Every finding on record at Treasure Hills Healthcare and Rehabilitation Cente

Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 6 resident rooms (Resident #2), reviewed for environment.The facility failed to ensure Resident #2's room was free of food crumbs on the bed linens and floor.This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.Findings included:Record review of Resident #2's admission record, dated 6/10/2026, reflected a [AGE] year-old female with an admission date of 10/13/25. Her diagnoses included cognitive communication deficit (trouble speaking, listening, or understanding others, caused by problems with thinking skills), dysphagia (difficulty swallowing), muscle weakness, need for assistance with personal care, and reduced mobility.Record review of Resident #2's quarterly MDS assessment, dated 6/1/26, reflected a BIMS score of 8 which indicated moderate cognitive impairment. Section GG, titled eating: was coded at 05 which indicated she required setup or clean-up assistance.Record review of Resident #2's quarterly care plan, dated 6/10/2026, reflected [Resident #2] has ADL Self Care Performance Deficit r/t dementia, limited mobility, intermittent confusion. Revision on 2/12/26. Interventions included: Eating: I require tray set-up to eat independently. Revision 2/12/26.During an observation on 6/09/2026 at 11:22 a.m., Resident #2 was lying in bed awake. 10-15 black ants were observed on top of the resident's blanket. The resident's blanket had food crumbs. Food crumbs were seen on the floor around and under Resident #2's bed. The CNAs immediately removed the bed linens and placed them in a plastic bag. No ants were seen on the resident's body during toileting and dressing. Resident #2 was transferred to the wheelchair, and no further ants were seen. The resident's wheelchair was clean, and the resident did not complain of itching or discomfort to her skin.During an interview on 6/09/2026 at 11:45 a.m., the RN said a negative outcome for a resident having a dirty and wet floor was that they could slip and fall, attract pests, and be bitten. She said housekeeping cleaned the rooms daily and as needed. The RN performed a skin assessment, and no indications of ant bites were seen.During an interview on 6/09/2026 at 12:00 p.m., the Housekeeping Supervisor said housekeeping cleaned the floors when the resident was up for her meals. She said if the resident is up and out of her room in the mornings, housekeeping would go into the room and clean. She said she was notified by the staff of the ants and performed spot checks for pests and notified maintenance if needed. She said maintenance keeps a log on pest management. The Housekeeping Supervisor said the residents' rooms were cleaned every day and as needed. She said having an unclean room can cause ants and a wet floor could cause a resident to slip and fall. The Housekeeping Supervisor said once meals were brought out to the resident's room, housekeeping could not clean due to the chemicals being used and would start to clean after the resident's meal trays were picked up.During an interview on 6/10/2026 at 5:25 p.m., the DON said in-services were started with the staff and were informed to keep residents' areas clean and to inform housekeeping of crumbs and food seen on the floors. She said increased monitoring of room cleanliness was done. She said an IDT meeting was held to discuss environment and pests and to ensure immediate notifications were made to supervisors if and whenever pests were seen. The DON said an uncleaned room could possibly attract insects and pests, causing residents to be bitten. She said a skin assessment was done on Resident #2 and there were no injuries.On 6/10/2026 at 5:45 p.m., the Administrator said that on 6/04/26, pest control was in the building and sprayed. She said the maintenance supervisor sprayed on 6/09/2026 and pest control returned on 6/09/26. She said she had created a timeline that started at 6 a.m. when the administrative assistant entered the resident's room and noted almost every half hour afterwards, different staff members entered Resident #2's room and did not see food crumbs around the resident's bed. She said, the housekeeper was let go on 6/9/26 because she had failed to clean under the resident's bed earlier that morning when she entered the room. The Administrator said an in-service was done on environment services and cleanliness. She said it was everyone's responsibility to keep the residents' rooms clean.Record review of the facility's Housekeeping policy, revised on 5/2025, reflected: Cleaning Routines A. Routine schedules must be established for the cleaning of: Floors, Fixtures, Furniture etc.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided with such care consistent with professional standards, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #1) of 3 residents reviewed for respiratory care.The facility failed to ensure Resident #1's oxygen was administered on 6/09/2026 as ordered by the physician.This deficient practice could place residents who receive respiratory care at an increased risk of developing complications and decreased quality of care.Findings included:Record review of Resident #1's admission record, dated 6/09/26, reflected an [AGE] year-old female with an admission date of 6/06/26. Her relevant diagnoses included acute respiratory failure with hypoxia (lungs suddenly stopped working properly to get oxygen into the blood, resulting in low oxygen levels throughout the body), asthma (long-term condition that caused the breathing tubes in the lungs to swell, tighten, and fill with thick mucus), and chronic obstructive pulmonary disease (an ongoing lung disease that makes it hard to breathe).Record review of Resident #1's Nursing Home PPS MDS assessment, dated 6/10/2026, reflected her BIMS score was left blank, which reflected her cognition was severely impaired.Record review of Resident #1's initial care plan, dated 6/06/26, reflected Resident #1 has Oxygen therapy r/t SOB Date initiated: 6/06/2026. Interventions included: Apply oxygen via NC at (2) LPM continuous to keep saturation at or above 90% every shift for SOB date initiated 6/09/2026.Record review of Resident #1's Medication Administration Record, dated 6/10/2026, indicated Apply oxygen via NC at (2) LPM continuous to keep saturation at or above 90% every shift for SOB order date: 6/06/2026.During an observation on 6/09/2026 at 11:18 a.m., Resident #1 was observed lying in bed awake. The oxygen concentrator was on, and the setting was at 2 liters per minute. Resident #1 did not have a nasal canula in place. The nasal canula tubing was at the head of the bed under the resident's head.During an interview and observation on 6/09/2026 at 12:04 p.m., the RN checked the resident's oxygen saturation, and it was at 93%. The nurse positioned the nasal canula in place and asked Resident #1 how she felt. Resident #1 responded, I feel fine. Resident #1 said she could not remember whether she had removed the nasal canula or it had fallen off. The RN said she had last checked the nasal canula placement at 10:24 a.m. She said negative outcomes to Resident #1 not receiving oxygen as ordered could be possibly go into distress or become confused. It can take longer for O2 sats to go up.During an interview on 6/10/2026 at 5:20 p.m., the DON said the facility does not have a respiratory therapist in-house. She said the nurses provided respiratory care services to the residents. The DON said the nurses receive annual training on respiratory care, upon hire, and as needed. She said Resident #1's oxygen saturations were checked daily and as needed and received nebulizer treatments as needed. She said respiratory assessments were done by the nurses daily. She said Resident #1 did not have a negative outcome from the nasal canula not being in place.Record review of the facility's Oxygen Administration policy, revised 5/2026, reflected: .12. Place the oxygen delivery device on the resident, adjusting it to achieve comfort: A. Nasal Canula 1) Place prongs in resident's nostrils. 2) Adjust head strap or chin for comfort, making sure cannula is secure.

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 5 residents (Resident #13) reviewed for assessments:Resident #13's quarterly MDS assessment, dated 9/29/2025, did not include a diagnosis of Displaced Unspecified Fracture of Right Great Toe. Initial Encounter for Closed Fracture.This failure could place residents at risk for inadequate care due to inadequate assessments.The findings included:Record review of Resident #13's electronic face sheet dated 12/10/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: End Stage Renal Disease (permanent kidney damage forcing waste and fluid to build up in the body which causes tiredness, nausea, and swelling requiring dialysis), Diabetes Mellitus Type II (a condition where the body either doesn't produce enough insulin or doesn't use insulin properly, leading to high blood sugar levels), Displaced unspecified fracture of right great toe, initial encounter for closed fracture, Age related osteoporosis without current pathological fracture ( silent disease where bone density declined, increasing future fracture risk.Record review of Resident# 13's physician order summary, dated 09/24/2025, reflected a diagnosis of Displaced Unspecified Fracture of Right Great Toe, Initial Encounter For Closed Fracture.Record review of Resident # 13's care plan, dated 9/24/25, reflected Focus: Resident #13 has right great toe proximal phalangeal Fracture r/t Osteoporosis, Mild osteoarthritis.Record review of Resident #13's Quarterly MDS dated [DATE] reflected: Section l - Active DiagnosesMusculoskeletal l4000. Other Fracture. The facility did not check off active diagnosis. l8000. Additional active diagnoses. The facility did not add Displaced Unspecified Fracture of Right Great Toe, Initial Encounter For Closed Fracture.In an interview on 12/10/2025 at 11:32 AM with the MDS Coordinator stated she was responsible for completing the MDS assessments for the facility which includes adding the diagnoses. She said the diagnosis of Displaced Fracture of Right Great Toe should have been included on the MDS assessment for Resident #13 and was not included as an oversight.In an interview on 12/10/2025 at 1:39 PM with the DON stated the MDS coordinator completed a course on MDS, and the facility provided routine in-house training. MDS nurse resources were available to the MDS coordinator and provide monthly training. The DON said they provided training on a quarterly basis by an outside resource training company. She said MDS is a compilation of all assessments done by all departments. The DON said not adding a diagnosis on the MDS would not directly impact the residents and billing could be affected due to the coding.Record review of the CMS's RAI Version 3.0 User's Manual dated October 2025, reflected section: l: Active Diagnoses l: Active Diagnosis in the last 7 Days- Check all that apply Musculoskeletal l4000, other fracture. Other- l8000, additional active diagnoses. There may be specific documentation in the medical record by a physician, nurse practitioner, physician assistant, or clinical nurse specialist of active diagnosis.

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity, and care for each resident in a manner, and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality for one (Resident #2) of three residents reviewed for facial hair.The facility failed to remove Resident #2's facial hair. This failure could affect the residents who require assistance with care from facility staff, by placing them at risk for social isolation, loss of dignity, and self-worth.Record review of Resident #2's Face Sheet, dated 12/08/2025, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including; need for assistance with personal care, muscle weakness, lack of coordination, and reduced mobility. Record review of Resident #2's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 09 which indicated moderately impaired cognition. The Quarterly MDS assessment also revealed Resident #2 required substantial/maximal assistance on personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands. Record review of Resident #2's Comprehensive Care plan dated 07/07/2025 revealed the resident required a Focus on ADL self-care performance deficit related to bilateral AKA. One of the interventions for this focus was Prefers to have facial hair shaved. Date Initiated: 08/06/2025 Record review of Resident #2 progress notes dated from 09/09/2025 through 12/10/2025 did not include documentation of Resident #2 refusing facial hair being shaved. During an observation and interview on 12/08/2025 at 10:33 am, revealed Resident #2 had long facial hair on her upper lip, chin area and both cheeks which extended from the front of her ears down to her chin. Resident #2 stated it had been about a month since she had been offered to be shaven. Resident #2 stated CNAs offered to shave her about every 2 weeks but this time it was about a month ago. Resident #2 stated that when she was younger, she shaved her face for swimming and felt that it caused her facial to now grow fast. Resident #2 stated she felt she did not want to bother the CNAs in not wanting to ask to be shaved. Resident #2 stated, I'm fine. During an interview on 12/10/2025 at 9:28 am, CNA S revealed CNAs have the task to shave residents, in which she stated shaving falls under personal hygiene task. CNA S stated she was aware Resident #2 had long facial hair. CNA S stated Resident #2 had not been shaven in a while. CNA S stated she had not asked Resident #2 if she wanted to be shaven. CNA S stated that when a resident refused a task such as a shower, or in this case shaving, she would report it to the nurse. CNA S stated she had reported to the nurses several times when Resident #2 had refused showers, but since she had never asked Resident #2 about shaving, she never reported it to the nurse. During an interview on 12/10/2025 at 9:42 am, CNA N revealed she was aware resident had long facial hair. CNA N stated, Yes, I saw she had a beard. CNA N stated she was a shower aide; she was one of two aides that showered residents. CNA N stated that it was mandatory for men to be shaved with every shower while women were not. CNA N stated Resident #2 had never asked her to be shaven nor had she offered Resident #2 to be shaved. CNA N stated CNA M was usually the one that would shave Resident #2. CNA N stated that if a resident is showered, they had to be shaven too. CNA N stated she did not know why she had never offered Resident #2 to be shaven. During an interview on 12/10/2025 at 9:52 am, CNA M revealed she had seen Resident #2 had long facial hair. CNA M stated she was usually the CNA that had shaven Resident #2 previously. CNA M stated the last time she shaved Resident #2's face was about two weeks ago. CNA M stated she had hoped other CNAs would have taken the initiative to shave Resident #2, but they had not. During an interview on 12/10/2025 at 9:59 am, LVN T revealed she recalled only one time that a CNA had come to her to report that Resident #2 had refused to shower along with shaving. LVN T stated that at time, she educated Resident #2 on the importance of good hygiene. During an interview on 12/10/2025 at 1:49 pm, the DON revealed Resident #2 did not like to shave. The DON stated that she had often asked Resident #2 if she wanted to shave and Resident #2 had refused every time. The DON stated she did not document Resident #2's refusal of care. The DON stated that CNAs were supposed to offer Resident #2 to shave when they offered her to shower. The DON stated there was nothing on the ADL tracking sheet to inform the CNAs to shave the residents. The DON stated the CNAs were just supposed to know to provide care, including shaving female facial hair. The DON stated that when a resident refused care, the CNAs were to notify the nurse. The DON stated that if a resident had not been shaven, it would affect his or her demeanor or how the person feels. Record review of the facility's undated policy on Resident Rights reflected the following: Dignity and Respect: The Resident has the right to be treated with dignity, courtesy, consideration and respect.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for 1 (Resident #100) of 3 residents reviewed for isolation precautions. Resident #100's RP did not don PPE on 12/8/2025 before entering Resident #100's room. Resident #100 was under contact isolations per physician orders. This failure could place residents who resided in the facility, as well as employees and visitors, at risk of communicable diseases.The findings included: Record review of Resident #100's face sheet dated 12/8/25 revealed a [AGE] year old male admitted to the facility on [DATE], with the diagnosis of UTI/MRSA (a dangerous type of staph bacteria resistant to common antibiotics, making UTIs harder to treat, especially in hospitalized patients or those with catheters. MRSA enters the urinary tract, causing symptoms like pain or urgency, but its resistance means standard treatments fail, requiring specific antibiotics and increasing risks for severe complications like sepsis). Review of Resident #100 Physician Orders dated 12/9/2025 revealed Contact Isolation Dx: MRSA bacteremia (bacteria that make them resistant to several common antibiotics, making infections harder to treat.) Review of Resident #100's care plan dated 12/4/2025 revealed the resident has infection of the urinary tract related to MRSA. Interventions: Contact isolation precautions for a DX of MRSA bacteremia. Observation on 12/8/25 12:00 p.m. revealed outside Resident #100's room was an isolation sign, but was not visible. There was personal protective equipment on the door that had masks, gloves and gowns available. Resident #100's RP was inside Resident #100 (contact isolation precautions) room up to the foot of the bed without any personal protective equipment. In an interview on 12/8/2025 at 12:00 p.m., Resident #100's RP stated that he was not notified that he needed to use the protective equipment. Resident #100's RP said that he knew that Resident #100 was on antibiotics. In an interview on 12/8/2025 at 12:05 p.m., RN A stated the isolation cart should contain gown, gloves, and mask outside of room and available to staff and family that enter the rooms when a resident was diagnosed with contact isolation precautions for MRSA to the urine. RN A stated that family was aware of the contact isolation. RN A stated that all staff and visitors should have worn personal protective precautions before entering rooms to prevent the spread of infection to other residents. In an interview on 12/10/25 at 1:40 PM, DON stated contact Isolation precautions should be followed by all staff because of the potential for spreading infections to other residents. DON stated that in-services (training) on infection control were the key to prevent this to happen again. Review of facility's policy titled Infection Prevention and Control Program with a revision date 12/2023 revealed; the infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of quality assurance and performance improvement program.Review of CDC guidelines revealed: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal protective equipment upon room entry and properly discarding before exiting the patient room is done to contain pathogens.

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 4 residents (Resident #51) reviewed for accuracy of records. The facility failed to ensure LVN D documented Resident #51's change of condition on 12/01/25.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 #51's admission record dated 12/09/25 reflected a [AGE] year-old-female with an admit date of 08/23/23 and an initial admission date of 03/18/23. Her relevant diagnoses included congestive heart failure, lack of coordination, legal blindness, end stage renal disease, and chronic obstructive pulmonary disease.Record review of Resident #51's quarterly MDS assessment dated [DATE] reflected a BIMS score of 14, which indicated her cognition was intact.Record review of Resident #51's quarterly care plan dated 10/08/25 reflected a focus of [Resident #51] is on pain medication therapy r/t left knee subacute patellar fracture (date initiated 12/09/25). Interventions in part included administer medication as ordered (date initiated 12/09/25.Record review of Resident #51's progress note dated 12/06/25 at 3:56 am, authored by LVN D reflected Tylenol Oral Tablet 325 MG. Give 2 tablet by mouth every 6 hours as needed for pain (650 mg) not to exceed 3gm in 24hrsRecord review of Resident #51's progress note dated 12/06/25 at 4:56 am, authored by LVN D reflected Tylenol Oral Tablet 325 MG. Give 2 tablet by mouth every 6 hours as needed for pain (650 mg) not to exceed 3gm in 24hrs. PRN Administration was: Effective Follow-up Pain Scale was: 0Record review of Resident #51's progress note dated 12/07/25 at 9:01 am, authored by LVN E reflected Tylenol Oral Tablet 325 MG. Give 2 tablet by mouth every 6 hours as needed for pain (650 mg) not to exceed 3gm in 24hrs left knee pain.Record review of Resident #51's progress note dated 12/07/25 at 12:20 pm, authored by LVN E reflected Tylenol Oral Tablet 325 MG. Give 2 tablet by mouth every 6 hours as needed for pain (650 mg) not to exceed 3gm in 24hrs. PRN Administration was: Effective Follow-up Pain Scale was: 0. Record review of Resident #51's progress note dated 12/08/25 at 6:45 am, authored by LVN E reflected Tylenol Oral Tablet 325 MG. Give 2 tablet by mouth every 6 hours as needed for pain (650 mg) not to exceed 3gm in 24hrs left knee pain. Record review of Resident #51's progress note dated 12/08/25 at 9:00 am, authored by LVN E reflected Placed call to Dr. resident complained of pain to left knee when bending knee no discoloration noted. New order for Xray of left knee and Tylenol administered. Called Rp and notified Rp. Record review of Resident 51's x-ray of her left knee taken on 12/08/25 reflected that she had mild knee osteoarthritis was present. There was a subacute patellar fracture. In an interview on 12/08/25 at 9:30 am, Resident #51 said her left knee started hurting couple of days ago. She said she had informed her nurse and had been administered pain medication which alleviated the pain. She said she thought the pain to her left knee was because of the cold weather since she did not remember hurting it.In a telephone interview on 12/10/25 at 3:56 pm, LVN D said Resident #51 had called her into her room on 12/06/25 at 3:56 am and told her she had pain in her left knee. She said she had conducted a lifted Resident #51's nightgown to assess her left knee. She said Resident #51 did not have any swelling or discoloration to her left knee. She said Resident #51 had told her left knee pain was probably due to the change in weather. She said she had administered pain medication which Resident #51 had told her it alleviated from 4 out of 10 to a zero. LVN D said 12/06/25 was the first night Resident #51 had complained of left knee pain. LVN D said she had not created a progress note in Resident #51's electronic medical record related to her complaint of left knee pain on 12/06/25 and said she did not remember if she notified the incoming nurse (LVN E). LVN D was not able to say if Resident #51 had any negative outcomes for her not documenting and informing the incoming nurse of her left knee pain.In an interview on 12/10/25 at 9:18 am, LVN E said Resident #51 had first complained of left knee pain on 12/07/25 at 9:01 am. She said Resident #51's pain level was 4 out of 10 and administered pain medication. LVN E said she had conducted a pain follow-up assessment and her pain was zero. LVN E said the following day 12/08/25, Resident #51 had again complained of left knee pain and that time her pain level was 6 out of 10. She said she administered pain medication which had reduced her pain to a zero. She said she called Resident #51's MD since it was the second consecutive day Resident #51 had complained of left knee pain. She said Resident #51's MD ordered an x-ray of her left knee. LVN E said she had not received report from the outgoing nurse of any changes to Resident #51 on 12/06/25, 12/07/25, or 12/08/25. In a telephone interview on 12/10/25 at 1:50 pm, MD said he was notified by the facility that Resident #51 had pain in her left knee. He said he ordered an x-ray of her left knee and was later notified by the facility she had a subacute fracture patellar fracture (kneecap). He said a subacute fracture referred to a fracture that was already in the healing process. He said the only treatment for a subacute fracture was to keep it immobilized and to apply ice for pain. The MD said he suspected Resident #51's subacute fracture to be between 2 weeks to 3 months old. The MD said he came to see Resident #51 on the evening of 12/08/25. An interview on 12/10/25 at 1:40 PM, the DON said Resident #51 first complained of left knee pain on 12/06/25 at 3:56 am to LVN D. She said LVN D had assessed her and had given her pain medication but had failed to document in Resident #51's electronic medical record the specifics of her pain. The DON said Resident #51 had complained of left knee pain again on 12/07/25 at 9:01 am and was given pain medication by LVN E. She said on 12/08/25, Resident #51 complained of left knee pain to LVN E at 6:45 am and was given pain medication and her MD was notified, and a change of condition was done. The DON said Resident #51's left knee pain had been alleviated by the administration of pain medication on 12/06/25, 12/07/25, and 12/08/25. She said Resident #51's MD ordered an x-ray of her left knee. The DON said there was a lack of communication between LVN D to LVN E to identify Resident #51's change of condition. She said outgoing nurses must give report to the incoming nurse of any changes, special instructions to residents. She said the negative outcome to Resident #51 was that now she has a fracture that could have been identified sooner. The DON said she was going to check if the facility had a policy for documentation but did not provide one.

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 1 of 4 (Resident #47) residents reviewed for respiratory care. The facility failed to ensure Resident #47's oxygen was administered at the correct setting of 3 liters per minute on 12/8/2025 as ordered by the physician. This deficient practice could place residents at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: Record review of Resident #47's admission record dated 12/8/2025 reflected a [AGE] year-old male with an admission date of 09/23/2025. Pertinent diagnoses included Shortness of Breath, Chronic Obstructive Pulmonary Disease (a progressive lung condition causing airflow blockage, making breathing difficult, and includes emphysema and chronic bronchitis), and Dependence on supplemental oxygen (a medical necessity for individuals whose bodies cannot get enough oxygen from the air to keep the organs functioning properly). Record review of Resident #47's admission MDS assessment, dated 09/29/2025 reflected Oxygen Therapy while a resident. Record review of Resident #47's person-centered care plan, initiated date 9/23/2025 reflected Resident #47 used oxygen therapy related to SOB, COPD, CHF. Intervention included oxygen settings: O2 via nasal cannula at 3 liters per minute continuous humidified. Record review of Resident #47's physician order dated 12/8/2025, reflected O2 at 3 LPM via NC every shift with a start date 10/2025. During an observation of Resident #47 on 12/8/2025 at 8:59 a.m. revealed the oxygen level on the oxygen concentration machine was at 2.5Liters Per Minute via nasal cannula. Observation of Resident #47 revealed the resident was in bed with head of the bed slightly elevated. No signs of respiratory distress noted. In an interview on 12/8/2025 at 9:05 a.m. RN A stated she was the nurse for Resident #47. RN A stated the O2 setting was set at 2.5 Liters Per Minute. She stated the oxygen setting was supposed to be at 3 Liters Per Minute per physician orders. She stated that she checked the settings at the beginning of her shift. She was not sure who might have moved it. RN A stated that she checked Resident #47's oxygen tubing and saturation in the mornings. She stated that she usually checked the oxygen every 2 hours on her shift. RN A stated that the negative outcome of keeping Resident# 47's oxygen setting at 2.5 Liters Per Minute was that the resident could go to respiratory distress, shortness of breath or hypoxia (low oxygen levels). In an interview on 12/10/2025 at 1:40 p.m. with the DON, stated that the nurses assigned to that hall were responsible for checking the Oxygen settings. She stated that the nurses were to check the setting twice per shift and as needed. The DON stated they were to follow oxygen settings on physician orders. The DON stated that the negative outcome could be that the resident could have difficulty breathing and hypoxia (low oxygen levels). Record review of the facility policy named Oxygen Administration not dated, revealed: It is the policy of this facility that oxygen therapy is administered, as ordered by the physician .

Based on observations, 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 2 of 4 residents (Resident #1, Resident #91) reviewed for comprehensive person-centered care plans. 1.The facility failed to ensure Resident #1's care plan included his code status. 2.The facility failed to ensure Resident #91's care plan had the correct interventions for her DNR code status. 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 included:1.Record review of Resident #1's admission record dated [DATE] reflected a [AGE] year-old male with an admit date of [DATE]. His relevant diagnoses included pneumonia (lung infection that inflames the air sacs, causing them to fill with fluid or pus), and acute respiratory failure with hypoxia (a life-threatening condition where the lungs can't get enough oxygen into the blood (severe low oxygen) due to sudden lung injury from things like pneumonia). His advanced directive was DNR/ Do Not attempt Resuscitation (the emergency process of reviving someone whose breathing or heartbeat has stopped).Record review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score of 5, which indicated his cognition was severely impaired.Record review of Resident #1's order summary dated [DATE] reflected a DNR/Do Not Attempt Resuscitation order effective [DATE].Record review of Resident #1's care plan assessment dated [DATE] did not include his code status.In an interview and observation on [DATE] at 1:55 pm, MDS C said Resident #1 had been admitted as a short-term resident. She said His code status was DNR. She was observed as she reviewed Resident #1's electronic medical record and said his dashboard indicated he was a DNR, he had an order for a DNR status, and his DNR form had been uploaded to his electronic medical record. MDS C said she did not find a code status on his care plan. MDS C said if Resident #1 were to code, the nursing staff would check his dashboard, order and DNR form on his electronic medical record. She said the nursing staff would not check his care plan. MDS C said there were no negative outcomes to Resident #1 not having his code status included on his care plan. MDS C said it was the responsibility of the facility's SW to ensure a resident's code status appeared correctly on their care plan.2.Record review of Resident #91's admission record dated [DATE] reflected a [AGE] year-old female with an admit date of [DATE] and an initial admission date of [DATE]. Her relevant diagnoses included chronic obstructive pulmonary disease (a progressive lung condition making it hard to breath), cognitive communication deficit (difficulty in expressing or understanding messages due to impaired thinking skills like attention, memory problem-solving, or organization), and vascular dementia (a decline in thinking skills due to reduced blood flow to the brain, often from strokes). Her advanced directive was DNR/Do not attempt resuscitation ((the emergency process of reviving someone whose breathing or heartbeat has stopped).Record review of Resident #91's quarterly MDS assessment dated [DATE] reflected a BIMS score of 3, which indicated her cognition was severely impaired. Record review of Resident 91's order summary dated [DATE] reflected a DNR/Do Not Attempt Resuscitation order effective [DATE].Record review of Resident #91's quarterly care plan dated [DATE] reflected a Focus: [Resident #2] has elected DNR status. Interventions in part included, Do not sent to hospital (date initiated [DATE]), Initiate full code measures in case of cardiac arrest, include CPR and AED use (date initiated [DATE]) .In an interview and observation on [DATE] at 2:00 pm, MDS B said Resident #91 was a long-term resident. She reviewed her electronic medical record and said Resident #91 had a code status of DNR. She said prior to [DATE], Resident #91 had a full code status. She said her intervention of initiate full code measures in case of cardiac arrest, include CPR and AED us was incorrect. She said that intervention was for residents who were full code. MDS B said it was the responsibility of the facility's SW to ensure a resident's code status appeared correctly on their care plan. MDS B said there was no negative outcomes to Resident #91 not having the correct intervention for her focus of DNR because her dashboard indicated she was a DNR, there was an order for DNR, and the DNR form had been uploaded in her electronic medical record.In an interview on [DATE] at 2:20 pm, the SW said it was her responsibility to ensure a resident's code status was care planned. She said whenever a resident was admitted or modified his code status, she would immediately include it in their care plan. She said she was part of the IDT meetings and quarterly, she would discuss the resident's code status with them or their RP to ensure that was the code status they wanted. She said I think I just skipped over it referring to Resident #1 and #91's care plan. She said Resident #91 had been a full code at one up until [DATE] and she must have not removed the intervention that read to initiate full code measures in case of cardiac arrest, to include CPR and AED use. She was not able to say if there were any negative outcomes to Residents #1 or #91 for not having their correct code status on their care plan. In an interview on [DATE] at 1:40 pm, the DON said in case a resident coded, the nursing staff would go directly to their order and reviewed their DNR form. The DON said she had been advised by the facility's SW that Resident #1 did not have his code status included on his care plan and that Resident #91 had an incorrect intervention. The DON said there were no negative outcomes to Resident #1 or Resident #91 for not having their care plan reflect their code status/interventions. Record review of the facility's Advance Directive Documentation policy revised on 12/2019 reflected: Procedures: 1. The admission Coordinator or Social Service Director, shall:General: C. Document in the resident's health record. Record review of the facility's Comprehensive Person-Centered Care Planning policy dated 11/2016 and revised on 01/2022 reflected:Policy: It is a policy of this facility that the interdisciplinary team shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives time frames to meet a resident medical, nursing, mental and psychosocial needs, that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum health care information as necessary to properly care for each resident and instructions needed to provide expressive and person-centered care that meets professional standards of quality care.Procedures: The residence comprehensive plan of care will be reviewed and or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments.

Based on interviews and record reviews the facility failed to ensure all alleged violations including abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, 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, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 2 of 4 residents (Resident #2, #3) reviewed for reporting alleged allegation of abuse. 1.The facility failed to report, within 2 hours, when Resident #2 and Resident #3 had a resident-to-resident altercation on 02/24/25. 2. The facility failed to report, within 24 hours, when there was a flash fire in the kitchen on 04/08/25. These failures could place residents at risk for undetected abuse, neglect and/or decline in feelings of safety and well-being.The findings included: 1. Record review of Resident # 2's admission sheet, dated 08/18/25, revealed the resident was a [AGE] year-old female with an admission date of 01/24/25 with diagnoses that included: unspecified dementia ( a group of thinking an social symptoms that interferes with daily functioning), muscle weakness, anxiety disorder (feeling worry or fear that are strong enough to interfere with one's daily activities), and cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, understanding jokes or metaphors, or following directions). Record review of Resident #2's quarterly MDS assessment, dated 08/02/25, revealed Resident #2 had a BIMS score of 07, indicating her cognition was severely impaired. Record review of Resident 2's quarterly care plan, dated of 08/12/25 reflected [Resident #1] has potential for a psychosocial well-being problem r/t another resident making contact to her throat and chest area (date initiated/revised 02/25/25). Her interventions in part included when conflict arises, remove residents to a calm safe environment and allow to vent/share feelings, needs assistance/supervision/support with identification of potential solutions to present problems. Record review of Resident #2's x-ray results dated 02/25/25 reflected: Chest x-ray 1 view, Impression: no acute cardiopulmonary process (no acute problems with heart or lungs). Spine cervical x-ray 2-3 views, impression: no acute osseous process (no bone abnormalities). Record review of Resident #2's Risk Management report with an effective date and time of 02/24/25 at 7:45 p.m., reflected This shift other resident made hand contact to resident's throat and upper chest area. [RP] was present at the time of this occurring. At this time pain medication offered and taken. Assessment done to site. No redness, no discolorations noted. Area flat. Call placed to [Dr] but no call back. At this time [Medical Director] was informed. Gave order for x-rays. [RP] was made aware of order pending to be done. Level of pain: 5, immediate action taken check x-ray and skin assessment, injuries reported post incident: no injuries observed post incident. In an attempted interview with Resident #2 on 08/19/25 at 3:00 p.m., Resident #2 was not interviewable. In an attempted telephone interview on 08/19/25 at 3:15 p.m., Resident #2's RP did not answer, voice message left. Record review of Resident #3's admission record dated 08/21/25 reflected an admit date of 04/28/2, an original admission date of 11/06/20, and a discharge date of 05/14/25. His relevant diagnosis included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), dementia (a group of thinking and social symptoms that interferes with daily functioning), and cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, understanding jokes or metaphors, or following directions). Record review on Resident #3's significant change MDS dated , 05/15/25, reflected a BIMS score of 99, which indicated his cognition was severely altered. Record review on Resident #3's quarterly care plan dated, 04/15/25 reflected:Focus: [Resident #3] has the potential to demonstrate physical behaviors r/t made contact to throat and chest on another resident (date initiated (02/25/25). Interventions: in part included to analyzed key times, places, circumstances, triggers and de-escalate behavior and document and document and observe behavior and attempted interventions (date initiated: 03/04/25). Record review of Resident #3's Risk Management report with an effective date and time of 02/24/25 at 8:49 p.m. and authored by the DON reflected This shift resident made hand contact ot other resident throat and upper chest area. [Resident #3] noted to be getting up from wheelchair and has been walking around facility aimlessly, immediate action take: assessment, call placed to [NP] to inform of resident's status. At this time gave order for Benadryl 50 mg im x 1 dose. Call placed to [RP] to inform of his status and order.Room change, new lab orders (CBC, ammonia, vitamin D, CMP, and UA), injuries report post incident: no injuries observed post incident, Predisposing psychological factors: confused, incontinent, recent change of condition, and impaired memory. Record review of the facility's incident report dated 08/18/25 reflected:Resident-to-Resident incidents: Resident #2 and Resident #3 on 02/24/25 at 7:45 p.m. Record Review of TULIP (HHSC online incident reporting application) on 08/18/25 at 4:00 p.m. revealed a self-report by the facility's Administrator was received on 02/25/25 at 8:15 p.m. more than 24 hours after Resident #2 and Resident #3's an altercation on 02/24/25 at 7:45 p.m. The allegation was abuse. In an interview on 08/20/25 at 2:00 p.m., the DON said either the facility's Administrator or herself were responsible to ensure all allegations of abuse were reported timely. She said this incident, the Administrator was the one who reported it to the state agency. She said the incident occurred on 02/24/25 at 7:45 p.m., and it was reported to the state agency on 02/25/25 at 8:15 p.m. She said prior to May 2025, she and the Administrator thought, they had either 2 or 24 hours from when the Administrator or herself were notified of the incident. She said sometime in May 2025, they were cited for not reporting ANE allegations within the allotted timeframes. She said the surveyor who cited them educated them on the timeframes. She said Resident #2 had not sustained any injuries and Resident #3 was moved to another hall. In an interview on 08/20/25 at 2:30 p.m., the Administrator said it was her responsibility to ensure all ANE allegations were reported within the allotted timeframes to the state agency. the Administrator said the resident-to-resident altercation between Resident #2 and Resident #3 on 02/24/25 had been reported within 24 hours. 2. Record Review of TULIP (HHSC online incident reporting application) on 04/05/25 reflected an anonymous complaint with the allegation of physical environment and administration/personnel. The complainant alleged that during the week 04/07/25, a small explosion that occurred with a faulty stove in the facility's kitchen. There were no injuries to the residents or the staff. The local fire department was called. It was alleged the facility's Administrator failed to address the kitchen's faulty stove prior to the small explosion. In an interview on 08/18/25 at 9:30 a.m., the DM said she started working at the facility in June 2025. She said she heard that sometime in April 2025, there had been an implosion related to a hot plate left in the oven which pop and caused a loud boom effect. She said she was told after that incident; the stove was not operable. She said by the time, she was hired, there was a new stove in the kitchen. She said she was also told by her kitchen staff that the local fire department had been called and the residents in the dining room had been evacuated. She said that was all she was told about the implosion. She explained the hot plates were stainless steel plates that were heated in an oven or plate warmer and placed in an insulated dome as an underliner. The serving place was placed on top of the stainless-steel plate and covered with an insulated dome cover. The DM one of the major changes she implemented when she was hired the to no longer use hot plates to keep the resident's meals warm. In an interview on 08/18/25 at 10: 30 a.m., Maintenance Supervisor C said he had been working at the facility for one month. He said he did not know the details of what the incident with the stove was about, all he knew was that the kitchen got a new stove. In an interview on 08/18/25 at 10:15 a.m., the Dish Washer G said he had been working at the facility for the past 6 months. He said he knew the old stove had been replaced but was not sure why. He said was not working at the time of the incident. In a telephone interview on 08/18/25 at 11:00 a.m. to Maintenance Supervisor D but the phone number provided by the facility had been disconnected. In an attempted telephone interview on 08/18/25 at 11:05 a.m. and 2:15 p.m., to [NAME] I, there was no answer. In an interview on 08/18/25 at 2:41 p.m., [NAME] F. She said was one of 2 cooks in the facility and she worked the morning shift. She said the stove had been having issues with the oven and stove top. She said she had reported it to Maintenance Supervisor D on several occasions. She said prior the 04/08/25 incident, the Administrator had already purchased a new stove, but it had not arrived yet. She said the stove had two ovens, one of them would heat too much and other would not heat. She said it had to do something with the calibration. She said the silver plates were placed in the oven that would heat too much to expedite the serving process. She said whoever placed the silver plates on that side of the oven had to be vigilant because they would heat up too much. She said there were times where she would hear the silver plates cracking and that's when she knew they had been left in the oven too long. She said the afternoon cook was the one working when the incident occurred. She said when she came back the next day, she was told by the Maintenance Supervisor D to not use the stove and later that day it was taken outside. In an interview on 08/18/26 at 2:23 p.m., Dietary Aide E said only the kitchen cooks were allowed to use the stove. She said she knew there had been times in which the oven would work and then all of a sudden it didn't but did not know the specifics. She said on 04/08/25, she was scheduled with [NAME] I. She said between 6:00 and 6:30 pm (after dinner) as she was exiting the kitchen she heard a loud boom, she said at the same time she saw what she said looked like a lightening. She said she got very scared and quickly made her way to the dining room where she heard a CNA (not name given) yell fire. She said her first instinct was to transfer the few residents who were in the dining room to another hall. She said she called out for help and several staff members responded and quickly started transferring the residents away from the dining room. She said she first transferred a resident who was in a wheelchair and then a resident who was visually impaired. She said all residents were transferred to another hall. She said she was afraid for the residents. She said once she realized it was safe to reenter the kitchen, [NAME] I opened the oven door and saw a silver plate in the oven. She said the silver plate was enlarged. She said there was no smoke, no damage. She said immediately after that the stove was not used. She said what she remembered was that the residents were served sandwiches and nothing hot. She said she had been in-serviced on the topics of fire safety, food safety and temperature settings. In an interview on 08/18/25 at 4:20 p.m., The Administrator said that on 04/08/25 after dinner, she received a call from [NAME] I who told her that there had been a fire in the kitchen. She said she immediately asked him if the fire department had been called and he told her no. She said [NAME] I told her that it just went boom and saw a flame coming out of the oven and immediately went back in. The Administrator said [NAME] I told her the fire extinguisher was not used because the fire had immediately disappeared. She said [NAME] I told her after the boom sound and the flash, he went back into the kitchen to check for any damages and there were none. The Administrator said [NAME] I told her there was no smoke, no damage to the stove/oven, no injuries, and the flash fire had not registered with the monitoring company. The Administrator said she was told by [NAME] I the incident happened between 6:30 p.m. and 6:35 p.m. She said [NAME] I told her he had immediately shut off the gas to the kitchen. She said by the time she returned to the facility the Maintenance Supervisor H had shut off the gas to the entire building. The Administrator said she instructed Maintenance Supervisor D to call the local fire department before turning on the gas to the building. She said the fire department was called as a precaution only, she wanted to make sure there was no gas leaks. She said the fire department was called around 8:00 p.m. and after they inspected the entire building, it was deemed safe to turn on the gas back on. The Administrator said what she was told by [NAME] I was that he had accidently left a silver plate in the oven when he was cooking dinner. The Administrator said she was told (not sure by who) there were only two residents who were ambulatory in the dining room during the flash fire. She said she had not reported the incident to the state agency because it did not pose any threat to resident safety and according to the provider letter it said to not report to state emergency situations that do not pose a threat to resident health and safety secondary to proper management. She said since the cooks were having a hard time with the burners, she had already ordered a new stove prior to the incident. The Administrator provided a copy of the FD's report but stated the first sentence was not correct ( Ladder 4 responded to a report of a gas leak inside a structure), and the alarm/arrival/departure time was not correct. She said she had spoken to the FD Captain and was waiting for him to call her back to dispute the first sentence and time listed on the report. Record review on 08/19/25 at 10:00 a.m., of the local fire department incident report dated 04/08/25 reflected they had been received the call at 10:08 p.m., arrived at the facility at 10:15 p.m., and left the facility at 10:47 p.m. Under remarks it stated Ladder 4 responded to a report of a gas leak inside a structure at [facility]. We arrived at the location where we were greeted by the [Maintenance Supervisor D] with maintenance department. [Maintenance Supervisor D] stated to us that around 8:00 p.m. they had a fire in te kitchen that was not reported to us. He explained that when the worker was opening the over door, to the stove/oven, a flash fire occurs. [ Maintenance Supervisor D] secured the gas to the appliance at the stove and on the las line for the appliance. He stated that administration wanted us to check the hallway for any smell of gas in the building. We checked the hallway to the kitchen, kitchen, and dining areas. Nothing was picked up by the gas monitor.The employee was not injury and didn't seek medical attention as per [the Maintenance Supervisor D]. Record review of the facility's Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment policy with an original date of 11/2017 and a revision date of 12/2023 reflected: Policy: It is the policy of this facility that each president has a right to be free from abuse calmly liberal, misappropriation of resident property, exploitation, and mistreatment. This includes but is not limited to freedom from, involuntary seclusion in any physical or chemical restraint not required to treat the residents and medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to facilities staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. If there is an allegation or suspicion reviews, the facility will make a report to the appropriate agencies as designated by state and federal laws. Procedure:In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will:Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but: Note later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury. No later than twenty-four (24) hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (Cart 1) of 5 medication carts. The facility failed to ensure that the nurses medication cart for 100 hall was secured by a lock when it was left unattended by RN A. These failures could place residents at risk of injury if medication left unsecured were consumed. Findings included: During an observation on 08/20/2025 from 02:40 PM revealed the A Wing Hall nurse's medication cart was left unlocked and unattended against the nurse's station. During the observation RN A approached the nurses' medication cart and notice that was unlocked and the RN A secured the cart by locking it. During an interview on 08/20/2025 at 02:42 PM with RN A revealed she was responsible for the nurse's medication cart that was left unlocked. She stated he was expected to lock the nurse's medication cart when she walked away from it. She stated if it was left unlocked then a resident could open a drawer and take anything that was not for them. She stated he had left the cart unlocked because she just went to another cart to use the computer. During an interview on 08/20/2025 at 04:18 PM with the DON revealed numerous staff, including her and the ADON, were responsible for ensuring medications carts were locked. The DON stated her expectation of staff when they walk away from the medication cart was to lock it. DON stated that the negative outcome for leaving the cart unlocked was that a resident or visitor could grab the medication from the cart, and it could harm them. She stated she had provided in-services to the staff, and she visually monitored daily. Record review of undated facility policy Medication Access and Storage: revealed It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications

Based on observation, interview and record review, the facility failed to incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report for 1 of 12 residents (Resident #1) reviewed for PASRR. The facility failed to initiate an NFSS within 20 business days following the date the services were agreed upon in the IDT meeting for Resident #1. This failure could affect residents by placing them at risk of their specialized needs not being met. Findings included: Record review of Resident #1's admission record dated 08/18/25 reflected an [AGE] year-old female admitted on [DATE]. Her relevant diagnoses included, lack of coordination, unsteadiness on feet, age-related osteoporosis (increased fracture risk due to declining bone mass and strength), and seizures (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain). Record review of the resident's quarterly MDS assessment dated [DATE] reflected, a BIMS score of 99, which reflected her cognition was severely impaired. Further review indicated she required a wheelchair (manual or electric) for mobility. Record review of Resident #1's quarterly care plan dated 08/12/25 reflected: Focus: [Resident #1] is receiving PASRR services for IDD PASRR positive diagnosis (date initiated 07/11/25). Interventions: in part included occupational, speech, and physical therapy with long- and short-term goals. During an observation on 08/19/25 at 9:00 a.m., Resident #1 was observed sitting on her specialized wheelchair in the dining room. She was not interviewable. Record review on 08/20/25 of Resident #1's LIDDA's Individual Profile-Nursing Facility dated 01/09/25 reflected:Adaptive Aids and Medical Supplies: Due to recent falls, team agreed to specialized mattress, bolsters and concave mattress to support her from falling off the bed. An interview and observation on 08/19/25 at 9:20 a.m., MDS/RN B said she was responsible for submitting PASRR specialized services through the Simple Online Portal, but that she was not working at the facility when Resident #1 had her initial Interdisciplinary Team meeting on 01/09/25. She said the facility had 20 days to submit a completed request for nursing facility specialized services on the Simple Online Portal after the Interdisciplinary Team meeting. She was observed as she reviewed Resident #1's electronic medical record and said Resident #1's initial interdisciplinary team meeting was held on 01/09/25 and what was recommended was independent living skills training, physical therapy, occupational therapy, speech therapy, and a specialized wheelchair. She said she did not find a request for any durable medical equipment (support surface mattress). An interview on 08/19/25 at 9:45 a.m., DOR said she had been present during Resident #1's initial Interdisciplinary Team meeting held on 01/09/25. She said she remembered discussing Resident #1 required a specialized wheelchair and the possibility of a concave mattress. She said she remembered she received a call from the Administrator asking her if a specialized mattress had been ordered during the Interdisciplinary Team meeting, because she had received an email from the PASSR state office coordinator inquiring on it. She said she had told the Administrator that Resident #1 had been assessed by an Occupational Therapist and it was determined that she did not require a specialized mattress only bolsters (because she was a fall risk). Record review on 08/20/25 of Resident #1's LIDDA's Individual Profile-Nursing Facility dated 01/09/25 reflected:Adaptive Aids and Medical Supplies: Due to recent falls, team agreed to specialized mattress, bolsters and concave mattress to support her from falling off the bed. Record review on 08/20/25 of Resident #1's progress note dated 01/09/25, authored by the DOR reflected, Initial IDT meeting for [Resident #1] held with LIDDA. Resident chose not to participate in meeting. [The DOR] requested specialized wheelchair through PASRR as well as concave mattress if possible. An interview on 08/20/25 at 10:00 a.m., the DON said her involvement with PASSR was very minimum. She said she did not know the timeframes after the IDT meeting, she said the MDS nurse in charge of that. An interview on 08/20/25 at 10:20 a.m., the Administrator said she had been present during Resident #1's initial Interdisciplinary Team meeting held on 01/09/25. She said she remembered the team had not requested a specialized mattress. She said what was requested was a specialized wheelchair, therapy (physical, occupational, and speech), and a provider to visit resident daily. She said it's the LIDDA caseworker responsibility to upload a resident's Individual Profile to LTC Simple portal after the Interdisciplinary Team meeting. She said since a specialized mattress had not been requested during the IDT meeting, she did not follow-up on it. The Administrator said she remembered she received an email from PASSR (state office) inquiring on a specialized mattress and she had forwarded it to the current MDS/RN B to handle it. She said the current MDS/RN B had responded to the email. The Administrator said MDS/RN B received an email back from PASSR (state office) advising them it had been resolved, she did not remember the date and did not provide a copy. The Administrator said the facility did not have access to the LIDDA's Individual Profiles and did not know the timeframes they had to submit to the Simple portal. She said what she suspected was that the LIDDA caseworker had included a request for a specialized mattress after the IDT meeting without the facility's knowledge. The Administrator said the facility did not have a PASSR policy but did provide their Behavioral Health Services policy. Record review on 08/20/25 of Resident #1's LIDDA's Individual Profile-Nursing Facility dated 01/09/25 reflected:Adaptive Aids and Medical Supplies: Due to recent falls, team agreed to specialized mattress, bolsters and concave mattress to support her from falling off the bed. Record review on 08/20/25 of the facility's Behavioral Health Services policy, dated 08/2017 which reflected: It is the policy of this facility to provide resident with necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well0being, which includes the prevention and treatment of mental and substance use disorders, as well as psychosocial adjustment difficulty, or those with history of trauma and/or post-traumatic stress disorder. Procedure:8. The IDT will also review PASRR recommendations.

Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, 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, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 4 of 9 residents (Resident #1, #2, #3, #4) reviewed for reporting alleged allegation of abuse. 1.The facility did not report, within 2 hours, when Resident #1 and Resident #2 had a resident to resident altercation on 01/02/25. 2. The facility did not report, within 2 hours, when Resident #3 and Resident #4 had a resident to resident altercation that resulted in a skin tear to Resident #3's hand on 01/04/25. This failure could place residents at risk for undetected abuse, neglect and/or decline in feelings of safety and well-being. The findings included: 1. Record review of Resident #1's face sheet, dated 06/18/25, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: schizophrenia (disorder that affects a person's ability to think, feel and behave clearly.), unspecified, bipolar disorder, (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) unspecified and unspecified dementia ( a group of thinking an social symptoms that interferes with daily functioning), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Record review of Resident #1's quarterly MDS assessment, dated 03/19/25, revealed Resident #1 had a BIMS score of 07, indicating her cognition was severely impaired. Record review of Resident #1's care plan with an initiation date of 12/12/24 reflected [Resident #1] has potential to demonstrate physical behaviors r/t (related to) another resident alleged [Resident #1] hit her with an initial date of 01/02/25, and [Resident #1] is at risk for impaired cognitive function r/t (related to) dementia, schizophrenia with an initiation date of 12/12/24. Record review of Resident #1's progress note with an effective date and time of 01/01/25 at 10:00am stated LVN A heard a loud voice coming from hallway and when arriving she noted Resident #1 was standing in the hall way and stated in Spanish, Yo no le pegue ya me [NAME] a mi cuarto which translated to, I did not hit them, I'm going to my room. As per same note LVN A redirected Resident #1 to her room and completed a full body skin assessment with no injuries or discoloration noted and Resident #1 denying any pain or discomfort. LVN A documented that she had made notifications at that time to the medical doctor (MD), Resident #1's responsible party, the DON and the Administrator. Record review of Resident #1's skin evaluation completed by LVN A on 01/01/25 revealed a full body assessment was completed after a resident to resident altercation with no injuries, no discoloration and no complaints of pain or discomfort. Record review of Resident #1's change in condition evaluation completed by LVN A on 01/01/25 stated a resident to resident altercation occurred on 01/01/25 with no changes to skin and no pain. Primary care physician was notified and provided new orders after alteration including labs and urinalysis. During an interview with Resident #1 on 06/11/25 at 4:34pm Resident #1 stated her and Resident #2 had never gotten into any fight and had never hit each other and stated she thought the two of them were friends. 2. Record review of Resident #2's face sheet, dated 06/18/25, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: unspecified dementia ( a group of thinking an social symptoms that interferes with daily functioning), mild, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and anxiety disorder (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), unspecified. Record review of Resident #2's quarterly MDS assessment, dated 05/06/25, revealed Resident #2 had a BIMS score of 14, indicating her cognition was intact. Record review of Resident #2's care plan with an initiation date of 04/15/24 reflected focuses of [Resident #1] has potential for a psychosocial well- being problem r/t (related to) alleging [sic] another resident hit her in the face with an initial date of 01/02/25, and [Resident #2] is at risk for impaired thought process r/t (related to) anxiety, dementia with an initiation date of 04/15/24. Record review of Resident #2's progress note written by LVN A with an effective date and time of 01/01/25 at 10:00am stated LVN A heard a loud voice coming from hallway and when arriving Resident #2 alleged she was ambulating through the hallway and all of a sudden Resident #1 hit her in the face all of a sudden. As per note LVN A completed a skin assessment with no skin tears or discolorations noted and Resident #2 denied any pain or discomfort. LVN A documented that she had made notifications at time of altercation to the medical doctor (MD), Resident #2's responsible party, who did not answer and was left a voicemail by LVN A, the DON and the Administrator. Record review of Resident #2's skin evaluation completed by LVN A on 01/01/25 at 10:00am revealed a skin assessment was completed after a resident to resident altercation with no skin tears and no discoloration noted. Record review of Resident #2's change in condition evaluation completed by LVN A on 01/01/25 stated a resident to resident altercation occurred on 01/01/25 with no changes to skin and no pain. Primary care physician was notified and provided recommendation to monitor for any skin injuries or pain. Record Review of TULIP (HHSC online incident reporting application) on 06/12/25 at 9:30 AM revealed a self-report received by the facility on 01/02/25 at 12:38pm more than 2 hours after Resident #1 and Resident #2's had an altercation on 01/01/25. Record review of Administrators written undated statement in facility's submitted provider investigation report gave description of video surveillance that Administrator reviewed and stated Resident #2 was observed ambulating down A wing hall when Resident #1 spontaneously emerged from her room and walked up to Resident #2 without reason or cause and raised her hand towards Resident #2 to strike her. As per statement written by the Administrator Resident #1 was able to hit Resident #2 on her upper shoulder and neck with Resident #2 making no attempt to strike back. Resident #2 was removed by staff and the Administrator interviewed Resident #1 who did not recall any incident occurring. During an interview with Resident #2 on 06/11/25 at 6:21pm she stated one day Resident #1 went at her and made contact with her shoulder. Resident #2 stated when the incident occurred nursing went to check and assess her and stated staff was right there. Resident #2 stated she did not get hurt, did not have any injury, and did not have any open areas. Resident #2 stated it was not a big a deal because Resident #1 was just raising her arm and was not aiming for anything. Resident #2 was not sure of the exact date of the altercation with Resident #1 but stated she felt safe in the facility and stated no other similar incident had occurred since. During an interview with LVN A on 06/18/25 at 2:01pm she stated she was the responding nurse to the altercation between Resident #1 and Resident #2 on 01/01/25, LVN A stated she had heard Resident #2 screaming and responded but when she got there Resident #1 was already in her room and stated she then took Resident #2 to her room to complete a full body assessment and then she went to Resident #1 who did not recall anything. LVN A stated she did not witness any contact between Resident #1 and Resident #2 and stated Resident #2 told her that she was walking in the hallway when Resident #1 came out of her room and tried to slap Resident #2 in the face and then then went back to her room after she hit Resident #2. LVN A stated there were no injuries noted on Resident #1 or Resident #2. LVN A stated she had been trained over resident to resident altercations and stated as soon as she was able to separate and assess the residents she would report within 1 hour to the Administrator, LVN A stated she notified the Administrator shortly after the incident with Resident #1 and #2 but did not recall the exact time of notification. LVN A stated the Administrator went to the facility and LVN A was able to review the surveillance footage of the incident. LVN A stated that they zoomed into the video which was very blurry and stated they saw Resident #1 swipe at Resident #2 but were unable to tell if there was contact made. LVN A stated neither Residents #1 or #2 had similar previous incidents and stated they had not had any similar incidents since either. LVN A stated she did not consider the altercation between Residents #1 and #2 abuse because Resident #1 was not fully alert or there. During an interview with the Administrator on 06/18/25 at 6:04pm she stated LVN A was the responding nurse to the altercation between Resident #1 and Resident #2. The Administrator stated LVN A did not witness any contact between Resident #1 and Resident #2 and stated Resident #2 told her that she was hit all of a sudden by Resident #1. The Administrator stated she did review the surveillance footage at time of the incident and stated she saw Resident #1 extend her arm but did not see Resident #1 hit Resident #2 on her face area and saw her only make contact with Resident #2's shoulder. The Administrator stated staff removed residents and completed change in condition, progress note, made notifications and skin assessments that revealed no injuries noted on Resident #1 or Resident #2. The Administrator stated Resident #2 had poor cognition and her ability to make decisions was extremely poor. The Administrator stated she was not aware of neither Resident #1 or #2 having similar incident prior this incident and stated they had not had any similar incidents since either. The Administrator stated staff had been trained over resident to resident altercations, behavioral management and what their procedures and policy required them to do and stated staff were to notify her of any resident to resident altercations as soon as staff did everything to keep the resident safe. The Administrator stated she was notified of the resident to resident altercation immediately after the incident by nursing but did not recall the exact date or time of incident occurring or of being notified. The Administrator stated she did not consider the altercation between Resident #1 and Resident #2 abuse. The Administrator stated she reported the incident to HHSC within 24 hours and stated she was previously following a QSO but was not able to recall exactly which one and stated her understanding was that she had 24 hours because there was no major physical injury. The Administrator stated according to the guidelines she learned recently it should have been reported in 2 hours, the Administrator stated she had not received any training on the guidance of reporting abuse allegations within 2 hours. The Administrator stated the facility abuse policy did not give a specific time frame for reporting and stated to follow the regulation and report anything with major injury within 2 hours. The Administrator stated in this situation she and her staff followed the facility policy based on the time frame she was aware of. Administrator stated how resident to resident altercations negatively impact residents was dependent on a case by case bases on residents' cognition and ability to recall the event. The Administrator stated reporting allegations of abuse within 2 hours was important to ensure patients were safe and that staff responded appropriately and timely. 3. Record review of Resident #3's face sheet, dated 06/18/25, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: unspecified dementia ( a group of thinking an social symptoms that interferes with daily functioning), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, other Alzheimer's disease (most common cause of dementia - progressive decline in memory, thinking and behavior.) and hemiplegia (paralysis on one side) and hemiparesis (weakness of one side) following unspecified cerebrovascular disease (conditions that affect blood flow to brain) affecting left non -dominant side Record review of Resident #3's quarterly MDS assessment, dated 03/20/25, revealed Resident #1 had a BIMS score of 03, indicating her cognition was severely impaired. Record review of Resident #3's care plan with an initiation date of 10/25/2019 reflected focuses of 1/4/25 [Resident #3] has potential for a behavior problem r/t (related to) SN (staff nurse) heard loud voices from dining room upon arrival noted resident sitting in w/c (wheelchair), both residents pulling same towel. SN (staff nurse) pulled both residents apart from altercation immediate. Resident voiced she has my towel with an initial date of 01/06/25, and [Resident #3] is at risk for impaired cognitive function/dementia or impaired though process r/t (related to) Dementia, ALZHEIMERS [sic] with an initiation date of 01/26/2020. Record review of Resident #3's progress note with an effective date and time of 01/04/25 at 9:45am stated LVN A heard loud voices coming from dining room and upon arrival noted resident #3 sitting in w/c (wheelchair), LVN A's note stated both residents were pulling the same towel and she immediately pulled both residents apart from altercation with Resident #3 stating she has my towel. LVN A completed a full body skin assessment on Resident #3 and noted a scratch to right hand with scant bleeding, area was cleaned with normal saline and band aide put in place. Resident #3 had no signs or symptoms of pain or discomfort. LVN A stated she made notifications to the DON, responsible party for Resident #3 and the MD who gave new orders for urinalysis and labs, LVN A documented that she notified the Administrator of the altercation. Record review of Resident #3's progress note with an effective date and time of 01/04/25 at 9:18am stated LVN B noted discoloration to left shin of Resident #3 measuring 2.0 x 7.0 x 0, (unit of measurement was not included) with no complaint of pain to site. Record review of Resident #3's skin evaluation completed by LVN B on 01/04/25 at 9:22pm revealed greenish discoloration to left shin that measured 2.0x7.0 (unit of measurement not included) Resident #3 had no complaint of pain and was unable to recall if/when she bumped self. Record review of Resident #3's change in condition evaluation completed by LVN B on 01/04/25 at 9:32pm had check placed on skin wound or ulcer and stated it started on 01/04/25 that noted a discoloration to front of left lower leg measuring 2 x 7 x 0 with no unit of measurement noted. Primary care physician was notified and provided recommendation to monitor. Record review of Resident #3's change in condition evaluation completed by LVN A on 01/04/25 at 9:45am stated resident to resident altercation occurred on 01/04/25 with no changes to skin other than skin tear to right arm and no pain. Primary care physician was notified and provided new orders after alteration including labs and urinalysis and to clean skin tear with normal saline and apply triple antibiotic ointment and leave open to air. Record review of Resident #3's skin evaluation completed by LVN A on 01/04/25 at 2:35pm revealed skin tear to back of right hand measuring 1.2 x 0.2 (unit of measurement not included) with scant bleeding, resident denied pain or discomfort. During an interview with Resident #3 on 06/11/25 at 3:58 PM Resident #3 stated her she had never been hit, grabbed, kicked, or abused in anyway at the facility and stated she knew who resident #4 was and denied any arguments or incident had occurred with Resident #4. Resident #3 denied Residents #4 ever swinging at her or kicking her and stated she did not recall any incident with a towel. Resident #3 stated Resident #4 was nice to her, had never abused her and stated they liked to go and play with one another. Resident #3 stated she felt safe at the facility. 4. Record review of Resident #4's face sheet, dated 06/18/25, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: paranoid schizophrenia, schizophrenia (disorder that affects a person's ability to think, feel and behave clearly.), unspecified, bipolar disorder, (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) unspecified, unspecified intellectual disabilities, (condition that limits intelligence and disrupts abilities necessary for living independently) not otherwise specified. Record review of Resident #4's quarterly MDS assessment, dated 05/20/25, revealed Resident #4 had a BIMS score of 11, indicating her cognition was moderately impaired. Record review of Resident #4's care plan with an initiation date of 04/27/22 reflected focus's of [Resident #4] has potential for a behavior problem r/t bickering heard from down the hall to be coming from the small dining room. upon arrival, resident noted to be sitting in her wheelchair pulling on a towel that another resident [Resident #3] had in her hands and was pulling as well. With an initiation date of 01/06/25. [Resident #4] is at risk for impaired cognitive function/dementia or impaired thought processes [sic] BIMS scored 8 with an initiation fate of 04/27/22. Record review of Resident #4's progress note written by RN C with an effective date and time of 01/04/25 at 9:45am stated RN C heard bickering from down the hall coming from the small dining room, upon arrival RN C noted Resident #4 to be sitting in her wheelchair pulling on a towel that another resident had in her hands and was pulling as well with resident stating, she had my stuff and scratched my arm while gesturing towards her upper left arm. Both residents were immediately separated, and skin assessment was conducted with no visible injuries noted. Left arm was assessed with no redness noted and skin intact with no swelling. MD was made aware, DON and administrator. Record review of Resident #4's skin evaluation completed by RN C on 01/04/25 at 9:45am revealed a skin assessment was completed after a resident to resident altercation with Resident #4 reporting she was scratched to upper left arm however area was free of redness, swelling and had no open areas, no new skin injuries noted, and Resident #4 denied pain or discomfort. Record review of Resident #4's change in condition evaluation completed by RN C on 01/04/25 stated resident to resident altercation occurred on 01/04/25 with no changes to skin and no pain. Primary care physician was notified and provided no new orders. During an interview with Resident #4 on 06/11/25 at 4:58pm she stated she did not know who Resident #3 was and stated she not been abused by anyone in the facility and stated she had not had any incidents involving a towel, swinging a wallet or kicking a resident chair or legs. Record review of Administrators written undated statement in facility's submitted provider investigation report gave description of video surveillance that Administrator reviewed and stated Resident #3 was seated in the small dining room folding towels when Resident #4 approached her and started pulling at the towel she had in hand. Once Resident #4 had pulled the towel away from Resident #3 she processed to pursue Resident #4 requesting her towel back. Resident #3 then took a hold of another residents wallet and began swinging it while another resident swung the towel at Resident #3, resident proceeded to kick Resident #3's chair and leg resulting in Resident #3 taking hold of her arm and attempted to raise it. Nursing intervened and separated both residents. Record Review of TULIP (HHSC online incident reporting application) on 06/12/25 at 9:30 AM revealed a self-report received by the facility on 01/05/25 at 8:19am more than 2 hours after Resident #3 and Resident #4's had an altercation on 01/04/25. During an interview with RN C on 06/17/25 she stated she and LVN A were the responding nurses to the altercation between Resident #3 and Resident #4 , RN C stated she heard arguing so she entered the small dining room and stated Resident #3 and #4 were arguing over a towel that Resident #3 had with Resident #4 saying Resident #3 had her towel. RN C stated she did not see any contact between Resident #3 and Resident #4 and stated she did not see any kicking. RN C stated Resident #4 stated Resident #3 scratched her hand. RN C stated she completed a skin assessment on Resident #4 and did not note any injuries and did not recall any scant bleeding to her hand. RN C stated Resident #4 had no discoloration to legs, and stated Resident #4 had any injuries. RN C stated she had to see what really happened to see if Resident #4 scratched Resident #3 intentionally and if so, then yes she could consider that abuse. RN C stated she had been trained over resident to resident altercations and stated she would report to the Administrator as soon as possible and stated they only have 2 hours to report. RN C stated she and LVN A notified the Administrator shortly after the incident with Resident #3 and #4 but did not recall the exact time of incident or notification. RN C stated neither Residents #3 or #4 had similar previous incidents and stated they had not had any similar incidents since either. During an interview with LVN A on 06/18/25 at 2:01pm she stated she and RN C were the responding nurses to the altercation between Resident #3 and Resident #4 , LVN A stated she was the nurse for Resident #3 and stated at time of the incident she was called by RN C when she was on the floor. LVN A stated RN C told her that Resident #3 and #4 were fighting over something but LVN A did not recall what Resident #3 and #4 were fighting about and stated she saw Resident #3 on one table and Resident #4 on another. LVN A stated she did not see any contact between Resident #3 and Resident #4 and stated she did not remember if she saw the video surveillance of incident. LVN A stated neither resident had any injuries. LVN A stated she had been trained over resident to resident altercations and stated as soon as she was able to separate and assess the residents she would report within 1 hour to the Administrator, LVN A stated she notified the Administrator shortly after the incident with Resident #3 and #4 but did not recall the exact time of notification. LVN A stated neither Residents #3 or #4 had similar previous incidents and stated they had not had any similar incidents since either. LVN A stated she did not consider the altercation between Residents #3 and #4 abuse. During an interview with the Administrator on 06/18/25 at 6:04pm she thought LVN A was the responding nurse to the altercation between Resident #3 and Resident #4. The Administrator stated nursing staff did not witness any contact between Resident #3 and Resident #4. The Administrator stated she did review the surveillance footage at the time of the incident and stated she saw Resident #3 and #4 fighting over a towel that Resident #3 was initially folding at the table and then Resident #4 wanted and stated both residents then had a tug of war with the towel and Resident #4 yelled that Resident #3 hit her. The Administrator stated when she reviewed the camera that did not happen and stated Resident #3 was kicking her feet while in her wheelchair but it was slow and did not reach Resident #4, as per the Administrators observation of the video surveillance she did not see any contact between Residents #3 and #4 and only saw them hitting the chair and Resident #4 trying to raise Resident #3's arm. The Administrator stated staff completed skin assessments, change in condition documentation, and made notifications. The Administrator stated both Residents were noted to have no injuries. The Administrator stated Resident #3 and Resident #4 had poor cognition and their ability to make decisions was poor. The Administrator stated she was not aware of neither Resident #3 or #4 having similar incidents prior to this incident and stated they had not had any similar incidents since either. The Administrator stated staff had been trained over resident to resident altercations, behavioral management and what their procedures and policy required them to do and stated staff were to notify her of any resident to resident altercations as soon as staff did everything to keep the resident safe . The Administrator stated she was notified of the resident to resident altercation immediately after the incident by nursing but did not recall the exact date or time of incident occurring or of being notified. The Administrator stated she did not consider the altercation between Resident #3 and Resident #4 abuse. The Administrator stated she reported the incident to HHSC within 24 hours and stated she was previously following a QSO but was not able to recall exactly which one and stated her understanding was that she had 24 hours because there was no major physical injury. The Administrator stated according to the guidelines she learned recently it should have been reported in 2 hours, the Administrator stated she had not received any training on the guidance of reporting abuse allegations within 2 hours. The Administrator stated the facility abuse policy did not give a specific time frame for reporting and stated to follow the regulation and report anything with major injury within 2 hours. The Administrator stated in this situation she and her staff followed the facility policy based on the time frame she was aware of. the Administrator stated how resident to resident altercations negatively impact residents was dependent on a case by case bases on residents' cognition and ability to recall the event. The Administrator stated not reporting allegations of abuse within 2 hours was important to ensure patients were safe and that staff respond appropriately and timely. Record review of facility Inservice dated 06/09/25 that was provided by the DON and the Administrator covered, Abuse and neglect Coordinator - [Administrator], Behavior Management, Abuse and Neglect, Physical, Sexual, Verbal, Psychological, Misappropriation signs and symptoms - unexplained discolorations, injuries, refusing to eat, crying, isolation, missing items, withdrawal, depression, avoidance, poor hygiene, etc. revealed LVN A and RN C had received the training. Record review of LVN A's training transcript revealed she completed a training titled Abuse, Neglect and Exploitation Self -Paced on 10/22/24. Record review of RN C's training transcript revealed she completed a training titled Abuse, Neglect and Exploitation Self -Paced on 10/27/24. Record review of facility policy with a revision date of 4/2025 and titled, Abuse: Prevention of and Prohibition Against stated, Physical Abuse includes but is not limited to hitting, slapping, pinching, and kicking. And stated, allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to the appropriate State or Federal agencies in the applicable time frames, as per this policy and applicable regulations,

Based on interview and record review, the facility failed to ensure the residents had the right to be free from abuse, neglect and misappropriation of property for 4 of 9 residents (Residents #1, #2, #3 and #4) reviewed for abuse, in that: 1. Resident #1 and Resident #2 had a resident to resident altercation when Resident #1 struck Resident #2 on her upper shoulder and neck. 2.Resident #3 and Resident #4 had a resident to resident altercation that resulted in a skin tear with scant bleeding to Resident #3's hand. These deficient practices could affect residents and place them at risk for abuse, trauma, psychosocial harm, injuries, or hospitalization. The findings included: 1. Record review of Resident #1's face sheet, dated 06/18/25, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: schizophrenia (disorder that affects a person's ability to think, feel and behave clearly.), unspecified, bipolar disorder, (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) unspecified and unspecified dementia ( a group of thinking an social symptoms that interferes with daily functioning), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Record review of Resident #1's quarterly MDS assessment, dated 03/19/25, revealed Resident #1 had a BIMS score of 07, indicating her cognition was severely impaired. Record review of Resident #1's care plan with an initiation date of 12/12/24 reflected [Resident #1] has potential to demonstrate physical behaviors r/t (related to) another resident alleged [Resident #1] hit her with an initial date of 01/02/25, and [Resident #1] is at risk for impaired cognitive function r/t (related to) dementia, schizophrenia with an initiation date of 12/12/24. Record review of Resident #1's progress note with an effective date and time of 01/01/25 at 10:00am stated LVN A heard a loud voice coming from hallway and when arriving she noted Resident #1 was standing in the hall way and stated in Spanish, Yo no le pegue ya me [NAME] a mi cuarto which translated to, I did not hit them, I'm going to my room. As per same note LVN A redirected Resident #1 to her room and completed a full body skin assessment with no injuries or discoloration noted and Resident #1 denying any pain or discomfort. LVN A documented that she had made notifications at that time to the medical doctor (MD), Resident #1's responsible party, the DON and the Administrator. Record review of Resident #1's skin evaluation completed by LVN A on 01/01/25 revealed a full body assessment was completed after a resident to resident altercation with no injuries, no discoloration and no complaints of pain or discomfort. Record review of Resident #1's change in condition evaluation completed by LVN A on 01/01/25 stated a resident to resident altercation occurred on 01/01/25 with no changes to skin and no pain. Primary care physician was notified and provided new orders after alteration including labs and urinalysis. During an interview with Resident #1 on 06/11/25 at 4:34pm Resident #1 stated her and Resident #2 had never gotten into any fight and had never hit each other and stated she thought the two of them were friends. 2. Record review of Resident #2's face sheet, dated 06/18/25, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: unspecified dementia ( a group of thinking an social symptoms that interferes with daily functioning), mild, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and anxiety disorder (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), unspecified. Record review of Resident #2's quarterly MDS assessment, dated 05/06/25, revealed Resident #2 had a BIMS score of 14, indicating her cognition was intact. Record review of Resident #2's care plan with an initiation date of 04/15/24 reflected focuses of [Resident #1] has potential for a psychosocial well- being problem r/t (related to) alleging [sic] another resident hit her in the face with an initial date of 01/02/25, and [Resident #2] is at risk for impaired thought process r/t (related to) anxiety, dementia with an initiation date of 04/15/24. Record review of Resident #2's progress note written by LVN A with an effective date and time of 01/01/25 at 10:00am stated LVN A heard a loud voice coming from hallway and when arriving Resident #2 alleged she was ambulating through the hallway and all of a sudden Resident #1 hit her in the face all of a sudden. As per note LVN A completed a skin assessment with no skin tears or discolorations noted and Resident #2 denied any pain or discomfort. LVN A documented that she had made notifications at time of altercation to the medical doctor (MD), Resident #2's responsible party, who did not answer and was left a voicemail by LVN A, the DON and the Administrator. Record review of Resident #2's skin evaluation completed by LVN A on 01/01/25 at 10:00am revealed a skin assessment was completed after a resident to resident altercation with no skin tears and no discoloration noted. Record review of Resident #2's change in condition evaluation completed by LVN A on 01/01/25 stated a resident to resident altercation occurred on 01/01/25 with no changes to skin and no pain. Primary care physician was notified and provided recommendation to monitor for any skin injuries or pain. Record review of Administrators written undated statement in facility's submitted provider investigation report gave description of video surveillance that Administrator reviewed and stated Resident #2 was observed ambulating down A wing hall when Resident #1 spontaneously emerged from her room and walked up to Resident #2 without reason or cause and raised her hand towards Resident #2 to strike her. As per statement written by the Administrator Resident #1 was able to hit Resident #2 on her upper shoulder and neck with Resident #2 making no attempt to strike back. Resident #2 was removed by staff and the Administrator interviewed Resident #1 who did not recall any incident occurring. During an interview with Resident #2 on 06/11/25 at 6:21pm she stated one day Resident #1 went at her and made contact with her shoulder. Resident #2 stated when the incident occurred nursing went to check and assess her and stated staff was right there. Resident #2 stated she did not get hurt, did not have any injury, and did not have any open areas. Resident #2 stated it was not a big a deal because Resident #1 was just raising her arm and was not aiming for anything. Resident #2 was not sure of the exact date of the altercation with Resident #1 but stated she felt safe in the facility and stated no other similar incident had occurred since. During an interview with LVN A on 06/18/25 at 2:01pm she stated she was the responding nurse to the altercation between Resident #1 and Resident #2 on 01/01/25, LVN A stated she had heard Resident #2 screaming and responded but when she got there Resident #1 was already in her room and stated she then took Resident #2 to her room to complete a full body assessment and then she went to Resident #1 who did not recall anything. LVN A stated she did not witness any contact between Resident #1 and Resident #2 and stated Resident #2 told her that she was walking in the hallway when Resident #1 came out of her room and tried to slap Resident #2 in the face and then then went back to her room after she hit Resident #2. LVN A stated there were no injuries noted on Resident #1 or Resident #2. LVN A stated she had been trained over resident to resident altercations and stated as soon as she was able to separate and assess the residents she would report within 1 hour to the Administrator, LVN A stated she notified the Administrator shortly after the incident with Resident #1 and #2 but did not recall the exact time of notification. LVN A stated the Administrator went to the facility and LVN A was able to review the surveillance footage of the incident. LVN A stated that they zoomed into the video which was very blurry and stated they saw Resident #1 swipe at Resident #2 but were unable to tell if there was contact made. LVN A stated neither Residents #1 or #2 had similar previous incidents and stated they had not had any similar incidents since either. LVN A stated she did not consider the altercation between Residents #1 and #2 abuse because Resident #1 was not fully alert or there. During an interview with the Administrator on 06/18/25 at 6:04pm she stated LVN A was the responding nurse to the altercation between Resident #1 and Resident #2. The Administrator stated LVN A did not witness any contact between Resident #1 and Resident #2 and stated Resident #2 told her that she was hit all of a sudden by Resident #1. The Administrator stated she did review the surveillance footage at time of the incident and stated she saw Resident #1 extend her arm but did not see Resident #1 hit Resident #2 on her face area and saw her only make contact with Resident #2's shoulder. The Administrator stated staff removed residents and completed change in condition, progress note, made notifications and skin assessments that revealed no injuries noted on Resident #1 or Resident #2. The Administrator stated Resident #2 had poor cognition and her ability to make decisions was extremely poor. The Administrator stated she was not aware of neither Resident #1 or #2 having similar incident prior this incident and stated they had not had any similar incidents since either. The Administrator stated staff had been trained over resident to resident altercations, behavioral management and what their procedures and policy required them to do and stated staff were to notify her of any resident to resident altercations as soon as staff did everything to keep the resident safe. The Administrator stated she was notified of the resident to resident altercation immediately after the incident by nursing but did not recall the exact date or time of incident occurring or of being notified. The Administrator stated she did not consider the altercation between Resident #1 and Resident #2 abuse. The Administrator stated she reported the incident to HHSC within 24 hours and stated she was previously following a QSO but was not able to recall exactly which one and stated her understanding was that she had 24 hours because there was no major physical injury. The Administrator stated according to the guidelines she learned recently it should have been reported in 2 hours, the Administrator stated she had not received any training on the guidance of reporting abuse allegations within 2 hours. The Administrator stated the facility abuse policy did not give a specific time frame for reporting and stated to follow the regulation and report anything with major injury within 2 hours. The Administrator stated in this situation she and her staff followed the facility policy based on the time frame she was aware of. Administrator stated how resident to resident altercations negatively impact residents was dependent on a case by case bases on residents' cognition and ability to recall the event. The Administrator stated reporting allegations of abuse within 2 hours was important to ensure patients were safe and that staff responded appropriately and timely. 3. Record review of Resident #3's face sheet, dated 06/18/25, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: unspecified dementia ( a group of thinking an social symptoms that interferes with daily functioning), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, other Alzheimer's disease (most common cause of dementia - progressive decline in memory, thinking and behavior.) and hemiplegia (paralysis on one side) and hemiparesis (weakness of one side) following unspecified cerebrovascular disease (conditions that affect blood flow to brain) affecting left non -dominant side Record review of Resident #3's quarterly MDS assessment, dated 03/20/25, revealed Resident #1 had a BIMS score of 03, indicating her cognition was severely impaired. Record review of Resident #3's care plan with an initiation date of 10/25/2019 reflected focuses of 1/4/25 [Resident #3] has potential for a behavior problem r/t (related to) SN (staff nurse) heard loud voices from dining room upon arrival noted resident sitting in w/c (wheelchair), both residents pulling same towel. SN (staff nurse) pulled both residents apart from altercation immediate. Resident voiced she has my towel with an initial date of 01/06/25, and [Resident #3] is at risk for impaired cognitive function/dementia or impaired though process r/t (related to) Dementia, ALZHEIMERS [sic] with an initiation date of 01/26/2020. Record review of Resident #3's progress note with an effective date and time of 01/04/25 at 9:45am stated LVN A heard loud voices coming from dining room and upon arrival noted resident #3 sitting in w/c (wheelchair), LVN A's note stated both residents were pulling the same towel and she immediately pulled both residents apart from altercation with Resident #3 stating she has my towel. LVN A completed a full body skin assessment on Resident #3 and noted a scratch to right hand with scant bleeding, area was cleaned with normal saline and band aide put in place. Resident #3 had no signs or symptoms of pain or discomfort. LVN A stated she made notifications to the DON, responsible party for Resident #3 and the MD who gave new orders for urinalysis and labs, LVN A documented that she notified the Administrator of the altercation. Record review of Resident #3's progress note with an effective date and time of 01/04/25 at 9:18am stated LVN B noted discoloration to left shin of Resident #3 measuring 2.0 x 7.0 x 0, (unit of measurement was not included) with no complaint of pain to site. Record review of Resident #3's skin evaluation completed by LVN B on 01/04/25 at 9:22pm revealed greenish discoloration to left shin that measured 2.0x7.0 (unit of measurement not included) Resident #3 had no complaint of pain and was unable to recall if/when she bumped self. Record review of Resident #3's change in condition evaluation completed by LVN B on 01/04/25 at 9:32pm had check placed on skin wound or ulcer and stated it started on 01/04/25 that noted a discoloration to front of left lower leg measuring 2 x 7 x 0 with no unit of measurement noted. Primary care physician was notified and provided recommendation to monitor. Record review of Resident #3's change in condition evaluation completed by LVN A on 01/04/25 at 9:45am stated resident to resident altercation occurred on 01/04/25 with no changes to skin other than skin tear to right arm and no pain. Primary care physician was notified and provided new orders after alteration including labs and urinalysis and to clean skin tear with normal saline and apply triple antibiotic ointment and leave open to air. Record review of Resident #3's skin evaluation completed by LVN A on 01/04/25 at 2:35pm revealed skin tear to back of right hand measuring 1.2 x 0.2 (unit of measurement not included) with scant bleeding, resident denied pain or discomfort. During an interview with Resident #3 on 06/11/25 at 3:58 PM Resident #3 stated her she had never been hit, grabbed, kicked, or abused in anyway at the facility and stated she knew who resident #4 was and denied any arguments or incident had occurred with Resident #4. Resident #3 denied Residents #4 ever swinging at her or kicking her and stated she did not recall any incident with a towel. Resident #3 stated Resident #4 was nice to her, had never abused her and stated they liked to go and play with one another. Resident #3 stated she felt safe at the facility. 4. Record review of Resident #4's face sheet, dated 06/18/25, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: paranoid schizophrenia, schizophrenia (disorder that affects a person's ability to think, feel and behave clearly.), unspecified, bipolar disorder, (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) unspecified, unspecified intellectual disabilities, (condition that limits intelligence and disrupts abilities necessary for living independently) not otherwise specified. Record review of Resident #4's quarterly MDS assessment, dated 05/20/25, revealed Resident #4 had a BIMS score of 11, indicating her cognition was moderately impaired. Record review of Resident #4's care plan with an initiation date of 04/27/22 reflected focus's of [Resident #4] has potential for a behavior problem r/t bickering heard from down the hall to be coming from the small dining room. upon arrival, resident noted to be sitting in her wheelchair pulling on a towel that another resident [Resident #3] had in her hands and was pulling as well. With an initiation date of 01/06/25. [Resident #4] is at risk for impaired cognitive function/dementia or impaired thought processes [sic] BIMS scored 8 with an initiation fate of 04/27/22. Record review of Resident #4's progress note written by RN C with an effective date and time of 01/04/25 at 9:45am stated RN C heard bickering from down the hall coming from the small dining room, upon arrival RN C noted Resident #4 to be sitting in her wheelchair pulling on a towel that another resident had in her hands and was pulling as well with resident stating, she had my stuff and scratched my arm while gesturing towards her upper left arm. Both residents were immediately separated, and skin assessment was conducted with no visible injuries noted. Left arm was assessed with no redness noted and skin intact with no swelling. MD was made aware, DON and administrator. Record review of Resident #4's skin evaluation completed by RN C on 01/04/25 at 9:45am revealed a skin assessment was completed after a resident to resident altercation with Resident #4 reporting she was scratched to upper left arm however area was free of redness, swelling and had no open areas, no new skin injuries noted, and Resident #4 denied pain or discomfort. Record review of Resident #4's change in condition evaluation completed by RN C on 01/04/25 stated resident to resident altercation occurred on 01/04/25 with no changes to skin and no pain. Primary care physician was notified and provided no new orders. During an interview with Resident #4 on 06/11/25 at 4:58pm she stated she did not know who Resident #3 was and stated she not been abused by anyone in the facility and stated she had not had any incidents involving a towel, swinging a wallet or kicking a resident chair or legs. Record review of Administrators written undated statement in facility's submitted provider investigation report gave description of video surveillance that Administrator reviewed and stated Resident #3 was seated in the small dining room folding towels when Resident #4 approached her and started pulling at the towel she had in hand. Once Resident #4 had pulled the towel away from Resident #3 she processed to pursue Resident #4 requesting her towel back. Resident #3 then took a hold of another residents wallet and began swinging it while another resident swung the towel at Resident #3, resident proceeded to kick Resident #3's chair and leg resulting in Resident #3 taking hold of her arm and attempted to raise it. Nursing intervened and separated both residents. During an interview with RN C on 06/17/25 at 1:53 pm she stated she and LVN A were the responding nurses to the altercation between Resident #3 and Resident #4 , RN C stated she heard arguing so she entered the small dining room and stated Resident #3 and #4 were arguing over a towel that Resident #3 had with Resident #4 saying Resident #3 had her towel. RN C stated she did not see any contact between Resident #3 and Resident #4 and stated she did not see any kicking. RN C stated Resident #4 stated Resident #3 scratched her hand. RN C stated she completed a skin assessment on Resident #4 and did not note any injuries and did not recall any scant bleeding to her hand. RN C stated Resident #4 had no discoloration to legs, and stated Resident #4 had any injuries. RN C stated she had to see what really happened to see if Resident #4 scratched Resident #3 intentionally and if so, then yes she could consider that abuse. RN C stated she had been trained over resident to resident altercations and stated she would report to the Administrator as soon as possible and stated they only have 2 hours to report. RN C stated she and LVN A notified the Administrator shortly after the incident with Resident #3 and #4 but did not recall the exact time of incident or notification. RN C stated neither Residents #3 or #4 had similar previous incidents and stated they had not had any similar incidents since either. During an interview with LVN A on 06/18/25 at 2:01pm she stated she and RN C were the responding nurses to the altercation between Resident #3 and Resident #4 , LVN A stated she was the nurse for Resident #3 and stated at time of the incident she was called by RN C when she was on the floor. LVN A stated RN C told her that Resident #3 and #4 were fighting over something but LVN A did not recall what Resident #3 and #4 were fighting about and stated she saw Resident #3 on one table and Resident #4 on another. LVN A stated she did not see any contact between Resident #3 and Resident #4 and stated she did not remember if she saw the video surveillance of incident. LVN A stated neither resident had any injuries. LVN A stated she had been trained over resident to resident altercations and stated as soon as she was able to separate and assess the residents she would report within 1 hour to the Administrator, LVN A stated she notified the Administrator shortly after the incident with Resident #3 and #4 but did not recall the exact time of notification. LVN A stated neither Residents #3 or #4 had similar previous incidents and stated they had not had any similar incidents since either. LVN A stated she did not consider the altercation between Residents #3 and #4 abuse. During an interview with the Administrator on 06/18/25 at 6:04pm she thought LVN A was the responding nurse to the altercation between Resident #3 and Resident #4. The Administrator stated nursing staff did not witness any contact between Resident #3 and Resident #4. The Administrator stated she did review the surveillance footage at the time of the incident and stated she saw Resident #3 and #4 fighting over a towel that Resident #3 was initially folding at the table and then Resident #4 wanted and stated both residents then had a tug of war with the towel and Resident #4 yelled that Resident #3 hit her. The Administrator stated when she reviewed the camera that did not happen and stated Resident #3 was kicking her feet while in her wheelchair but it was slow and did not reach Resident #4, as per the Administrators observation of the video surveillance she did not see any contact between Residents #3 and #4 and only saw them hitting the chair and Resident #4 trying to raise Resident #3's arm. The Administrator stated staff completed skin assessments, change in condition documentation, and made notifications. The Administrator stated both Residents were noted to have no injuries. The Administrator stated Resident #3 and Resident #4 had poor cognition and their ability to make decisions was poor. The Administrator stated she was not aware of neither Resident #3 or #4 having similar incidents prior to this incident and stated they had not had any similar incidents since either. The Administrator stated staff had been trained over resident to resident altercations, behavioral management and what their procedures and policy required them to do and stated staff were to notify her of any resident to resident altercations as soon as staff did everything to keep the resident safe . The Administrator stated she was notified of the resident to resident altercation immediately after the incident by nursing but did not recall the exact date or time of incident occurring or of being notified. The Administrator stated she did not consider the altercation between Resident #3 and Resident #4 abuse. The Administrator stated she reported the incident to HHSC within 24 hours and stated she was previously following a QSO but was not able to recall exactly which one and stated her understanding was that she had 24 hours because there was no major physical injury. The Administrator stated according to the guidelines she learned recently it should have been reported in 2 hours, the Administrator stated she had not received any training on the guidance of reporting abuse allegations within 2 hours. The Administrator stated the facility abuse policy did not give a specific time frame for reporting and stated to follow the regulation and report anything with major injury within 2 hours. The Administrator stated in this situation she and her staff followed the facility policy based on the time frame she was aware of. the Administrator stated how resident to resident altercations negatively impact residents was dependent on a case by case bases on residents' cognition and ability to recall the event. The Administrator stated not reporting allegations of abuse within 2 hours was important to ensure patients were safe and that staff respond appropriately and timely. Record review of facility Inservice dated 06/09/25 that was provided by the DON and the Administrator covered, Abuse and neglect Coordinator - [Administrator], Behavior Management, Abuse and Neglect, Physical, Sexual, Verbal, Psychological, Misappropriation signs and symptoms - unexplained discolorations, injuries, refusing to eat, crying, isolation, missing items, withdrawal, depression, avoidance, poor hygiene, etc. revealed LVN A and RN C had received the training. Record review of LVN A's training transcript revealed she completed a training titled Abuse, Neglect and Exploitation Self -Paced on 10/22/24. Record review of RN C's training transcript revealed she completed a training titled Abuse, Neglect and Exploitation Self -Paced on 10/27/24. Record review of facility policy with a revision date of 4/2025 and titled, Abuse: Prevention of and Prohibition Against stated, Physical Abuse includes but is not limited to hitting, slapping, pinching, and kicking. And stated, allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to the appropriate State or Federal agencies in the applicable time frames, as per this policy and applicable regulations,

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation and sanitation. The facility failed to ensure equipment was kept clean. The facility failed to ensure food holding pans were not dented. The facility failed to ensure spice in the dry storage area was sealed tightly. The facility failed to ensure there were no expired can goods in the dry storage area. The facility failed to ensure plastic dishes were clean on the clean rack. The facility failed to ensure personal items were kept out of the kitchen. The facility failed to ensure the floors were free of standing water. These failures could place residents at risk for complications from food contamination. The findings were: Observation and initial tour of the kitchen on [DATE] at 1:45 PM revealed 4 of 5 steam wells had a thick flaking whitish substance around the insides. The underside of the shelf above the steam table holding wells had dark brown and reddish substances hanging from it. There were 4 dented holding pans in use. One of the pans had a removable sticky yellowish stain inside of it. 1 of 11, 18 oz. container of spice was open to air and the lid would not close. There were 9, 6-pound cans of fruit with a use by date of [DATE]. There were 12 of 30 plastic coffee cups and bowls with debris inside of them on the clean rack. There was a paper plate (with another upside-down paper plate covering it) and an open, partially full 12 oz. can of soda on a shelf above the clean rack of dishes. The paper plate had a slice of pizza on it. The convection oven was not working and it was being used as a storage area for plates. There was a large light purple cup on the table next to the juice machine. The dry storage area and the area around the ice machine had a significant amount of water on the floor that required continuous mopping. In an interview with the DW on [DATE] at 1:55 PM, she stated the plastic dishes were on the clean rack and she was responsible for checking the dishes for cleanliness. She said the kitchen staff that served food and beverages checked them again. She said someone brought her pizza, but she did not have time to take it to the break room. She did not say who brought it. She would not say how far away the break room was. She said cross contamination could occur and make the residents sick. In an interview with the DA on [DATE] at 1:57 PM, she stated the purple cup belonged to her and she knew it should not be there but did not know why. She said she did not wash her hands or use gloves before or after touching her cup in the kitchen. She said cross contamination could occur and make the residents sick. In an interview with the FPM on [DATE] at 2:00 PM, he stated he had a bid out for a replacement element for the convection oven. He said it had not been working for about a week. He said it should not be used for storage. He said the ADM knew about the bid. He said there must be a broken water pipe somewhere causing the water on the floor in the dry storage area and around the ice machine. He said he just noticed the water this morning, and he had already called a plumber. He said he just got the cans of fruit on a shipment. The dates written on top of the cans were [DATE]. He said he was responsible for checking items when they came off the trucks. He said nothing when asked if he checked the use by dates on the cans before he accepted them. He said he did not know when or why dented pans should be discarded. He said he did not know what the substance was inside of the holding pan, and said it must be some kind of food. He said he did not check the pans when they were on the use rack. He said the substance on the inside of the holding pans could come off in the food and it could make residents sick. He said he did not know how long the substance in the pan had been there. He said the lid on the container of spice would not close. He said leaving spices open to air caouls cause them to become old faster and not taste good. He was unaware spices left open to air could result in contamination of the spices and cause illness to residents if they consumed them. Re-visit to the kitchen on [DATE] at 3:36 PM revealed significant water remaining on the floor in the dry storage room and around the ice maker, requiring continuous mopping. The container of spice remained open to air. The walk-in freezer had significant icicles hanging from the back of the condenser fan. In an interview with the FPM on [DATE] at 3:45 PM, he said the plumber came in Monday [DATE] and stuck a wire in all the drains. He said the plumber told him they would be back and bring a camera, they might have to re-pipe, because all the water pipes were going into one. He said he was unaware of the ice in the freezer. Interview with the MS on [DATE] at 12:34 PM, she said the plumbers had not come back yet. She said they told her they would need a snake (auger) to run through the drains. She said the leak started on Monday [DATE] and she could not determine where it came from. She said the company that looked at the freezer today told her there were a lot of small holes in the condenser and they would have to patch the holes before they fixed an opening near the roof where the freezer exhaust was located. She said she was assigning 2 personnel to mop the water in the dry storage room and around the ice maker. In an interview with the ADM on [DATE] at 1:33 PM, she said the breakroom for the kitchen staff was the same breakroom for everyone. She said it would take less than a minute to get there from the kitchen. She said personal items were not allowed in the kitchen area at any time due to cross contamination. She said she was made aware of the water on the floor on Monday [DATE]. She said the plumbers came in on Monday [DATE] and had to leave because they there may have been a leak and they needed to get an auger (snake). She said today there was a leak discovered in the walk-in freezer. She said it was checked by the company today and they told her the freezer had a leak on top of the freezer condenser that would require repair and they were awaiting a quote. She said the FPM was responsible for making sure the food that came from the kitchen was right, meaning the temperatures of the meals needed to be reasonable, accurate, and on time. She said the FPM and RD should be working together to make sure the meal trays were not getting cold, and the food matched the menus. She said the staff rotated for kitchen duty daily. She said there was a list of the kitchen duties they were supposed to follow. She said the FPM was responsible for everything the kitchen staff was doing but she was ultimately responsible. She said the residents could be affected because if the equipment went down, there would be no food coming out and if the kitchen staff were not paying attention to cross contamination, the residents could become ill. Policies requested: Personal Items in the kitchen, Distribution of food, Food holding temperatures, Food serving temperatures, cleaning dishware, Equipment-good working condition, storage of dishware, and following menus. Kitchen staff in-services/training and invoices for the condenser, convection oven element, and the plumbing also requested. The list of kitchen duties was also requested. Record review of kitchen staff in-services: [DATE]-lunch breaks, [DATE], [DATE], [DATE], [DATE], [DATE]-handwashing, [DATE]-cleaning/responsibilities included ovens/floors, steamers/table, grills/floors, coffee machine/table, hoods, all carts, juice machine/table, [DATE]-areas of opportunity included trash cans, pots and pans, 3-compartment sink, clean as you go, code dates, assigned equipment, and no eating or drinking in the kitchen!, [DATE]-dining duty included ensure staff assigned to meal monitoring is present in dining room, assures RN/LVN is present to verify diet with meal tray, use hand sanitizer before and after touching trays, remove dishes and utensils from tray and verify diet slip matched food served, assist residents with coverings and condiments, and feeding as needed/requested, report additional food requests from residents to the nurse for verification if allowed on diet and request from kitchen, assure entire table is served before proceeding to another table, any resident arriving after table has been served, request tray from FPM/kitchen staff, assure supervision is available in dining room for meal, [DATE]-dates, [DATE]-fruits, [DATE]-how do you know the meals we serve are correctXXX[DATE]-wet floors in kitchen/mopping schedule every hour and as needed, [DATE] tray times, distribution, meal times. Record review of facility kitchen policies titled, Food and Nutrition Services revised ,d+[DATE], Menus, it is the policy of this facility to assure that menus are developed and prepared to meet the nutritional needs of the residents and resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines. Procedures 4. If any meal served varies from the planned menu, the change and the reason for the change are noted on the posted menu in the kitchen and/or in the record book used solely for recording such changes. Dietary Services revised ,d+[DATE], Food, Sanitary Conditions for: Procedures 10. Personal food items or belongings are not allowed in the kitchen area. Record review of invoice #20464 dated [DATE] revealed checked walk-in freezer and found unit with ice formed on section of line. Will need to regulate and seal holes where condensation is coming in freezer box causing crystalized drops and ice to form in box. Will send quote. Record review of FDA Food Code 2022 Ch. ,d+[DATE].20 Food Protection Manager Certification ,d+[DATE] Duties ,d+[DATE].11 Person in Charge. The PERSON IN CHARGE shall ensure that: (E) EMPLOYEES are visibly observing FOODS as they are received to determine that they are from APPROVED sources, delivered at the required temperatures, protected from contamination, UNADULTERED, and accurately presented, by routinely monitoring the EMPLOYEES' observations and periodically evaluating FOODS upon their receipt ,d+[DATE] Hygienic Practices ,d+[DATE] Food Contamination Prevention ,d+[DATE].11 Eating and Drinking. (A) Except as specified in (B) of this section, an EMPLOYEE shall eat or drink only in designated areas where the contamination of exposed FOOD; clean EQUIPMENT, UTENSILS, or other items needing protection cannot result. (B) A FOOD EMPLOYEE may drink from a closed BEVERAGE container if the container is handled to prevent contamination of: (1) The EMPLOYEE'S hands; (2) The container.ChXXX,d+[DATE] Reheating ,d+[DATE].11 Reheating for hot holding. (A) Except as specified under (B) and (C) and in (E) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74 C (165 F) for 15 seconds. Ch. ,d+[DATE] Preventing contamination from the premises ,d+[DATE].11 Food Storage: FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Ch. ,d+[DATE] Cleanability ,d+[DATE].11 Food-Contact Surfaces. (A)Multiuse FOOD-CONTACT SURFACES shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; (4) Finished to have smooth welds and joints. Ch. ,d+[DATE] Maintenance and Operation ,d+[DATE] Equipment ,d+[DATE].11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts ,d+[DATE] and ,d+[DATE]. ,d+[DATE] Frequency ,d+[DATE].11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred. If used with TIME/TEMPERATURE CONTROL FOR SAFETY FOOD, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned throughout the day at least every 4 hours.

Based on observations, interviews, and record reviews, the facility failed to ensure the meals served reflected the nutritional needs of residents in accordance with established national guidelines for all residents when the facility failed to ensure menus were followed for all residents for 2 of 2 meals observed. The facility failed to follow the posted menus for two lunch services served at the facility on Wednesday, 09/17/24 and Thursday, 09/18/24. These failures could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance, and/or weight loss. The findings included: Observation of the dining room on 09/17/24 at 11:53 AM revealed the trays were being checked by RN A to ensure preference cards were correct and whether the resident was present. There were several trays that were held back due to missing items on the meal trays. All plates served revealed no Spanish rice or peach cobbler. Pinto beans or green beans with carrots, dry beef enchiladas, and what appeared to be apple pie with crust and cornbread were served. The cycle menu called for enchiladas/chili gravy with Spanish rice or grilled chicken, fettuccini Alfredo, tossed salad/dressing, garlic bread or tortilla, peach cobbler, and beverage choice. The posted menu called for beef enchiladas, Spanish rice, tossed salad/dressing, and pie/beverage. Observation of the dining room on 09/18/24 11:45 AM revealed the posted menu was not what the residents had on their trays. The cycle menu called for meat loaf/brown gravy or Mexican meatloaf, scalloped corn, breaded okra, cornbread, fudge cake and beverage choice. The posted menu called for Mexican meat loaf, buttered corn, coin carrots/cornbread, and banana/beverage. The food on the resident's trays was meatloaf, corn, carrots, and a banana. In an interview with RN A on 09/17/24 at 12:43 PM, she said she asked residents sometimes about their food when she did her rounds. RN A stated the CNAs should be asking the residents if there was anything they needed or if the food needed to be warmed. She said the residents had not complained to her about the food but did not ask directly about the food. She said the menu posted on the wall in the dining rooms should reflect what the residents were being served. She said she was neither informed of substitutions nor checked the menu to the trays. She said she only checked the trays to the preference cards for texture and likes/dislikes. She said the temperature of the food or not getting what was on the menus could cause weight loss. She said the residents could be adversely affected because they wouldn't eat at all or eat less and could cause a decline in their health, dehydration and/or grow weak. She said no one was responsible, that she was aware of, to ensure the trays were passed out in a timely manner, food was warm, and the residents were receiving the correct foods. In a phone interview with the RD on 09/18/24 at 3:45 PM, she said a vegetable was a vegetable and if the menus did not match the trays, it was because a substitution was needed. She said she did not know if the FPM made the residents or staff aware of substitutions. She said breaded okra had a similar nutritional value to carrots. She said if residents were not eating because the food was not right, it could adversely affect the residents in that they could possibly have weight loss and depending on their disease processes, could cause other health problems such as dehydration. She said she came to the facility twice a month and checked on new admissions, re-admissions, and anyone who triggered weight loss. She said she did not necessarily communicate with the FPM. She said she expected the FPM to follow the menus. In an interview with the ADM on 09/19/24 at 1:12 PM, she stated the FPM was responsible for overseeing the process of making sure menus were being followed. She said the RD and the FPM should have been working together to make sure menus were followed and that residents could be affected by weight loss or dehydration and dissatisfaction if they were not eating because they were not getting what they expected on their trays. Training for the kitchen staff was requested. Kitchen Policies pertaining to distribution of food, food holding/time/serving temperatures were requested. Record review of QAPI dated 09/17/24 revealed problems: Meal service issues during lunch and grievances received from residents regarding meals. Root Cause Analysis: Dietary manager (FPM) not supervising kitchen process, meal distribution, and meal services. Serving cold food, late trays, not following menus, and resident meal choice not followed. Interventions included Additional training for all dietary staff and FPM, new food warming tray carts and a hot plate warmer, review of seating charts, resident interviews for meal choices, likes, and dislikes, menus, changes to menus. Assignments: FPM, RD, DON. Record review of facility kitchen policies titled, Food and Nutrition Services revised 09/2017, Menus, it is the policy of this facility to assure that menus are developed and prepared to meet the nutritional needs of the residents and resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines. Procedures 4. If any meal served varies from the planned menu, the change and the reason for the change are noted on the posted menu in the kitchen and/or in the record book used solely for recording such changes.

Based on observations, interviews, and record review, the facility failed to provide residents with food that was at an appetizing temperature by failing to ensure meal trays were served with food at a preferred temperature to 2 of 5 residents (Resident #83 and Resident #85). checked for appropriate temperatures. The facility failed to ensure food was palatable and at an appetizing temperature for Resident #83 and Resident #85 on 09/17/2024 for the lunch meal. This failure could affect the residents who received oral nutrition, by placing them at risk for weight loss and/or altered nutritional status. The findings included: During an observation and interviews beginning on 09/17/24 at 11:53 AM in the second dining area, 7 staff members were observed checking preference cards prior to taking meal trays off the meal cart and properly handling of meal trays. The meal trays were being checked by RN A to ensure preference cards were correct and whether the residents were present. There were several trays that were held back due to missing items on the meal tray. On 09/17/24 at 12:10 PM 15 meal carts were observed in the second dining room with meal trays on them. At 09/17/24 at 12:12 PM a third cart with 8 meal trays arrived. Temperatures taken on 5 plates revealed the enchiladas ranged from 82 degrees F to 93.2 F. The pinto beans averaged 88 F and the green beans with carrots were an average of 82 F. On 09/17/24 at 12:29 PM meal trays left the dining room to the 100 hall. 09/17/24 at 12:32 PM Resident #83 stated his food was always cold. The enchiladas temped at 74.7 F and the beans temped at 74.2 F. There was no rice on his meal tray as stated on the menu. On 09/17/24 at 12:36 PM Resident #85 stated his food was always cold. There was no rice on his meal tray as stated on the menu. On 09/17/24 at 12:41 PM Enchiladas 89.8 F and green beans and carrots 89 F. In an interview on 09/17/24 at 12:44 PM RN A stated the meal trays get delivered to the dining room and get checked for accuracy. RN A stated once the trays were checked they are passed out in the dining room and then the room trays are taken to the residents in their room. RN A stated usually by the time the residents in the dining room were done eating, the meal trays for the halls come out and are passed out to residents that were in their room. RN A stated the CNA's should be asking the residents if there was anything they need or if the food needed to be warmed. RN A stated the amount of time the meal trays were out on the meal cart, about an hour or longer, she thought the food would not have been warm by the time the food was served to the residents in the rooms but did not ensure food was reheated. RN A stated she was not sure about the process on what to do if the food was getting cold and would need to ask. RN A stated by the food being cold could cause the residents to eat less or possibly not eat at all which could lead to weight loss and a possible decline. RN A stated if residents were eating less, then they could become dehydrated and become weaker. RN A stated there was no one that was responsible that she was aware of to ensure the meal trays were passed out in a timely manner and the food was warm. RN A stated the expectation was for the residents to have warm food. In a phone interview on 09/18/24 at 3:45 PM, the RD stated the cold food was not her problem. The RD stated if residents were not eating because the food was cold, it could adversely affect the residents in that they could possibly have weight loss and depending on their disease processes, could cause other health problems such as dehydration. The RD stated she came to the facility twice a month and checked on new admissions, re-admissions, and any residents who triggered for weight loss. In an interview on 09/19/24 at 1:12 PM the ADM stated the facility put a QAPI in place and interviewed residents who said the food was cold. The ADM stated they did a root cause analysis on the process of getting food from kitchen to the residents, and it revealed they needed to change their process. The ADM stated they in-serviced the staff on meal service tray schedule and reviewed resident seating charts. The ADM stated the facility's dietary manager was responsible for overseeing the meal service process as to ensure meals are being delivered in a timely manner. The ADM stated she had ordered a plate warmer and a tray cart with a warmer inside and she would provide the invoice for that purchase. The ADM stated the facility was currently borrowing a meal tray cart warmer from a sister facility to ensure food is now being served warm and appropriate temperatures. Record review of kitchen staff in-service on Service Tray Schedule last dated 10/23/23. Record review of Dietary Service policy for Food, Sanitary Conditions dated 4/2023 stated: Procedures It is the policy of this facility to procure food from sources approved or considered satisfactory by Federal. State, and/or local authorities. 2. Hot foods will leave the kitchen (or steam table) above 140 F and cold foods at or below 41 F.

Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions, and the expiration date when applicable in 1 of 3 medication carts (medication cart located in A wing hallway) reviewed for medication storage and labeling. The facility failed to ensure that all insulin in medication cart A wing hallway were not past their expiration date. The facility's failure could result in residents receiving expired insulin not being maintained at their best therapeutic level. The findings included: During an observation on 09/17/24 at 04:10 PM the medication cart on A wing hallway revealed 1 insulin vial passed the 28th day, opened date was 8/12/2024. During an interview on 09/17/24 at 04:30 PM the ADON stated the last time the insulin was given was on 9/16/24 at 09:02 PM. The ADON stated the insulin must be discarded after 28 days from the opened date. The ADON also stated the charge nurse of each wing had to make sure the insulin was not expired, and it was not appropriate to give expired insulin to residents because it could cause an adverse reaction. During an interview on 09/17/24 at 04:29 PM LVN A stated residents could get reactions if expired medications were given to the residents. LVN A stated insulins need to be discarded after 28 days from the opening date. LVN A stated expired insulin was not as potent as it supposed to be, residents could get a false reading because of the expired insulin administered. During an interview on 09/18/24 09:20 AM RN A stated the insulin vials needed to be discarded in the sharps container and the vials were good for 28 days after the opened date. RN A stated if given to a resident after the 28 days, the insulin could cause an adverse reaction, or the insulin would not work as it is supposed to. During an interview with on 09/19/24 at 04:10 PM the DON stated the insulins were good for 28 days after the insulins were open. The DON stated the lifetime of the insulin could be altered. Record review of policy titled Storing and Controlling medications with revision date of May 2023 revealed: It is the policy of this Facility to store medications safely, securely, and properly following manufacturer's recommendations or those of the supplier, and in accordance with federal and state laws and regulations. The medication supply is accessible only to authorized personnel. Medications that are discontinued, expired contaminated, or deteriorated, and those that are in containers that are cracked, soiled, o without secure closures are immediately removed from the locked medication storage area and disposed of in accordance with the Facility policies and procedures.

Based on interviews and record review the facility failed to ensure residents who have not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #68) of 3 residents whose records were reviewed for pharmacy services. The facility failed to ensure Resident #68 was not prescribed Zyprexa (an antipsychotic) without appropriate diagnosis for its use. This deficient practice could place residents without a diagnosis for taking psychotropic medications at risk for receiving unnecessary medications. The findings were: Review of Resident #68's admission record, dated 09/17/2024, revealed he was a [AGE] year old male, admitted to the facility on [DATE], with diagnoses that included, dementia (a group of thinking and social symptoms that interferes with daily functioning), unspecified severity, with other behavioral disturbance, type 2 diabetes mellitus with hyperglycemia (high blood glucose), and neurocognitive disorder with Lewy bodies (Lewy body dementia [LBD] is a progressive brain disease that causes a decline in thinking and other abilities over time. It is the second most common type of dementia after Alzheimer's disease.) Review of Resident #68's quarterly MDS assessment dated [DATE], revealed Resident #68 had a BIMS score of 04 which indicated his cognition was severely impaired. Resident #68 was always incontinent of bladder and frequently incontinent of bowels. Review of Resident #68's comprehensive person-centered care plan revised date of 09/12/2024 revealed, Focus .is on Psychotropic medications use r/t LEWY BODY DEMENTIA WITH BEHAVIORAL DISTURBANCE 4/11/24 ZyPREXA Oral Tablet 2.5 MG (Olanzapine) Give 1 tablet by mouth at bedtime. Interventions/Tasks .Administer medications as ordered .06/13/2023. Review of Resident #68's Consent for Antipsychotic or Neuroleptic Medication Treatment dated and signed by the DON on 06/13/2023 and the NP on 07/29/2023, revealed My diagnosis is based on the following dominant characteristics exhibited by this individual: Anxiety with aggression. The need for, and benefits of, the proposed treatment with antipsychotic or neuroleptic medication(s) is indicated: Improve aggression and anxiety. Review of Resident #68's Physician Orders dated 06/04/24 revealed, Order Date: 06/04/24 Start Date: 06/05/24 Doctor; Summary: ZyPREXA Oral Tablet 2.5 MG (Olanzapine) Give 1 tablet by mouth at bedtime related to unspecified dementia related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE (F03.918); NEUROCOGNITIVE DISORDER WITH LEWY BODIES (G31.83). Resident #68 did not have a diagnosis of psychosis and Resident #68 was a [AGE] year-old male who had a diagnosis of dementia. Review of Resident #68's Medication Administration Record for July 2024, August 2024, and September 2024 revealed Resident #68 received ZyPREXA Oral Tablet 2.5 MG (Olanzapine) Give 1 tablet by mouth at bedtime related to unspecified dementia related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE (F03.918); NEUROCOGNITIVE DISORDER WITH LEWY BODIES (G31.83) 07/01/2024 - 09/16/2024 at bedtime. On 09/17/2024, order was changed to read, ZyPREXA Oral Tablet 2.5 MG (Olanzapine) Give 1 tablet by mouth at bedtime related to MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL WITH MANIC FEATURES (F06.33) Start Date: 09/17/2024 1900 (07:00 pm) and administered at bedtime 09/17/2024 - 09/19/2024. In an interview on 09/17/24 at 03:04 p.m., the DON stated Resident #68 was getting Zyprexa for aggression. The DON stated Resident #68 had been getting the antipsychotic for a long time. The DON said she was unaware that an antipsychotic being given with a diagnosis of dementia was not allowed. The DON stated they would get the indication on the medication changed . In an interview on 09/17/24 at 03:10 p.m., the Administrator stated she had not known a dementia diagnosis could not be given with an antipsychotic medication. The Administrator stated she had asked several other people about a dementia diagnosis for an antipsychotic, some said yes it could and some said no it could not, but now she knew that an antipsychotic could not be given with the diagnosis of dementia. She stated they would talk to the doctor to get the order changed . Record review of the facility's Psychotropic Medication Policy, dated 05.2007 Revision/review date(s): 12.2019; 02.2022; 12.2023, revealed: Policy It is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Psychotropic medications shall not be administered for the purpose of discipline or convenience. Based on a comprehensive assessment, the facility will ensure that: - Residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; - Residents do not receive psychotropic drugs pursuant to an as needed (PRN) order unless medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; Procedure 5. Medications not classified as one of the psychotropic medication categories can also affect brain activity and should not be used as a substitution for another psychotropic medication unless prescribed with a documented clinical indication consisted with accepted clinical standards of practice.

Based on observations, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice for 1 of 6 (Resident #293) residents reviewed for oxygen. Resident #293's oxygen was administered at 3 Lpm and the physician's order was written for 2 Lpm. This failure could place Residents, who received oxygen, at risk of developing respiratory complications and a decreased quality of care. The findings included: Record Review of Resident #293's face sheet dated 9/17/2024 indicated she was a [AGE] year-old female initially admitted on [DATE], with the diagnoses of sleep apnea (is a potentially serious sleep disorder in which breathing repeatedly stops and starts) and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of Resident #293's comprehensive care plan dated 9/5/24 indicated Resident #293 had oxygen therapy related to ineffective gas exchange, oxygen at 2 Lpm via nasal cannula every shift to relieve signs and symptoms of hypoxia related to shortness of breath, Date Initiated: 09/6/2024 and Revision on: 09/6/2024. Record Review of Resident #293's significant change Minimum Data Set assessment dated [DATE] indicated she received continuous oxygen therapy . Residet #293 BIMS score was 12 (moderately imparied). Record review of Resident #293's July 2024 physician's orders indicated OXYGEN at 2 liters per minute via Nasal cannula every shift for to relieve signs and symptoms of hypoxia related to shortness of breath. Observation of Resident #293 on 09/16/24 at 13:05 PM revealed her oxygen concentrator was set at 3 liters per minute, the concentrator setting was not set to the doctor's orders . During an interview on 09/19/24 at 9:05 AM LVN A stated the physician's orders had to match with the concentrator settings. LVN A stated if a resident were to receive too much oxygen, it could hurt the resident. During an interview on 9/19/2024 at 09:10 AM the ADON stated nurses were responsible to check the O2 settings. The ADON stated if nurses don't follow the physician orders, it could cause hyperoxygenation to the resident . During an interview on 9/19/2024 at 4:10 PM the DON stated if the concentrator settings were not followed as per doctor's orders, it could cause an increase of carbon dioxide in the blood. Record review of the facility's oxygen administration policy dated 05/2007, reflected it is the policy of this facility that oxygen therapy is administered, as ordered by the physician, or as an emergency measure until the order can be obtained. Reassess oxygen flowmeter for correct liter flow.

Based on observations, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for one (Resident #10) of three residents reviewed for call light. The facility failed to ensure Resident #10's call light was within reach and functioning properly. This failure could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings were: Record review of Resident #10's Admission record dated 08/15/24 reflected a [AGE] year-old male with an initial admitted [DATE] and a readmitted [DATE] with diagnoses of Dysphagia oropharyngeal phase (difficulty swallowing), Unspecified convulsion (rapid involuntary muscle contractions resulting in uncontrolled shaking), Unspecified Speech disturbance, Cognitive communication deficit (trouble with communication), and Muscle Weakness (Generalized). Record Review of Resident #10's Quarterly MDS dated [DATE] reflected a BIMS score of 0 indicating severe cognitive impairment. Record review of Resident #10's MDS dated [DATE] reflected no impairment of Resident #10's functional range of motion of upper extremity shoulder, elbow wrist, or hand. The ability to come to a standing position from sitting in a chair or wheelchair Resident #10 requires supervision or touching assistance. Resident #10 uses manual wheelchair. Observation and interview on 08/13/24 at 11:53 a.m. revealed the call light was on the floor near the wall in Resident #10's room. The call light was pressed, but light outside Resident #10's room did not turn on. When interviewed, Resident #10 was alert, when asked questions, however he was non-verbal. When handed call light, Resident #10 was able to press it when asked to do so. Resident #10 was communicating by hand gestures and sounds. During an interview on 08/13/24 at 12:05 p.m. the Maintenance Supervisor said that she was not aware that Resident #10's light was not working. She said managers were assigned to each Resident rooms and they were supposed to check every morning on each resident ensuring that rooms were clean, residents were not in need of assistance and were also supposed to check that call lights are within residents reach and working properly. She said if they were not working the staff will let her know and also input a work order on their computer program system which automatically sends her an alert to her cellular phone. She said she had not gotten any notification regarding Resident #10's call light. During an interview on 08/13/24 at 12:25 p.m. the Dietary Manager said he was in charge of checking Resident #10 and his room every morning. He said he was supposed to check in on him and make sure his room was clean. He said he has a checklist of things to look at and make sure everything was functioning like it should be. He said he did not check that morning if the call light was working. He said he's not sure why he didn't check. He said if the call light was not working, he will let the maintenance manager know or he will input the work order request in their computer system. He said Resident #10 used his call light sometimes or sometimes he yells out calling for staff to come to his room. The Dietary Manager said if Resident #10's call light was not working and needed help, he may end up having a fall or getting hurt. During an interview on 08/13/24 at 2:00 p.m., CNA T said she checked in the morning to make sure Resident #10 had his call light near him. She said she did not check if it was working. She said Resident #10 sometimes used his call light. CNA T said she was supposed to be checking if call lights work. She said they had in services on this subject several times out of the month. CNA T said Resident #10 can end up getting hurt if he needed help and he can't reach his call light or if it does not work. During an interview on 08/13/24 at 4:18 p.m., the Administrator said that she assigns department heads to certain rooms. She said that they were supposed to be checking daily on residents and their room. The Administrator also said that staff should be checking periodically to make sure residents had call lights within reach and that they were working properly. She said staff were in serviced as needed and yearly on call lights. Record review of facility's policy titled Policy/Procedure - Nursing Clinical, Subject: Call Light/Bell Policy, revised 05/2023 states; Policy: It is the policy of this facility to provide the resident a means of communication with nursing staff Procedures: 1. Answer the light/bell within reasonable time 2. Turn off call light/bell . 5. Leave the resident comfortable. Place the call device within resident's reach before leaving room. If the call light/bell is defective, immediately report this information to the unit supervisor.

Based on observation, interview and record review, the facility failed to provide assistance devices (bed and/ or chair alarms) for two (Residents #1 and #3) of five Sampled Residents (SR#1- SR#5) who were assessed as being at high risk for falls to prevent accidents. -SR#1's admission plan of care required a chair alarm to be placed on SR#1's wheelchair to prevent falls. On 07/12/11 no chair alarm was placed on SR#1's wheelchair. SR#1 fell from the wheelchair and sustained a head injury requiring 10 sutures to the right side of SR#1's head, three sutures to the front of SR#1's head and skin tears to SR#1's right elbow and right knee. -SR#3 was assessed by the facility to be at high risk for falls. The plan of care for SR#3 required use of bed and chair alarms to prevent falls. On 07/18/11, no bed alarm was observed for SR#3. Failure to provide assistance devices to prevent falls could place 37 of 37 residents assessed as being at high risk for falls at risk for injury. The findings were: 1. SR#1's history and physical examination [REDACTED]. SR#1's Admission Baseline Data and Guidelines For Care and Treatment dated 05/18/11 indicated SR#1's fall risk assessment score was 22. The fall risk assessment indicated a score above 10 represented a high risk for falls. SR#1's Admission Care Plan dated 05/18/11 indicated SR#1 was to have a sensor alarm (a device that sounds an alarm to alert a caretaker when a resident is attempting to stand unattended) to the bed and wheelchair. SR#1's Minimum Data Set (MDS) assessment dated [DATE] indicated SR#1 was admitted to the nursing facility on 05/18/11. SR#1's MDS indicated SR#1 had fallen the month prior to admission to the nursing facility and had fallen two to six months before admission to the nursing facility. SR#1's MDS indicated he required extensive assistance by two persons for bed mobility, extensive assistance by one person for transfers, extensive assistance by one person for locomotion and SR#1's surface to surface transfer was not steady, only able to stabilize with human assistance. SR#1's MDS indicated he was able to make himself understood and had the ability to understand others. SR#1's MDS indicated he scored a 10 of 15 on a short interview to assess memory. SR#1's Care Plan, dated 06/09/11, indicated SR#1 had potential for falls and/or injuries that related to generalized body weakness, lack of coordination, and abnormal gait. The approaches listed for the Care Plan were: "1. Gather information on past falls and attempt to determine cause of falls. Anticipate and intervene to prevent future recurrence. 2. Be sure call light is within reach and encourage (SR#1) to use it for assistance as needed. 3. Ensure the floors are even and free from spills or clutter, adequate lighting, side rails as ordered, and personal items within reach. 4. Physical therapy to evaluate and treat as ordered or as needed. 5. Provide activities that minimize a potential for falls. 6. Ensure the resident is wearing appropriate footwear (shoes, bedroom slippers, nonskid socks) when ambulating or up in wheelchair." SR#1's Computerized physician's orders [REDACTED]. SR#1's Incident/Event Investigation, dated 07/12/11, stated "Incident: Fall causing head injury, traumatic wounds to the head, right knee, right elbow and ER (emergency room ) transfer so Resident can be evaluated." The investigation section indicated SR#1 was showered and dressed at 7:08 a.m. by Certified Nurse Aide (CNA) "B". CNA "A" and CNA "B" transferred SR#1 to a wheel chair at 7:09 a.m.. CNA "A" then transported SR#1 to his room and failed to notice SR#1 did not have a chair alarm on his wheelchair. SR#1's roommate activated the call light after SR#1 fell while attempting to transfer self from his wheelchair to his bed. SR#1 had 10 sutures to the right lateral aspect of the head and three sutures to the frontal aspect of the head. SR#1 also had skin tears to the right elbow and right knee. SR#1's investigation indicated there was no alarm on SR#1's wheelchair to alert a staff member of SR#1's attempt to self transfer from the wheelchair to the bed. Certified Nurse Aide (CNA) "A" was suspended until further investigation for not ensuring SR#1 had an electronic sensor alarm on his wheelchair and incorrectly documenting SR#1 had a wheelchair alarm in place. AccuNurse (a program that prompts a CNA to check for bed or chair alarms) documentation for SR#1, dated 07/12/11, indicated CNA "A" transferred SR#1 to a chair at 7:09 a.m. and checked for the chair alarm. SR#1's Daily Skilled Nurse's Note, dated 07/12/11, indicated Maintenance Coordinator (MC) "G" called the nurse to SR#1's room at 7:55 a.m. The Nurse's Note indicated SR#1 was laying on his right side between the wheelchair and the A and B beds. SR#1 stated he was trying to get to the bed. The Nurse's Note indicated there was blood on the floor from two open areas to SR#1's head, one in the front and one on the right lateral side. SR#1 had no complaints of dizziness but stated he had pain to the right shoulder. Emergency Medical Services (EMS) was called, and SR#1 left the faciity on a stretcher at 10:00 a.m. with EMS. SR#1's Physician's Telephone Orders dated 07/12/11 indicated the Physician ordered to send SR#1 to the emergency room for evaluation and treatment due to a fall. SR#1's Nurse's Notes, dated 07/12/11, indicated SR#1 was readmitted to the facility at 10:45 p.m. and had no complaints of pain. The Nurse's Notes indicated SR#1 had sutures to the right lateral head, right frontal head, and a skin tear to the right elbow and right knee. SR#1's Care Plan dated 07/12/11 indicated SR#1 fell while attempting to transfer self from wheelchair to bed without assistance on 07/12/11. The approaches were: "1. Monitor labs as ordered by physician. 2. Orthostatic B/Ps monthly, after falls or as needed. Report abnormal labs to physician. 3. Notify family of all falls and injuries. 4. Monitor for side effects of medications. 5. Keep area clear of clutter and hazards. 6. Keep bed wheels in locked position. 7. Keep call light in reach of resident at all times. 8. Encourage resident to ask for assistance as needed. 9. Transfer with assist of two staff member. 10. Respond to toileting needs immediately when urge is voiced. 11. Attend therapy as ordered." On 07/18/11 at 8:30 a.m. the Director of Nurses (DON) said SR#1 fell on [DATE], causing two lacerations, one to the right side of his head and one to the front of his head. SR#1 also had skin tears to the right elbow and right knee. The DON said SR#1 received 10 sutures to the right side of his head and three sutures to the front of his head. SR#1 was taken to the emergency room right after the fall and came back to the nursing facility on the same day. The DON said on 07/12/11 CNA "A" and CNA "B" showered SR#1. CNA "A" and CNA "B" then transferred SR#1 from the shower chair to the wheelchair and brought SR#1 to the dining room. The DON said SR#1 was scheduled for a colostomy that day and was on a clear liquid diet, so CNA "A" removed SR#1 from the dining room and placed SR#1 in his room next to the bed and left the room. The DON said before SR#1 received his breakfast tray, SR#1 attempted to transfer himself from the wheelchair to the bed. The DON said the wheelchair wheels were not locked and SR#1 fell forward, suffering the head injuries. The DON said CNA "A" said when she was interviewed she had locked the wheels of SR#1's wheelchair. The DON said SR#1 was to have a bed alarm and chair alarm. The DON said the facility's policy was that all residents were to have bed and chair alarms for the first 90 days from admission to evaluate a resident's fall risk. The DON said SR#1 had been admitted to the facility less than 90 days ago. The DON said SR#1 had previous falls at home prior to admission to the facility. On 07/18/11 at 8:55 a.m., SR#1 was in bed eating breakfast. SR#1 said he remembered falling, because he tried to go from the wheelchair to the bed. SR#1 said an alarm went off. On 07/18/11 at 8:57 a.m., SR#2 said he witnessed SR#1 fall on 07/12/11. SR#2 said two nurses brought SR#1 to the room, and he saw one nurse bend down as if to lock the wheelchair. SR#2 said the nurses told SR#1 to stay in the chair, and they would be right back. SR#2 said he saw SR#1 get out of the chair by himself and fall. SR#2 said he did not hear an alarm go off. SR#2 said nurses came to SR#1's aide, because SR#1 was yelling. On 07/18/11 at 9:45 a.m. Medical Records Coordinator (MRC) "C" said she saw SR#1 lying on the floor on 07/12/11. MRC "C" said the Assistant Director of Nurses (ADON) "J", CNA "A" and CNA "B" helped SR#1 after the fall by taking his vital signs. MRC "C" said SR#1 had skin tears to the back and side of his head. MRC "C" said SR#1 was transferred by stretcher to the emergency room but had no complaints of pain. MRC "C" said every resident received bed and chair alarms for the first 90 days. If a resident refused to have the alarms on and was stable, MRC "C" would encourage the resident to keep the alarms. MRC "C" said she was responsible for placing the bed and chair alarms for all the new residents, and SR#1 had alarms for the bed and the wheelchair. MRC "C" said she observed there was no chair alarm on SR#1's wheelchair when SR#1 fell . MRC "C" said she did not know why there was no chair alarm on the wheelchair, but possibly, SR#1 had been in somebody else's wheelchair. On 07/18/11 at 12:15 p.m. Licensed Vocational Nurse (LVN) "H" said she was working the day that SR#1 fell . LVN "H" said SR#1 had a shower and then was taken to the dining room, but SR#1 was on a clear liquid diet so the CNA brought SR#1 back to his room. LVN "H" said SR#1's normal routine would be to go to the shower and then go back to bed, but because of a doctor's appointment, the CNA did not put SR#1 back to bed. LVN "H" said Maintenance Coordinator (MC) "G" was passing by SR#1's room and saw the call light was on, so he looked in the room, saw SR#1 on the floor, and called for LVN "H." LVN "H" said she assessed SR#1. SR#1 was awake and did not complain of any pain. LVN "H" said she observed no chair alarm on SR#1's wheelchair. LVN "H" said the facility's policy was all new admissions should have a wheelchair and bed alarm, especially for SR#1 due to a history of falls. On 07/18/11 at 12:17 p.m. SR#1's Family Member (FM) "K" said SR#1 did not like the alarms on the bed and the wheelchair, but SR#1 had not attempted to take them off. On 07/18/11 at 12:50 p.m. MC "G" said Maintenance Staff (MS) "I" alerted him SR#1 was on the floor. MC "G" said he called for a nurse right away and did not hear an alarm going off. On 07/18/11 at 12:55 p.m. MS "I" said he did not remember but thought an alarm was going off. MS "I" said he thought he heard the alarm, and then looked and saw SR#1 on the floor. MS "I" said he did not turn off an alarm. On 07/18/11 at 2:15 p.m. CNA "B" said CNA "A" brought SR#1 to the shower. After CNA "B" showered SR#1, both CNA "B" and CNA "A" transferred SR#1 from a shower chair to a regular wheelchair. CNA "B" said there was no alarm on the wheelchair. On 07/18/11 at 2:25 p.m. CNA "A" said she took SR#1 to the shower in a shower chair, went back and cleaned SR#1's room, and then went back to the shower room. CNA "A" said she helped CNA "B" dress SR#1 and transfer him from the shower chair to the wheelchair. CNA "A" said she did not check for a wheelchair alarm. CNA "A" said she then wheeled SR#1 to the nurse's station, and a nurse told her to take SR#1 to the dining room. CNA "A" said another nurse said SR#1 could not be in the dining room, because he was on a clear liquid diet for his doctor's appointment, so CNA "A" took SR#1 back to his room. CNA "A" said she placed SR#1 next to his bed, locked the wheels on the wheelchair, and placed the bedside table next to SR#1 to prepare for his meal. CNA "A" said 10 minutes later she heard SR#1 had fallen. CNA "A" said she did not check for the wheelchair alarm and did not remember ever seeing SR#1 with a bed alarm. On 07/18/11 at 2:55 p.m., the DON reviewed SR#1's care plan dated 06/09/11 and 07/12/11. The DON verified there were no indications of a bed and/or chair alarm in SR#1's most current care plans. The DON said use of bed and chair alarms should have been addressed on SR#1's care plans. 2. SR#3's history and physical examination [REDACTED]. SR#3's History and Physical indicated she was at risk for falls. SR#3's Fall Risk assessment dated [DATE] indicated SR#3's score was 14. The Fall Risk Assessment indicated a score of 10 or higher was at risk for falls. The Fall Risk Assessment indicated if a Resident scored a 10 or above, interventions should be initiated. SR#3's intervention section of the Fall Risk Assessment form was blank. SR#3's July 2011 physician's orders [REDACTED]. SR#3's Admission Care Plan, undated, indicated SR#3 was to have a bed and wheelchair sensor alarm. SR#3's Communication Form dated 07/15/11, 12:10 p.m. indicated SR#3's family would no longer be staying consistently at the facility and the three-month trial for bed and wheelchair alarms was to be reinstated. SR#3's AccuNurse Documentation dated 07/01/11, 7:05 p.m. through 07/15/11, 7:31 a.m. indicated the SR#3's bed alarm was checked by the CNA on 12 separate occasions. 12 of the 12 times the bed alarm was checked the CNA indicated a bed alarm was in place. SR#3's AccuNurse Documentation of 07/15/11, 1:04 p.m. through 07/18 /11, 7:10 a.m. indicated SR#3's bed alarm was checked on seven separate occasions. six of the seven occasions the CNA indicated the bed alarm was in place. The Weekly Alarms List as of 07/13/11 indicated SR#3's bed and chair alarms were in place. On 07/18/11 at 10:30 a.m., surveyor and LVN "D" observed SR#3 did not have a bed alarm on her bed. SR#3's family members were present in the room, but SR#3 was in physical therapy. SR#3's FM "L" said she had signed a waiver so SR#3 did not have to have a bed alarm. On 07/18/11 at 11:10 a.m., MRC "C" said SR#3's family was with SR#3 all day long and even slept at the facility at night. MRC "C" said she allowed them to sign a waiver to remove SR#3's bed alarm. MRC "C" said recently, SR#3 received a roommate and SR#3's family could no longer spend all night, so the bed alarm was reinstated on 07/15/11. MRC "C" said she did not know why SR#3 did not have a bed alarm. MRC "C" said the waiver would be in SR#3's medical chart. On 07/18/11 at 2:00 p.m., LVN "F" reviewed SR#3's medical chart and said the waiver to remove the bed alarm for SR#3 could not be found. On 07/18/11 at 2:05 p.m., ADON "J" said waivers for bed alarms should be given to her so she can update the AccuNurse system . ADON "J" said she did not recall seeing a waiver for the bed alarm for SR#3. The ADON said the CNAs use a system called AccuNurse, which would prompt the CNA to check for a bed or chair alarm whenever they did a transfer of a resident. The ADON said she was responsible for changing the prompt in the AccuNurse program whether to discontinue for a bed or chair alarm, and she had not discontinued the bed or chair alarm for SR#3 since SR#3 was admitted . The ADON said the CNAs should had been checking for a bed and chair alarm for SR#3 since SR#3's admission on 06/19/11. The facility's Falling Star Program Policy Statement, effective 05/12/05 states "Our purpose is to provide a safe environment for our resident and help prevent accidents by monitoring them adequately and anticipating their needs." On 07/18/11 at 4:30 p.m. the Administrator and the DON were asked if there was any additional information they would like to present regarding interventions for fall prevention. No additional information was presented. The facility Weekly Alarms List dated 07/13/11 identified 37 of 89 residents required bed and/or chair alarms.