [DATE]. Her relevant diagnoses included senile degeneration of the brain (encompasses a range of neurological disorders characterized by a progressive decline in cognitive function, impacting memory, reasoning, and the ability to perform everyday activities), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and dementia (a progressive decline in mental abilities, like memory, thinking, and reasoning, that significantly impacts a person's ability to perform daily activities). Further review reflected she had a Resident Representative. Record review of Resident #1's quarterly MDS assessment, dated 04/10/25 reflected a BIMS score of 00, which indicated her cognition was severely impaired. Record review of Resident #1's quarterly care plan, dated 02/17/25 reflected she had impaired thought process related to Alzheimer's disease. Her intervention in part included notify MD of any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding other, level of consciousness, mental. (date initiated 08/29/23). 2. Record review of Resident #2's admission record, dated 04/30/25, reflected an [AGE] year-old female admitted on [DATE] and an original admitted [DATE]. Her relevant diagnoses included Parkinson's disease ( a disorder of the central nervous system that affects movement, often including tremors), vascular dementia (brain damage caused by multiple strokes), and cognitive communication deficit (occurs when communication problems are caused by issues with cognitive processes like attention, memory, or executive function). Further review reflected she had a Resident Representative. Record review of Resident #2's quarterly MDS assessment dated [DATE], reflected her BIMS score was 99, which reflected her cognition was severely impaired. Record review of Resident #2's quarterly care plan dated 03/17/25, reflected she had impaired cognitive function and impaired processes related to vascular dementia. Her interventions, in part included to communicate with the resident/family/caregivers regarding residents capabilities and needed as needed. In an interview on 04/30/25 at 11:00 a.m., the BOM said both Resident #1 and Resident #2 had received a spending account card from their medical insurance provider that ran from 01-01-24 to 12-31-24. She said each month both residents received a deposit of $50.00 into their spending account card for them to use on over-the-counter medications and/or groceries. She said if the funds were not used, they rolled over onto the following month. The BOM said the spending account cards did not require a personal identification number when used. She said at one point (not sure when) she advised the AD that Resident #1 and Resident #2 had a spending account card that had not been used and had given her permission to use them to buy snacks for Resident #1, Resident #2, and other residents. She said both Resident #1 and Resident #2 had RPs, but she had failed to call them to get their permission to use their spending account cards. The BOM said the AD used Resident #1 and Resident #2's cards on several occasions. The BOM said at first she kept Resident #1 and Resident #2's spending account cards in a safe she kept in her office along with the receipts of what was purchased. She said at some point (not sure when) she said the AD had kept Resident #1's and Resident #2's spending cards in her office (did not remember the reason) and she had forgotten to get them back. The BOM said on 10/18/24, Resident #1's RP approached her and asked if the facility had received Resident #1's spending account card. She said that's what prompted the investigation into the use of Resident #1 and Resident #2's spending cards. The BOM said after their investigation, it was discovered the AD had used $318.64 from Resident #1's spending account card and $313.72 from Resident #2's spending account card. The BOM said prior to that incident, the facility did not have a protocol on how to manage a resident's spending account cards, and she did not know the cards could not be used for other residents or that they needed their RPs permission to use them. The BOM said Resident #1 and Resident #2 spending account cards had been mailed to the facility and were not given to their RP's. She said after the investigation, the Administrator had purchased 2 gift cards to reimburse Resident #1 and Resident #2 RP's but had not yet reimbursed them because he was waiting until after the state's investigation. Record review of Resident #1's receipts reflected: 1. On 05/22/24 at 12:36 p.m., a total of $82.39 was purchased with program card. 2. On 05/22/24 at 3:24 p.m., a total of $85.62 was purchased with program card. 3. On 08/16/24 at 2:14 p.m., a total of $150.63 was purchased with program card. Record review of Resident #2's receipts reflected: 1. On 05/22/24 at 3:18 p.m., a total of $120.09 was purchased with program card. 2. On 08/16/24 at 1:04 p.m., a total of $193.63 was purchased with program card. During an observation on 04/30/25 at 1:10 p.m., Resident #2 was observed in the dining room, she required feeding assistance, her plate consisted of a pureed diet. Resident #2 had her eyes closed and was not verbal. During an observation on 04/30/25 at 1:30 p.m., Resident #1 was observed lying sleep in her bed. In an interview on 04/30/25 at 2:44 p.m., Resident #1's RP said on 10/18/24, while she visited Resident #1 at the facility, she was approached by an insurance representative who tried to recruit Resident #1 and as an incentive, the representative told her Resident #1 would qualify for a spending account card. Resident #1's RP said that's when she remembered she had already applied for Resident #1 in January 2024 but never received the spending account card. She said she approached the BOM and asked her if Resident #1's spending account card had been mailed to the facility. Resident #1's RP said the BOM told her yes, but when the BOM opened the safe she had in her office, the card was not in there. the BOM told her she needed to ask the AD if she had Resident #1's spending account card and that she would get back with her. Resident #1's RP said she had told the BOM, Resident #1 should have a large amount in the card since it had not been used, that's when she was told by the BOM that Resident #1's card had already been used to purchase snacks for Resident #1 and other residents. Resident #1's RP said later that day while still at the facility, she had bumped into the AD and asked her why she had Resident #1's spending account card, not asking her for permission to use the card and why she had purchased snacks for other residents. Resident #1's RP said the AD told her she did have the Resident #1's spending account card but did not know she needed her permission to use it and that she was not supposed be used to purchase snacks for other residents. Resident #1's RP said she observed the AD going back to her office to get Resident #1's spending account card and then gave it to her. Resident #1's RP said she was upset because the facility never called to get her permission to use Resident #1's spending account card much less to buy snacks for other residents. She said her mother suffered from senile and was not able to give consent. She said the Administrator called her days later to let her know he had completed his investigation and that the AD had been terminated. Resident #1's RP was told if she wanted to contact the local law enforcement, she could. Resident #1's RP said the Administrator had also told her she would be reimbursed the full amount that was used from Resident #1's spending account card but up until 04/30/25, she had not been reimbursed. In an interview on 04/30/25 at 4:47 p.m., the Administrator said the BOM had been approached by Resident #1's RP regarding Resident #1's spending account card. He said the RP found out the AD had used Resident #1's spending account card to purchase snacks for her and other residents without her permission. The Administrator said he immediately started an investigation and self-reported to State. He said he had spoken with the AD, and she had confirmed that she used Resident #1's spending account card to buy snacks for Resident #1 and other residents and that she had not called her RP to get permission to use the spending account card. He said he explained to the AD that she should not have purchased snacks/groceries for other residents. He said in reviewing Resident #1's receipts, he noticed the AD had purchased a 12-pack energy drinks. He said he asked the AD about the purchase and the AD said the 12-pack energy drinks were for her personal use and had accidently included in the items purchased with Resident #1's card. The Administrator said he immediately suspended her pending the investigation. The Administrator said during the investigation he discovered the AD had also used Resident #2's spending account card to purchase snacks for Resident #2 and other residents. He said the AD had failed to call Resident #1 and Resident #2's RP to get permission to use their spending account card. He said he had purchased two gift cards for the amount the AD had spent on Resident #1 and Resident #2's spending card to reimburse their RP's. The Administrator said he still had the gift cards because he wanted to wait until after the intake had been investigated by state. He said at the time of the incident, the facility did not have a policy on how to manage a resident's spending account cards. He said he had included Resident #2 in his investigation but had not self-reported the incident to state nor had informed her RP. The Administrator said the BOM had been responsible for giving the AD permission to use Resident #1 and Resident #2's spending account cards and had failed to call their RP's. He said after his investigation, the AD had been terminated, the BOM had received a written write-up, the allegation of misappropriation had been confirmed and the facility had created a policy related to the resident's spending account cards effective 10/29/24 (he said which was good for the remained of 2024 only). The Administrator said he had not contacted the local law enforcement because the facility's policy did not indicate to do so but had advised Resident #1's RP she could call herself. The Administrator said all staff had been in-serviced on the topic of abuse, neglect, neglect and exploitation on 10/18/24. In a telephone interview on 05/01/25 at 3:49 p.m., Resident #2's RP said she had received a telephone call from the Administrator on 05/01/25 to let her know the former AD had used Resident #2's spending account card without her permission and had purchased snacks for Resident #2 and other residents. The RP said the administrator told her he had already investigated the incident, and the AD had been terminated but had forgotten to call her to let her know when he concluded the investigation. She said the Administrator told her he would be reimbursed the entire amount the AD used from Resident #2's spending account card. The RP said she had wished she had been notified before the purchases since Resident #2 was not verbal and would not be able to say what she wanted. The RP said the Administrator gave her the option to contact law enforcement if she wanted to pursue charges. The RP said she was not going to press charges. In an interview on 05/04/25 at 7:50 p.m., the AD (former) said the BOM had informed her that Resident #1 and Resident #2 had been allowed spending cards from their insurance. She said the BOM had given her permission to use Resident #1 and Resident #2's spending account cards to buy snacks for them and other residents. She said she was never told she needed to get Resident #1 and Resident #2 RP's permission before using their spending account cards. The AD said she used Resident #1 and Resident #2's spending account card on several occasions to buy snacks for them and other residents but did not remember the amount used. She said all the food items bought were for Resident #1, Resident #2, and other residents except for one time she accidently included a 12-pack energy drink when buying groceries for Resident #1. The AD said she had immediately told the BOM about it and told her she wanted to reimburse Resident #1's spending account card but that the BOM told her she did not know how to reimburse monies back into the spending account cards and that she would get back to her. She said at the beginning of the year, the BOM kept Resident #1 and Resident #2's spending account cards in a safe in her office but sometime before the BOM went on vacation (not sure of the date) she told her to keep the spending account cards in her office in case she needed them while she was out. The AD said on 10/18/24, the Administrator approached her and asked her if she had used Resident #1 and Resident #2's spending card for other residents, if she had purchased a 12-pack energy drink, and if she had asked their RP's for permission to use their card. The AD said she told the Administrator the BOM had given her permission to use Resident #1 and Resident #2's spending account cards to buy snacks/groceries for them and other residents. The AD said she also told the Administrator that she had purchased a 12-pack energy drink for her personal use with Resident #1's spending account card by accident. The AD said she told the Administrator she had immediately notified the BOM of the purchase and her intention to reimburse Resident #1's spending account card but that the BOM told her she did not know how to reimburse monies back into the spending account cards. The AD said she was terminated because she had not requested permission from Resident #1 and Resident #2 RP's, because she had used Resident #1 and Resident #2's spending account card for other residents and because she had purchased a 12-pack energy drink with Resident #1's spending account card. Record review of the facility's Statement of Resident Rights policy implemented on February 2017 and revised in January 2023 reflected: Compliance Guidelines: The community should educate, encourage, and honor the rights of those we serve. Further, the community should assist a resident/patient to fully exercise their rights as applicable. Residents/Patients do not give up their rights when entering a [NAME] Community. Resident/Patient Rights include: 3.The right to be free from abuse and exploitation. Record review of the facility's policy on Abuse Guidance: Preventing, Identifying and Reporting policy implemented on February 2017 and revised in January 2024 reflected: Compliance Guidelines: Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It is the responsibility of our team members, community consultants, attending physicians, family members, visitors, etcetera. To promptly report any incident, I was suspected neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to community management. Seven Elements of ANE .Prevention-The Administrator/Abuse Coordinator has the overall responsibility for the coordination and implementation of the ANE prevention and reporting program.