Every finding on record at Vidor Health & Rehabilitation Center

Based on observation, interview, and record review the facility failed to have sufficient nursing staff to assure resident safety and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 1 of 4 halls (500 Hall) reviewed for sufficient nursing staff. *The facility did not always have the secured unit (500 Hall) staffed with 2 CNAs as indicated in the facility assessment. This failure could place residents who reside on the 500 Hall at risk of diminished quality of life and quality of care, injuries, elopement risk, and delayed treatment. Findings included: Record review of the Facility assessment dated [DATE] indicated: .Staff AssignmentsDescribe how you determine and review individual staff assignments for coordination and continuity of care for residents within and across these staff assignments. Resident-centered collaborative care is defined by the Agency for Healthcare Research and Quality as care that is relationship-based with an orientation toward the whole person, and that includes partnering with residents and their families to understand and respect each resident's unique needs, culture, values, and preferences. Care that is resident-centered also supports residents in learning to manage, organize, and participate in their own care at the level the resident chooses. Based on the information provided in this assessment, the facility's staffing needs per unit and per shift is on the following pages: .Unit-Hall 5006a-2p or 6a-6p Licensed Nurse 1 CMA CNA 2 2p-10p (blank if 12 hr shift) Licensed Nurse 1 CMA CNA 210p-6a or 6p-6a (blank if 12 hr shift) Licensed Nurse see below CMA CNA 1. During observations on 07/13/26 of the 06:00 a.m. to 02:00 p.m. shift indicated:-at 09:15 a.m. there was 1 LVN and 1 CNA (LVN A and CNA B) on the secured unit. LVN A had RN C orientating with her. -at 09:18 a.m. the nursing office on the secured unit had no CCTV monitoring of the hall, dining area, or sitting room. These areas were not visible from the nurse office. -at 10:37 a.m. CNA B left the dining room area, where there were 10 residents, to attend to a resident in their room. LVN A and RN C were in the nursing office at the opposite end of the hall.-at 10:41 a.m. a resident stood up out of his wheelchair and was trying to walk around. -at 10:42 a.m. CNA B returned to the dining room and assisted the resident back to his wheelchair to sit down. -at 12:15 p.m. CNA B left the dining room area where there were 14 residents to attend to a resident in their room. LVN A and RN C were in the nursing office at the opposite end of the hall.-at 12:18 p.m. CNA B returned to the dining room. LVN A and RN C were in the nursing office at the opposite end of the hall.-at 12:21 p.m. dietary staff brought the lunch trays on an open slotted cart to the unit. LVN A was not there to check the trays. -at 12:32 p.m. LVN A left the secured unit without checking the lunch trays on the cart. -at 12:34 p.m. RN C brought a resident to the dining room and sat them at one of the tables for lunch then left the dining room. Lunch trays remained on the cart untouched. -at 12:35 p.m. LVN A returned to the secured unit nurse office. Lunch trays remained on the cart unchecked.-at 12:36 p.m. RN C returned to the dining room and began checking the lunch trays. RN C and CNA B began passing the lunch trays. LVN A remained in the nursing office on the unit. -at 12:48 p.m. CNA B was feeding resident and RN C was monitoring the dining room when a resident came into the dining room with no pants on. RN C assisted the resident back to his room to assist him with putting on pants. During an interview on 07/13/26 at 12:25 p.m. CNA B said she was the only CNA on the secured unit and it was like that several days a week. CNA B said there were times residents would be left unattended due to her having to change residents or her to obtain the meal cart. CNA B said she was not to pass out lunch trays until the charge nurse checked the trays for accuracy. CNA B said if RN C was not in the dining room she would have had to stop feeding the resident she was feeding and take the other resident back to his room to put his pants on for him leaving the residents in the dining area unattended. During further observations on 07/13/26 of the 06:00 a.m. to 02:00 p.m. shift indicated:-at 01:05 p.m. CNA B left the unit to take the lunch cart back to the kitchen. LVN A and RN C were not monitoring residents in the dining area; they were in the nursing office at the opposite end of the hall unable to see the dining area.-at 01:07 p.m. a resident was rolling back in her low sitting wheelchair and the metal arm that attaches the headrest to the wheelchair hit another resident, who was wearing a long sleeve t-shirt, in the left elbow area. The resident who was hit by the wheelchair jumped and said That hurt.-at 01:09 p.m. CNA B returned to the dining area and was informed of the incident. CNA B pulled up the resident's sleeve and checked the resident's left elbow. She said there was a skin tear and called for LVN A. During an interview on 07/13/26 at 03:55 p.m. LVN M said most evenings there was only 1 nurse and 1 CNA on the secured unit. She said they actually had an extra CNA until 6 p.m. She said if the nurse was passing medications or charting in the nursing office and the CNA was in a room changing a resident the residents would be left unattended. During an interview on 07/13/26 at 04:00 p.m. CNA D said she was the only CNA on the unit several evenings a week. She said there were only 2 full time CNAs for the evening shift. She said there were times when she had to leave the unit or be in a resident room to assist a resident and the nurse would be busy charting in the nurse office or passing medications and would not be able to monitor the residents. During an interview on 07/13/26 at 04:05 p.m. CNA E said she was PRN and would work some shifts because there was only 1 CNA working the secured unit. She said she was working until 6 p.m. today. Record review of the Daily Nursing Schedule sign in sheet dated 07/13/26 indicated:-the 06:00 a.m. to 02:00 p.m. shift had LVN A and CNA B listed with a second CNA with no name,-the 02:00 p.m. to 10:00 p.m. shift had LVN M and CNA D. CNA E was listed to work until 06:00 p.m. Record review of the resident roster provided by the Administrator on 07/13/26 at 08:54 a.m. indicated there were 19 residents on the 500 Hall (secured unit). During observations on 07/15/26 of the 06:00 a.m. to 02:00 p.m. shift indicated at 09:55 a.m. there was 1 LVN and 1 CNA (LVN A and CNA N) on the secured unit. During an interview on 07/15/26 at 10:26 a.m. CNA N said she was the only CNA on the unit for the morning shift. CNA N said there were several days she would be the only CNA on the secured unit. CNA N said she did the best she could but residents were left unattended if the nurse was not in the dining room monitoring the residents. CNA N said there were at least 12 incontinent residents and at least 6 residents with fall risk. During an interview on 07/15/26 at 11:03 a.m. LVN A said she usually had only 1 CNA on the secured unit with her. LVN A said she tried to be out of the nursing office to help monitor but she could not always. LVN A said there were no cameras to be able to monitor the residents on the hall, in the dining room, or in the sitting area from the nursing office on the unit. LVN A verified there were 18 residents on the secured unit, at least 12 residents were incontinent and required assistance, and at least 6 residents were a fall risk. Record review of the Daily Nursing Schedule sign-in sheet dated 07/13/26 indicated:-the 06:00 a.m. to 02:00 p.m. shift had LVN A and CNA B listed with a second CNA with no name,-the 02:00 p.m. to 10:00 p.m. shift had LVN M and CNA D. CNA E was listed to work until 06:00 p.m. Record review of the Daily Nursing Schedule sign in sheets for 06/15/26 through 06/30/26 indicated:-on 06/15 there was 1 nurse and 1 CNA on 6a-2p shift and 1 nurse and 1 CNA on the 2p-10 shift -on 06/16 there was 1 nurse and 1 CNA on 6a-2p shift and 1 nurse and 1 CNA on the 2p-10 shift;-on 06/18 there was 1 nurse and 1 CNA on 6a-2p shift;-on 06/22 there was 1 nurse and 1 CNA on 6a-2p shift and 1 nurse and 1 CNA on the 2p-10 shift; -on 06/24 there was 1 nurse and 0 CNA on the 2p-10 shift (both had called in);-on 06/25 there was 1 nurse and 1 CNA on the 2p-10 shift;-on 06/26 there was 1 nurse and 1 CNA on the 6a-2p shift and 1 nurse and 1 CNA on the 2p-10 shift; -on 06/27 there was 1 nurse and 1 CNA on the 2p-10 shift; -on 06/29 there was 1 nurse and 1 CNA on the 2p-10 shift; and -on 06/30 there was 1 nurse and 1 CNA on the 2p-10 shift. Record review of information provided on 07/14/26 at 01:28 p.m. by the RCN/Former DON indicated the census on the secured unit (500 Hall) for 06/15, 06/16, 06/18, 06/22, 06/24, 06/25, 06/26, 06/27, 06/29, and 06/30 was 19. Record review of the Daily Nursing Schedule sign in sheets for 07/01/26 through 07/15/26 indicated:-on 07/01 there was 1 nurse and 1 CNA on 6a-2p shift;-on 07/02 there was 1 nurse and 1 CNA on 6a-2p shift and 1 nurse and 1 CNA on the 2p-10 shift; -on 07/03 there was 1 nurse and 1 CNA on 6a-2p shift and 1 nurse and 1 CNA on the 2p-10 shift; -on 07/04 there was 1 nurse and 1 CNA on 6a-2p shift and 1 nurse and 1 CNA on the 2p-10 shift;-on 07/05 there was 1 nurse and 1 CNA on 6a-2p shift and 1 nurse and 1 CNA on the 2p-10 shift; -on 07/06 there was 1 nurse and 1 CNA on 6a-2p shift;-on 07/07 there was 1 nurse and 1 CNA on 6a-2p shift; -on 07/08 there was 1 nurse and 1 CNA on 6a-2p shift and 1 nurse and 1 CNA on the 2p-10 shift; -on 07/09 there was 1 nurse and 1 CNA on the 2p-10 shift; -on 07/10 there was 1 nurse and 1 CNA on 6a-2p shift and 1 nurse and 1 CNA on the 2p-10 shift; -on 07/11 there was 1 nurse and 1 CNA on 6a-2p shift; -on 07/12 there was 1 nurse and 1 CNA on 6a-2p shift and 1 nurse and 0 CNA on the 2p-10 shift; -on 07/13 there was 1 nurse and 1 CNA on 6a-2p shift; and -on 07/15 there was 1 nurse and 2 CNA on 6a-2p shift. Record review of information provided on 07/14/26 at 01:28 p.m. by the RCN/Former DON indicated the census on the secured unit (500 Hall) for 07/01 through 07/05 was 19, for 07/06 through 07/10 was 20, and 07/11 through 07/12 was 19. During an interview on 07/15/26 at 04:22 p.m. the CN/Former DON said the facility should follow what the Facility Assessment indicated on staffing. She said they tried to cover staffing as best as they could. During an interview on 07/15/26 at 04:46 p.m. the Administrator said she was not aware the Facility Assessment indicated there should be 2 staff on the secured unit. She said she had only been with the facility a few weeks but would work on the staffing.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 2 freezers (Freezer #2), 1 of 4 refrigerators (Refrigerator #4), and 1 of 1 kitchen reviewed for food and nutrition services. The facility failure to ensure food items in Freezer #2 were labeled, dated, and sealed. The facility failed to ensure Refrigerator #4 was clean and free of debris and spills. The facility failed to ensure the water and drainpipes under dish machine were free of leaks. The facility failed to ensure that the floor in the kitchen was clean and intact. The facility failed to ensure the kitchen ceiling was free of holes. The facility failed to ensure the garbage in the kitchen was in the receptacle with lid on the garbage barrel and away from food. The facility failed to store staff's personal drink away from food preparation area. This failure could place residents at risk for health complications, foodborne illnesses, and decreased quality of life. Findings included: During observations on 07/13/2026 from 8:30 to 9:15 a.m. *Freezer#2 had 2 unmarked and unsealed gallon bags which contain approximately 16 frozen cookies and approximately 20 frozen garlic bread rolls. *Refrigerator #4 had clear liquid on the bottom shelf and had spills and food debris. There were 2 cardboard boxes with 4 sealed bagged eggs and 8- 1 pound butter blocks not bagged on the bottom shelf with clear liquid, spills and food debris. The boxes were soaked with clear liquid. *Ceiling in the dish room had 3 holes around the air-conditioning vent approximately 3 by 4 inches and had black substance around the sheetrock with water damage. *The water pipes and drainpipes were leaking under the dish machine, and the floor was wet and 8 tiles were loose and the grout deteriorated. During an interview on 07/13/2026 at 9:20 a.m., the DM said all food items in the freezers and refrigerators should be dated, labeled and sealed to prevent contamination. The DM said the clear liquid had been there, and she was unaware why that happened. She said the refrigerators and freezers should be kept cleaned to prevent food related illnesses. She said she was new and would see why maintenance had not fixed issues in the kitchen. During an interview on 07/13/26 at 9:25 a.m., dietary staff K said the ceiling was like that when he hired on, one year ago. He said he put a bucket under the pipes and said the drain water still splashed and got on the floor and under the loose tiles. He said he had reported the leaking water and loose tiles. During an observation and interview on 7/15/26 at 11:45 a.m., approximately 1 cup of scrambled eggs was on the floor in front of the steam table as [NAME] L was placing items for lunch on the steam table. [NAME] L pureed the beef patties in the mechanical processor for the pureed diets. Next to the processor on the food preparation table was a personal drinking cup. [NAME] L said his coffee should not be there. He said each cook was responsible for cleaning up after each meal and he cooked breakfast and missed those eggs. He said his drink needed to be keep away from the food preparation area and cleaning after each meal prevents spread of germs. There was a rolling trash can 64 gallons without a lid 1/2 full of garbage next to the preparation table and a clean food rack which had clean trays and desserts. During an interview on 07/15/2026 at 12:30 p.m., Maintenance supervisor said he could not fix the ceiling in the kitchen until the roof was fixed, no one reported pipes were leaking again. He said he was unaware about the refrigerator having water in the bottom shelve. Record review of undated Inservice: Food Receiving and Storage indicated Specific procedures are required to maintain a safe food supply. The residents in our facility tend to be at a higher risk for infection and illness than the rest of the populations. floors needs to be kept clean.3. Date all food items with the date received it was received. Record review of undated Dietary Food Services Personnel policy and procedures indicated . dispose of food fallen on the floor .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for kitchen reviewed for physical environment.The facility failed to ensure the kitchen was free from gnats. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.Findings included:During an observation on 07/13/2026 at 9:05 a.m. there were 4 to 6 gnats in the kitchen in the dish room flying around the leaking pipes.During an interview on 7/13/2026 at 9:25 a.m., dietary staff K said there were gnats because of the drained water last 3 weeks.During an observation on 07/14/2026 at 11:50 a.m., approximately 5 to 6 gnats were flying around a box on the floor with garbage in it and over the preparation table where the [NAME] L was battering chicken. He said insects can cause spread of germs.During an interview on 7/15/26 at 3:30 p.m., the Maintenance supervisor said no one had reported pests in the kitchen and said the exterminator company was here a week ago, but no one reported the kitchen was having gnats. He said he would notify pest control company. Record review of the Texas Food Establishment Rules dated October 2015 indicated . (k) Controlling pests. The presence of insects, rodents, and other pests shall be control to eliminate their presence on the premises by: (1) routinely inspecting incoming shipments of food and supplies; .(2) routinely inspecting the premises for evidence of pests; .(3) using methods, if pests are found, such as trapping devices or other means of pest control as specified under S228.204(b) andS228.208(b) and (c) of this title; . and (4) eliminating harborage conditions. [34].

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident (Resident #54) reviewed for enteral devices. The facility failed to ensure RN G administered Resident #54's water flush by gravity instead of pushing it through his gastronomy tube (placement of a tube into the stomach used for nutrition and medication administration) with a syringe on 07/14/2026. This failure could affect residents receiving enteral nutrition, medications, and hydration by placing them at risk of health complications.Findings included: Record review of Resident #54's face sheet dated 07/14/2026 indicated he was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included cerebral infarction (stroke), gastronomy status (surgically placed soft flexible tube inserted through the abdomen into the stomach) and dysphagia (difficulty swallowing). Record review of Resident #54's Quarterly MDS assessment dated [DATE] indicated he had a BIMS score of 2, indicated severely impaired cognition with diagnoses of cerebral infarct. Resident #54's MDS assessment indicated the resident had a feeding tube. Record review of Resident #54's Order Summary Report dated 07/15/2026 indicated enteral feeding order flush tube with 30 ml water before and after medication and feeding with a start dated 10/16/2025 and three times a day flush gastronomy tube with 300 ml of water with a start date of 04/08/2026. Record review of Resident #54's care plan with a target date of 07/30/2026 indicated he had a gastronomy tube related to dysphagia.During an observation and interview on 07/14/2026 at 9:11 a.m., indicated Resident #54 was sitting up in his wheelchair. He said the staff gave him his medication in the tube in his stomach. During an observation of medication administration with RN G on 07/14/2026 starting at 9:15 a.m., RN G said she was providing care for Resident #54 today. She administered his medication through the gastronomy tube by gravity flow. She called for LVN H to bring a cup of water to her. RN G then she drew up the water in the syringe. LVN H asked RN G if she was going to give the water by gravity flow and RN G said no. RN G then pushed the water through Resident #54's g-tube slowly. RN G said she should have inserted the water by gravity instead of pushing it with the syringe with the plunger. She said she was educated to give medication and water by gravity. She said she was using the syringe and plunger to measure the water. RN G said the risk of pushing the water and not giving by gravity flow was it could cause regurgitation by the resident. During an interview on 07/14/2026 at 4:45 p.m. the DON said RN G should not have pushed water into the gastronomy tube, it should have been given by gravity. She said RN G may have gotten nervous and pushed the water in the gastronomy tube, but she was educated on gastronomy tube medication administration. The DON said RN G was being onboarded by LVN H. She said the resident risk was potentially gastric upset. The DON said her expectation was nurses follow policy giving gastronomy tube medication. During an interview on 07/15/2026 at 12:45 p.m., LVN H said she was training RN G yesterday. She said she was monitoring her while giving medication. LVN H said she asked RN G if she was going to give water to the resident by gravity and RN G said no. She said RN G was educated on gastronomy tube medication administration. She said the resident risk of giving liquid through a gastronomy tube by a push instead of gravity was potential stomach problems. During an interview on 07/15/2026 at 1:25 p.m. the Administrator said the charge nurse was responsible for giving gastronomy tube medication properly. She said she was unsure of RN G's background, and she may not be used to working in long term care. She said RN G had a nursing license and was educated on gastronomy medication procedures. The Administrator said RN G was being onboarded with another nurse. She said the resident risk of pushing fluid into the gastronomy tube instead of given by gravity was a potential contra indication such as nausea or vomiting. The Administrator said her expectation was gastronomy tube medication be given according to policy and procedure. Record review of the facility's policy titled, Enteral Tube Medication Administration, dated 3/2025, indicated, . The facility assures the safe and effective administration of enteral formulas and medication. 8. Flush the tube with 30 ml of water.10. allow medication to flow down tube via gravity. 11. Flush the tube with 30 ml of water and clamp. Prevents medication from clogging tube .

Based on observation, interview, and record review the facility failed to serve each resident food prepared in a form to meet individual needs for one of one meal (lunch meal 07/14/2026) reviewed for pureed food preparation. The facility failed to ensure [NAME] L prepared puree meat to pudding consistency with no pieces. These failures could result in choking hazards, decreased nutrient intake and weight loss. Findings included: During an observation on 07/14/2026 at 11:45 a.m., [NAME] L pureed chicken, green beans and made mashed potatoes for pureed diets. During an observation and tasting of the pureed tray on 07/14/2026 at 1:30 p.m., the test pureed lunch meal had 2 solid pieces chicken was 1/4 by 1/4 inch of meat and there was a part of whole green bean approximately 1/2 inch in the pureed meat and the DM said her bite was smooth. The DM said the pureed food should be smooth and pudding consistency to prevent choking. She said the cook was responsible for ensuring no solid pieces were in the pureed food. Record review of the Diet Type Roster dated 07/13/2026 indicated 9 residents had pureed as their diet orders. Record review of the recipe for fried chicken for pureed diet dated 07/14/2026 indicated .Desired texture should be mashed potatoes, pudding, or applesauce texture. There should be no large lumps or particles.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 2 dining rooms and for Resident #4 and Resident #80 observed for reviewed for physical environment. The facility failed to ensure the main dining room was free of water leaks and free of a water-stained ceiling. This failure could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. Findings included:Record review of Resident #4's admission record indicated she was admitted on [DATE] and was [AGE] years old with diagnoses included blood in her urine and chronic kidney failure. Record review of Resident #4's quarterly MDS assessment dated [DATE] indicated her BIMS was 12 which indicated she had moderate cognitive impairment. Record review of Resident #80's admission record dated 07/14/2026 indicated she was admitted on [DATE] and was [AGE] years old with diagnoses included stroke and heart disease. Record review of Resident #80's quarterly MDS assessment dated [DATE] indicated her BIMS was 13 which indicated she was cognitively intact. During an observation on 07/13/2026 at 11:00 a.m., revealed the main dining room's ceiling had 6 areas of discolored (tan) sheet rock. One of the discolored areas was oblong and was approximately 3 feet long and approximately 1 and 1/2 feet wide. The 5 others were round and approximately one foot to 6 inches. The areas were in the center of the dining room. During an observation on 07/14/2026 at 12:30 p.m., revealed the middle of the main dining room was blocked off with wet floor signs, a mop bucket and a blanket on the floor between 2 rows of tables. During an interview on 07/14/2026 at 12:40 p.m., Resident #4 and Resident #80 were sitting and were visiting. Resident #80 said she had to move to another table during lunch because of the roof leaking. They both said the ceiling had been leaking for a few months. During an interview on 07/15/2026 at 8:45 a.m., the Administrator said she wanted the dining room to be free of leaks and discolored ceiling. She said the facility had been trying to get it fixed. She said last April 2026 the facility had new air-conditioning installed. She said the facility had spent a lot of money on the new air-conditioning and the company had worked on duct work trying to get the leaks fixed. She every time they have new leaks when it rains rain. During an interview on 07/15/2026 at 9:30 a.m., the Maintenance Supervisor said the company was coming out Saturday (07/18/2025) to give an estimate to fix the leak. During an interview on 07/15/2026 at 2:00 p.m., the Housekeeping Supervisor said the housekeepers mopped the dining room several times a day if it rained. She said the ceiling leaked and the ceiling being discolored started 3 to 4 months ago. She said the company that had replaced the air-conditioning unit had come out and would patch around the duct work a couple of times, but when the rain started a new area would leak. She said when the leaking started, we had to shut the dining room down because the sheet rock ceiling was sagging so badly. She said the dining room only leaks in the middle of the room. Record review of the undated Resident Rights policy . Safe environment - The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must be provided- 1. A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.

Based on interview and record review, the facility failed to implement an antibiotic stewardship program that included antibiotic use protocols. * The facility did not include the antibiotic time out protocol in their Antibiotic Stewardship policy in the Infection Control Tracking and Trending review. This failure could place residents with infections at risk for unnecessary antibiotic use and increased infections that are resistant to antibiotics. Findings included: Record review of an undated Antimicrobial Stewardship Policy indicated Facility Antimicrobial Stewardship Mission StatementOur facility embraces the importance of an infection prevention and control program that includes an antimicrobial stewardship program, providing antibiotic use protocols and monitoring to prevent antibiotic resistance. We are committed to the prudent use of antimicrobials on behalf of all residents we are privileged to serve through a sustainable antimicrobial stewardship program. There was no indication in the policy of a protocol addressing the 72-hour Antibiotic Time Out. Record review of the Infection Control Tracking and Trending Book for 2026 indicated the IP was not conducting a 72-hour Antibiotic Time Out on residents with antibiotics ordered for infections. Reviews were only done on residents who had specimen collected for a C&S. During an interview on 07/14/26 at 10:58 a.m. the IP said she did not realize she needed to conduct a 72-hour antibiotic time out on all residents on antibiotics for infections to ensure they were improving on the antibiotic they were prescribed. She said she did not remember seeing the protocol in the policy. She said she would review the residents if there was a C&S specimen obtained. During an interview on 07/15/26 at 04:46 p.m. the Administrator said she expected staff to follow protocol/policy for what they have been assigned. She said not following protocol/policy regarding antibiotics could cause resident infections not to be addressed appropriately. Record review of the CDC's Core Elements of Antibiotic Stewardship for Nursing Homes accessed on 07/14/26 at https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-b-508.pdf Take Action through Policy and Practice Change to Improve Antibiotic Use:.Broad interventions to improve antibiotic use: Standardize the practices which should be applied during the care of any resident suspected of an infection or started on an antibiotic. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in your facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of anantibiotic when the clinical picture is clearer and more information is available.

Based on observations, interviews, and record review, the facility failed to follow menus for 1 of 2 meals reviewed for menus in that: The facility failed to follow the menu on 07/15/26 at the lunch meal service the pureed diets contained no rolls. This failure could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss. The findings were:Record review of the menu dated 07/15/2026 indicated chicken, mashed potatoes, gravy, vegetables, honey kissed roll and pudding for lunch meal.Record review of the recipe for honey kissed rolls pureed dated 07/15/2026 indicated the pureed diet should have a pureed roll with chicken base. desired thickness should be mashed potatoes or pudding texture.During an observation on 07/15/26 at 11:40 a.m., [NAME] L pureed items for lunch which included meat, potatoes, vegetables and pudding for the pureed diet. [NAME] L did not pureed rolls or bread for the pureed diets.During an interview on 07/15/2026 at 11:50 a.m., [NAME] L said he was unable to make pureed rolls to the right consistency for pureed diets. He said it was too thin or too thick. He said he had been the cook, and he was unable to provide bread for the pureed diet. During an interview on 07/15/2026 at 2:25 p.m., the DM said she was new and was unaware [NAME] L was unable to process bread or rolls to the right consistency. She said she was unaware the pureed diet did not have the rolls today. DM said the pureed diet should include all items on the menu to prevent weight loss.

Based on interview and record review, the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the option he or she prefers for 1 of 5 residents (Resident #3) reviewed for resident rights. The facility failed to ensure Resident #3 had a completed Consent for Antipsychotic or Neuroleptic Medication Treatment (HHSC form 3713) form for Risperidone (an antipsychotic medication). This failure could place residents at risk for treatment or services provided without their informed consent. Findings included: Record review of a face sheet dated 07/15/26 indicated Resident #3 was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Her diagnoses included bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs).She had a POA listed on the face sheet. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #3 had a BIMS score of 03 out of 15, which indicated she had severely impaired cognition. She had an active diagnosis of bipolar disorder. She received antipsychotic medication. Record review of a comprehensive care plan dated 05/24/26 indicated Resident #3 required anti-psychotic medications related to bipolar disorder with an intervention that read: .Educate the resident/family/caregivers about risks, benefits and the side effects. Record review of a physician's order summary report dated 07/15/26 indicated Resident #3 had a physician's order dated 03/28/25 which read .risperiDONE Oral Tablet 0.5 MG (Risperidone) Give 1 tablet by mouth two times a day related to BIPOLAR DISORDER,. Record review of the MARs for May, June, and July 2026 indicated Resident #3 received Risperidone 0.5 mg twice daily every day. Record review of the EMR indicated Resident #3 had an HHSC form 3713 dated 04/07/24 uploaded into the EMR. Risperidone was the antipsychotic listed on the form. The form did not have:-a Vendor Number listed;-in Section I, the dosage and frequency for the medication; and-in Section I, the signature of the person prescribing the medication. Record review of the EMR indicated Resident #3 had an HHSC form 3713 dated 01/14/25 uploaded into the EMR. Risperidone was the antipsychotic listed on the form. The form did not have:-a Vendor Number listed;-the resident's SS number listed;-in Section I, the dosage and frequency for the medication;-in Section II, information as to who was giving the consent; -in Section II, information as to on behalf of who the consent was being given for; and-the signature of the Resident or Resident's Representative, it was signed by staff member with a verbal consent from the POA. During an interview on 07/15/26 at 04:10 p.m., the RCN/Former DON said the form should have been completed with all the missing information prior to being uploaded. She did not realize a verbal consent could not be obtained for the HHSC form 3713. She said she could not make out which staff member signed as receiving verbal consent for Resident #3. She said residents could be at risk for adverse side effects and families may not be made aware of the residents' condition if they were not informed and given the opportunity to consent to treatment. During an interview on 07/15/26 at 04:35 p.m., the Administrator said nursing staff were responsible for ensuring medication consents were signed and in place for psychotropic medications. She said not obtaining completed consents and signed prior to administering psychoactive medications could take away the residents right to being informed regarding their medications and could possibly take away their right to refuse treatment. Record review of a facility policy titled Psychotropic Medication revised 02/12/25 indicated: .Resident's Right to be InformedResidents have the right to be informed of and participate in their treatment. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative will be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. The resident has the right to accept or decline the initiation or increase of a psychotropic medication. The resident's medical record will include documentation that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and was able to choose the option he or she preferred. A written consent form may serve as evidence of a resident's consent to psychotropic medication, but other types of documentation are also acceptable Record review of Provider Letter 2022-11 dated 05/05/22 indicated .2.2 Completing Form 3713The prescriber of the medication, the prescriber's designee, or the NF's medical director must complete Section I of Form 3713. HHSC cannot specify who can be the designee for the prescriber. Prescribers should consult their own board, such as the Texas Medical Board, to determine who can act as their designee. A prescriber can delegate the completion of Form 3713, Section I, if the prescriber's license permits it.The resident or the resident's legally authorized representative must sign Section II of Form 3713. The rule requires consent in writing by the resident or by a person authorized by law to consent on behalf of the resident. Verbal consent does not meet the rule requirements. NF staff cannot sign on behalf of the resident.The original Form 3713 or a copy of the completed form must be kept in the resident's clinical record to meet the consent requirement. Copies could be mailed, faxed or securely emailed if all parties are unable to sign the form in one sitting. Any copy or original consent form must be accurately completed and contain all required information and applicable signatures.

Based on interview and record review, the facility failed to consult with the resident's physician when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences) for 1 of 21 residents (Residents #9) reviewed for resident rights.The facility failed to ensure Resident #9's physician was notified of her insulin was held on 07/08/2026, 07/09/2026 and 07/10/2026.This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition.Findings included: Record review of Resident#9's face sheet dated 04/21/2023 indicated Resident #9 was admitted on [DATE], was a [AGE] year-old female with diagnoses that included acute kidney failure (when kidneys stop working suddenly), and diabetes. Record review of Resident #9's physician's orders for July 2026 indicated she had an order for Tresiba FlexTouch Subcutaneous Solution 100 UNIT/ML (Insulin Degludec) Inject 20 unit subcutaneously one time a day related to diabetes mellitus without complications with a start date of 07/08/2024. The physician's orders contained no hold orders. Record review of Resident #9's MAR dated July 2026 indicated on 7/8 blood sugar was 80, 7/9 blood sugar was 90, 7/10 blood sugar was 97 and the insulin was held. The MAR for Resident #9's was marked a code of 11. (11=BS within Normal Limits no administration was required). Record review of Resident #9 nurse's notes from 06/26/2026 to 07/14/2026 indicated no documented evidence the physician was notified the insulin was held for 3 doses. No evidence of negative impacts of insulin being held. During an interview on 07/15/2026 at 1:00 p.m., the DON said her expectation was for the nurses to notify physicians of holding medications 3 times in a row. She said the physician needed to know if he needed to adjust the medication or to prevent negative outcomes. During an interview on 07/15/2026 at 3:15 p.m., LVN F said she held insulin for 3 days in a row. She said she should have called the NP or physician in case they needed to make med adjustments. She said Resident #9 blood sugar was below 100 on 07/08/2026, 07/09/2026 and 07/10/2026 which was consider within normal limits. Record review of the Medication Administration and General Guidelines dated 03/2025 indicated Policy . 12. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g. Resident not in facility at scheduled dose time, initial dose of antibiotic), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. The physician must be notified when a dose of medication has not been given. If an electronic medical record is being utilized, then the caregiver administering the medication will enter the correct documentation that will then be electronically date / time stamped with their initials.

Based on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior 2 of 10 rooms and for (Rooms 104A, and 112B) observed for homelike environment.The facility failed to ensure room [ROOM NUMBER]A was in good repair and did not have a hole and missing sheet rock exposing the wood frame and insulation on 07/13/26, 07/14/26 and 07/15/26.The facility failed to ensure room [ROOM NUMBER]B was in good repair and did not have a hole and missing sheet rock exposing the wood frame and insulation on 07/13/26, 07/14/26 and 07/15/26.This failure could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.Findings included: During an observation on 07/13/2026 at 9:45 a.m. on hall 100: room [ROOM NUMBER]A, door wall had friction marks, torn and peeling paper of sheet rock exposing the white chalky core and a large hole in the sheet rock that exposed the brown wood frame and insulation. The hole was approximately 1.5 feet in length and 6 inches in width. On the floor was a build-up of chalky white dust. room [ROOM NUMBER]B, window wall had 4-5 linear abrasion grooves which were approximately 1-inch wide, 6-inches long and 1-2 inches deep and a large hole in the sheet rock that exposed the brown wood frame and insulation. There was a visible gap between the sheet rock and the insulation where the outside wall could be seen. The hole was approximately 2.5 feet in length and 1.5 feet in width. On the floor was a build-up of chalky white dust and torn paper. During an interview on 07/15/2026 at 3:00 p.m., CNA-J said he began employment in May of 2026 and was the person responsible for initially damaging the sheet rock in room [ROOM NUMBER]A but did not know about the wall in 112B. CNA-J said he was adjusting the head of the bed in room [ROOM NUMBER]A and the bed was too close to the wall and it scratched the sheet rock. CNA-J stated it was the responsibility of Maintenance Man to complete facility repairs. CNA-J said he reported room [ROOM NUMBER]A needing wall repairs verbally to the Maintenance man the day of the incident. CNA-J said over time it kept getting worse, but he did not report it again because he felt the Maintenance Man already knew about the hole since he was the one to report it. CNA-J said all staff could verbally report or enter issues in the maintenance log. CNA-J said not having the wall's sheet rock repaired could affect the facility's appearance and cleanliness. During an interview on 07/15/26 at 3:30 p.m. the Maintenance Supervisor said he had been employed at the facility since April 2026, and it was his expectation to try to complete repair issues the day they were submitted unless parts were required that needed to be ordered. The Maintenance Supervisor said if parts needed to be ordered then repairs were completed once the needed parts came in. The Maintenance Supervisor said he was in charge of repairs and scheduling repairs with outside vendors for facility maintenance and repairs. The Maintenance Supervisor said the facility staff put any maintenance requests or needs in the maintenance log that was at each of the nurse's stations or could tell him verbally. The Maintenance Supervisor said he checked the logs daily if possible but at a minimum of several times a week. The Maintenance Supervisor said he was responsible for completing maintenance requests and building repairs. The Maintenance Supervisor said it could potentially negatively affect a resident if building repairs were not completed. The Maintenance Supervisor said when showed room [ROOM NUMBER]A and 112B wall that he was aware of the repairs needing to be made and none of these items had been logged into the maintenance log binder. The Maintenance Supervisor said he was aware of the damaged walls in room [ROOM NUMBER] and 112 since hired and had made plans to repair but survey started He said he had started in another room on the same hall making repairs and had not gotten to rooms 104 or 112 yet. He said he would repair the current issues found but was working on other environment areas in the facility that took priority. During an interview on 07/15/26 at 3:40 p.m. the Administrator said she had been employed with the facility for about a month or so. The Administrator said it was her expectation that any facility repair request be communicated via the maintenance log repair binder unless it was an emergency then to call the Maintenance Supervisor or the Administrator. The Administrator said repairs are completed the next day unless parts are needed to complete the repair then as soon as parts come in the repair is completed. The Administrator said Maintenance Supervisor is responsible for checking the maintenance log binder daily and completing facility repairs. She said she reported all the issues with the environment a couple of weeks ago to the corporate staff and was told the building had been full remolded at the beginning of the year 2026 and facility was responsible for repairs. She said she knew the condition of the facility and the plan was to complete repairs and paint areas which needed painting, but it would take time. The Administrator said at this point there were other factors that took priority. The Administrator said she expected the facility to be homelike for the residents. The Administrator said she was responsible for ensuring the facility and resident rooms were homelike. The ADM said it could negatively impact the residents' quality of life and demeanor. The ADM said the facility was resolving environmental issues and had started on hall 100. Record review of Maintenance logs for the facility from 02/01/2026 through 07/13/2026 did not indicate wall in room [ROOM NUMBER]A or room [ROOM NUMBER]B had been reported needing repair. Review of the facility's policy Maintenance Services, revised December 2011, read in relevant part Maintenance services shall be provided to all areas of the building, grounds, and equipment. 1. The maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. maintaining the building in compliance in federal, state and local laws, regulations and guidelines. b. maintaining the building in good repair and free from hazards. Record review of a facility policy titled Resident Rights, dated November 2021, read, .Dignity and Respect: you have the right to: *Live in safe, decent and clean conditions.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #43 and #54) of 18 residents, reviewed for infection control. *RN G failed to don PPE prior to performing the high contact resident care activity on Resident #54 who was on enhanced barrier precaution. *The Wound Care Nurse failed to follow infection control procedures by dropping a gown on the floor then picking it up and wearing intending to perform direct patient care for Resident #43 on contact isolation. These failures placed residents at risk for healthcare associated cross contamination and infections.Findings included:1. Record review of Resident #43's face sheet dated 07/13/2026 indicated she was a [AGE] year-old-female admitted [DATE] and readmitted [DATE] with diagnoses of diabetes mellitus (chronic metabolic disease characterized by persistently high blood sugar) with foot ulcer (open sore on the foot).Record review of Resident #43's quarterly MDS Assessment, dated 05/26/2026, indicated a BIMS score of 8 indicated moderately impaired cognition. The resident had diagnoses which included diabetes mellitus and ulcer to left foot. The assessment included other ulcers, wounds and skin problems of diabetic foot ulcer and application of dressing to feet.Record review of Resident #43's Comprehensive Care Plan, with a target date of 08/08/2026 indicated she had infection to left heel wound with interventions that included Contact isolation.Record review of Resident #43's physician order dated 07/13/2026 indicated Contact Isolation for wound with a start date of 06/29/2026.During an observation on 07/15/2026 at 12:02 p.m., Resident #43's room had a Contact Isolation sign on the door and a cabinet with PPE beside the door. The Wound Care Nurse prepared supplies on a cleaned rolling table outside Resident #43's room, and she performed hand hygiene. The Wound Care Nurse grabbed a gown out of a PPE drawer that was not sealed in a plastic wrap, dropped it on floor, picked up the gown off the floor and put it on. She then assisted CNA J to put his gown on. She grabbed her rolling table loaded with supplies and pushed it to the doorway of Resident #43's room. After Surveyor intervention she stopped and removed the gown, washed her hands and applied a new gown. She said she was responsible for wound care in the facility and was educated in infection control practices. The Wound Care Nurse said she should not have put on the gown that fell on the floor. She said she got nervous and was not thinking. The Wound Care Nurse said the resident risk of using a gown that fell on the floor during direct patient care was potentially carrying bacteria to the resident.2. Record review of Resident #54's face sheet dated 07/14/2026 indicated he was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included cerebral infarction (stroke), gastronomy status (surgically placed soft flexible tube inserted through the abdomen into the stomach) and dysphagia (difficulty swallowing). Record review of Resident #54's Quarterly MDS assessment dated [DATE] indicated he had a BIMS score of 2, indicated severely impaired cognition with diagnoses of cerebral infarct. Resident #54's MDS assessment indicated a feeding tube. Record review of Resident #54's Order Summary Report dated 07/15/2026 indicated enteral feeding order flush tube with 30 ml water before and after medication and feeding with a start dated 10/16/2025 and three times a day flush gastronomy tube with 300 ml of water with a start date of 04/08/2026 and enhanced barrier precautions.Record review of Resident #54's care plan with a target date of 07/30/2026 indicated he received enhanced barrier precautions with indications that included gloves and gown should be donned if the following activities occur enteral (gastrostomy) feeding care or other high-contact activity. During an observation and interview on 07/14/2026 at 9:11 a.m., the door to Resident #54's room had an Enhanced Barrier Precaution (EBP) sign on the door and a cabinet with PPE beside the door. Resident #54 was sitting up in his wheelchair. He said the staff gave him his medication in the tube in his stomach. During an interview and observation on 07/14/2026 at 9:15 a.m. RN G prepared Resident #54's gastrostomy tube medication. She performed hand hygiene with hand sanitizer and entered the resident's room. RN G gave Resident #54's gastrostomy tube medication without wearing proper PPE (gown). She said she was responsible for giving medication to Resident # 54 today. RN G said she should have worn a gown when she gave the medication. She said she was educated to wear a gown with direct patient care for Residents on EBP. RN G said she forgot to put on her gown. She said the Resident risk of not wearing a gown for a resident on EBP was a potential for infection. During an interview on 07/14/2026 at 4:35 a.m., the ADON said she was responsible for infection control training and in-services. She said all nurses were educated on infection control procedures and EBP. She said she went over EBP with RN G prior to working the floor. She said the resident risk of not wearing a gown for a resident on EBP was a potential for infection. She said RN G should have worn a gown for direct patient care for a resident on EBP. During an interview on 07/14/2026 at 4:45 p.m., the DON said RN G should have worn a gown to give gastrostomy medication. She said RN G may have gotten nervous and forgot to put on a gown, but she was educated on EBP and aware to wear a gown. The DON said RN G was being onboarded by LVN H. She said the resident risk of not wearing a gown for a resident on EBP was potential infection. The DON said the Wound Care Nurse was responsible for wound care in the facility, and the weekend RNs were the back up. She said the Wound Care Nurse was educated on infection control policies and should not have used a gown that touched the floor. The DON said the Wound Care Nurse was not thinking clearly when she used a gown that touched the floor. She said the resident risk of using a gown that fell on the floor for direct patient care was the potential to spreading infection. The DON said her expectation was all staff follow the infection control policy.During an interview on 07/15/2026 at 1:25 p.m. the Administrator said the charge nurses were responsible for giving gastronomy tube medication properly. She said she was unsure of RN G's background, and she may not be used to working in long term care. She said RN G had a nursing license and was educated on gastronomy tube medication procedures and EBP and was being onboarded by another nurse. The Administrator said the resident risk of not wearing a gown for an EBP resident was potential infection or cross contamination. She said her expectation was everyone abide by EBP and know the policy and procedure. The Administrator said the Wound Care Nurse was responsible for wound care in the facility and was educated on infection control policies. She said the ADON was the infection preventionist that educated all staff on infection control procedures. The Administrator said the Wound Care Nurse may have been nervous and not thinking clearly when she used a gown that fell on the floor. She said the resident risk of wearing a gown that fell on the floor was potential cross contamination. The Administrator said her expectation was all staff follow infection control procedures. She said anything that fell on the floor should be disposed of in the trash. Record review of the facility's policy titled Enhanced Barrier Precautions dated 04/01/2024, indicated: .(EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities.Resident Activity/ Assistance . device care or use: . central line, urinary catheter, feeding tube . [NAME] gloves and gown .yes . Resident Activity/ Assistance . any other high -contact activity that includes close bodily contact or coming into contact with the indwelling medical device . don gloves and gown . yes .Record review of an undated facility's policy titled, Fundamentals of Infection Control Precautions indicated, . Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections. 1. Gowns and protective apparel are worn to provide barrier protection to reduce the opportunity for transmission of microorganisms in the LTCF. Gowns are worn to prevent contamination of clothing and to protect the skin of personnel from blood and body fluid exposures. 2. Gowns are also worn by personnel during the care of patients infected with epidemiologically important microorganisms to reduce the opportunity from transmission of pathogens from residents or items in their environment to other residents or environment.

Based on interviews and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 7 (Resident #1) residents reviewed for grievances. The facility failed to resolve and take prompt action to ensure the RP's grievance they were not notified of Resident #1's refusals was resolved and remained resolved as of 04/13/26. This failure could place residents at risk of unresolved grievances and decreased quality of life.Findings included: Record review of Resident #1's face sheet dated 05/06/26 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included cerebral infarction (stroke), major depressive disorder (serious mental health condition), and anxiety (intense, excessive and persistent worry and fear about everyday situations). The RP (listed ahead of emergency contact #2) and emergency contact #2 were listed under Contacts. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she was usually able to make herself understood and usually understood others and had moderate cognitive impairment (BIMS-11). Record review of a grievance dated 04/13/26 indicated Resident #1's RP was frustrated he was not getting notified when Resident #1 did not get out of bed. Corrective action included Resident #1 was care panned for refusals. Staff was inserviced on documentation of refusals in the clinical record. Staff would also call the RP when there was a refusal. The grievance was resolved as of 04/13/26 and the RP was notified as of 04/13/26. Record review of staff training dated 04/13/26 indicted Notify resident RP and/or Emergency Contact (named contact) of any refusal of care. For example, if she refuses to take a shower and ask for a bed bath instead or if she refuses to get up for the day. Record review of a progress note dated 04/14/26 at 7:36 p.m., completed by LVN A indicated Resident #1 refused to have her face washed. LVN A called emergency contact #2 and reported Resident #1 refused to wash her face. There was no attempt to contact the RP documented. Record review of Resident #1's care plan revised 04/19/26 indicated she was resistive to care, refused ADL care, showers, and bipap at night, and getting up out of bed. Interventions included allow resident to make decisions, educate resident of possible outcome of not complying with treatment or care, and if resident resisted with ADLS, leave and return 5-10 minutes later and try again. The interventions did not include RP notification of refusals. Record review of a progress note dated 04/14/26 at 7:36 p.m., completed by LVN A indicated Resident #1 refused to have her face washed. LVN A called emergency contact #2 and reported Resident #1 refused to wash her face. There was no attempt to contact the RP documented. Record review of Resident #1's Discharge summary dated [DATE] indicated Resident #1 was discharged to another facility on 04/17/26 and not available for interview. During an interview on 05/06/26 at 9:32 a.m., Resident #1's RP said he was not notified of Resident #1's refusals to wash her face on 04/14/26. He said he had submitted a grievance related to Resident #1's refusals on 04/13/26. He said the facility indicated they would care plan the refusal, and the staff would be trained to call him for all refusals of care. He said on 04/14/26, LVN A called the second emergency contact on Resident 1's face sheet for her refusal to wash her face. He said he was not called. He said the second person listed on the face sheet was only to be called if he was not available. He said he asked the emergency contact to find out why he was not called. He said he was informed that LVN A indicated she would not call the RP first. During an interview on 05/07/26 at 9:00 a.m., the RDO said LVN A called Resident #1's emergency contact #2 on 04/14/26 for her refusal because the RP was verbally aggressive with staff and intimidating. He said normally, notifications would usually be change of condition and not refusals of care. During an interview on 05/07/26 at 11:11 a.m., LVN A said she did not call Resident #1's RP because he was not nice to staff. She said she believed she could call the second emergency contact on Resident #1's face sheet instead of the RP. During an interview on 05/07/26 at 12:50 p.m., the SW said Resident #1's RP wanted to be called 100% of the time for all of Resident #1's refusals. She said the emergency contact would be called if the RP was not available or staff were not able to reach him. During an interview on 05/07/26 at 1:00 p.m., the DON said she had updated Resident #1's care plan for refusals but did not include RP notification into the care plan. She could not say why she did not include RP notification. She said staff training dated 04/13/26 indicated staff were to notify the RP and/or emergency contact #2. She could not say why the staff training did not specify the RP was supposed to be notified first for refusals. She said the RP was upset when he was not notified, and the emergency contact #2 was notified on 04/14/26. She said Resident #1 was discharged from the facility on 04/17/26. She said the risk of not reviewing and developing care plans could result in residents not receiving proper care or services. Record review of the facility's undated Grievance policy indicated: .2. The resident has the right to and the facility must make prompt efforts by the facility to resolve the grievances the resident may have .c. As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated; .

Based on observation, interview, and record review, the facility failed to properly store, prepare, distribute, and serve food in accordance with the professional standards for food service safety 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure the deep fryer was clean and free of food particles and contained fresh cooking oil. These failures could place residents, who received food and beverages from the kitchen, at risk for health complications, foodborne illnesses, and decreased quality of life. Finding included: During an observation and interview on 04/20/26 at 1:30 p.m., In the kitchen the deep fryer had food particles and blackish brown cooking oil. [NAME] A said the deep fryer should have been cleaned last week and they did not have new cooking oil. He said he did not report the need for cooking oil to DM. During an interview on 04/20/26 at 1:35 p.m., the DM said she was going to get cooking oil, and the deep fryer should be kept clean to prevent food born illnesses. Record Review of the Dietary Services Policy & Procedure Manual 2012 indicated 8. Work surfaces must be kept as neat and clean as possible during preparation and service. Clean up your area as you work, and do not let sinks become full of dirty utensils and bowls. 9. All utensils, pots, and pans must be properly washed and sanitized after use. 10. All work areas must be thoroughly cleaned and sanitized after use. Equipment Sanitation We will provide clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner. Procedure: . 9. Large equipment is to be sanitized by spraying or wiping with a chemical sanitizing solution at least twice the minimum strength of solutions needed for immersion sanitizing.

Based on interview and record review, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 2 meals (on 04/20/2026), reviewed food and nutrition services. This facility failed to ensure Resident #1 received a balanced breakfast meal that included protein, in accordance with established national guidelines, on Monday 04/20/2026. This failure could place residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake, weakness, and weight loss. The findings include: Record review of Resident #1's admission record dated 04/20/2026 indicated he was admitted on [DATE]. He was [AGE] years old and his diagnoses included high blood sugar, weak heart and uncontrollable worry. Record review of Resident #1's physician orders for April 2026 indicated regular diet ordered 04/15/2026. During an interview on 04/20/2026 at 11:35 a.m., Resident #1 said he did not receive any meat this morning for breakfast and had asked for bacon or sausage. He said it had happened before, however could not remember how frequently or when. He said he told a staff member he wanted meat and could not remember which staff he told. During an interview on 04/20/2026 at 11:40 a.m., [NAME] A said someone this morning asked for meat for Resident #1 for breakfast however he had already put breakfast away. He said he had prepared Resident #1's breakfast tray without his tray card and did not give him meat. [NAME] A said he should have got another tray card for Resident #1 to ensure he received his ordered diet. During an interview on 04/20/2026 at 11:42 a.m., the DM said residents should receive what was listed on their tray card and provided the printed tray card for Resident #1. She said she expected her staff to provide diets as ordered to prevent weight loss or nutritional problems. Record review of tray card dated 04/20/2026 for Resident #1 indicated he was to receive a breakfast sausage with his cereal, egg and biscuit for breakfast. Record Review of the Dietary Services Policy & Procedure Manual 2012 indicated To ensure correct understanding and interpretation of therapeutic diets, all diets are ordered as stated in the Diet Manual. The physician will prescribe diets in accordance with the approved Diet Manual. Dietary Food Service Personnel Policy and Procedures The next pages of information are designed for dietary employees to acquaint you with the rules and personnel procedures of this department. It is important that these be followed at all times in order to maintain the efficiency of the department and make this a pleasant place for you and others to work. The resident is the reason that we are here and our job in the residents' care plan is to serve attractive, appetizing, nourishing, and high-quality food to help keep them healthy.

Based on observation, interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care related to subtherapeutic lab levels. The facility failed to follow up after notifying the NP twice regarding Resident #1's phenytoin (anti-seizure medication) lab value of 5.6 (therapeutic range 10.0 - 20.0) on [DATE] and no intervention or assessments were put in place. Resident #1 was hospitalized on [DATE] due to subtherapeutic serum Dilantin (phenytoin- anti-seizure medication) level and status epilepticus. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm that was not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received and signed the IJ template on [DATE] at 11:20 a.m. These failures could place residents at risk for a delay in treatment or diagnosis of new symptoms, a decline in the resident's condition, the need for hospitalization, or death. Findings included: Record review of Resident #1's face sheet, printed [DATE], reflected he was a [AGE] year-old male re-admitted to the facility on [DATE]. His active diagnoses included anoxic brain damage (when the brain is completely deprived of oxygen, causing cell death within minutes) and epilepsy with status epilepticus (seizures lasting longer than 5 minutes or multiple seizures without regaining consciousness in between). Record review of Resident #1's Minimum Data Set (MDS) Comprehensive Resident Assessment, dated [DATE], reflected his BIMS summary score was 05 indicating severe cognitive impairment. The active diagnoses included seizure disorder or epilepsy. Record review of Resident #1's comprehensive care plan, date initiated [DATE], reflected The resident has seizure disorder.The resident will be free from injury from seizure activity through the review date.Give seizure medication as ordered by doctor. Monitor/document side effects and Effectiveness. Monitor labs and report any sub therapeutic or toxic results to MD. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Record review of Resident #1's order summary report, printed [DATE], reflected .DILANTIN (phenytoin) LEVEL Q 3 MONTHS (MARCH JUNE SEPT DEC) Prescriber Written Active [DATE].Phenytoin Oral Tablet Chewable 50 MG (Phenytoin) Give 250 mg by mouth one time a day. (Give 5 tabs to equal 250mg) Phone start date [DATE]. Record review of Resident #1's progress notes written by LVN A, dated [DATE] related to Resident #1, reflected, MD B here n/o decreases Dilantin (anti-seizure medication - same as phenytoin) to 200mg once daily. Repeat BMP, CBC, Dilantin every 2 months. Record review of Resident #1's order summary report, printed [DATE], reflected .Dilantin Oral Capsule 100 MG (Phenytoin Sodium Extended) Give 2 capsule by mouth one time a day for Seizures.start date [DATE]. Record review of Resident #1's Lab Result Report, dated [DATE], reflected .Phenytoin 5.6 ug/ml 10.0 to 20.0 (reference range) L (low) Final. This document had No New Orders handwritten on it and what looked to be initials or a signature. Record review of Resident #1's progress notes written by ADON C, dated [DATE], reflected .Resident bmp CBC and phenytoin labs reviewed by NP NNO given at this time. Record review of Resident #1's Medication Regimen Review, dated [DATE], reflected .Routine lab monitoring.order Dilantin oral capsule 100 mg (phenytoin sodium extended) give 2 capsules by mouth one time a day for seizures. Order date [DATE]. Level 5.6 on [DATE], 23.4 on [DATE] (reference range 10.0 to 20.0 ug/ml). Recommendation: Dose was decreased from 250 mg to 200 mg after the elevated level but is now low can we redraw and if still off adjust dose? . Physician Response Section: (the box was checked next to the following statement) I agree with this recommendation.physician signature present and dated [DATE]. Record review of Resident #1's order summary report, printed [DATE], reflected .Phenytoin | CBC w/Auto Diff | Basic Metabolic Panel ** SCHEDULED [DATE]; Auto-Send [DATE] 2:00 AM ** one time only Phone Active order date [DATE], start date [DATE]. Record review of Resident #1's progress notes between [DATE] and [DATE] did not reveal any other documentation related to this hospitalization and lab value. No documentation of any signs or symptoms of seizures. Record review of Resident #1's medication administration record for February 2026 reflected .Dilantin Oral Capsule 100 MG (Phenytoin Sodium Extended) Give 2 capsule by mouth one time a day for Seizures. There was a check mark showing the medication was given February 1st through February 23rd of 2026. Record review of Resident #1's progress notes written by LVN D, dated [DATE], reflected .Transfer notification.Resident #1 was transferred to a hospital on [DATE] 12:00 AM related to Screaming in severe pain. Record review or Resident #1's hospital records, printed [DATE], reflected [DATE] - ED to Hosp-admission (Current).Chief complaint Altered Mental Status.Hospital Problems.Status epilepticus.epilepsy.History.anoxic brain injury seizures apparently noncompliant with his Dilantin (phenytoin) checked out to me to load with Dilantin DC back to group home.Medical Decision Making.with seizures and apparent noncompliance with Dilantin as level was undetectable loaded with Dilantin here patient had another seizure gave Ativan (acute seizure medication). Diagnoses.subtherapeutic serum Dilantin level.his Dilantin level was low very low.positive for seizures.labs phenytoin less than 1.8. During an observation on [DATE] at 10:30 a.m., Resident #1 was at the hospital in his bed. An attempt to interview was made, but he was not interviewable and continued to fall asleep off and on. During an interview with FM #1 on [DATE] at 10:40 a.m., she stated the hospital neurologist told her he can't be taken off medications like that in that way. The hospitalization was all caused by the decrease in his medication. This was preventable. She stated he seemed to be doing better and was no longer having seizures. During an interview with FM #2 on [DATE] at 11:27 a.m., she stated the neurologist said this was preventable. She said the phenytoin levels were too low, critical level in December. She stated he was sent out in the middle of the night screaming. The ER said his levels were less than 1.8. She stated he hadn't had a seizure in 12 years. She stated she was told when he had these kinds of seizures brain cells died and did damage to his heart. She stated his phenytoin level was 5.6 in December, and they did nothing at that point. During an interview with the DON on [DATE] at 1:01 p.m., she stated Resident #1's [DATE] labs had 23.4 for his phenytoin level. MD B decreased his dosage from 250 mg to 200 mg in [DATE] and increased lab draws from every three months to every two months. She stated the next set of labs had a level of 5.6 and that was low. The NP reviewed the labs and gave no new orders. She stated it was a little behind because of the holidays. During an interview with the NP on [DATE] at 1:41 p.m., she stated I am at a loss I don't know what happened. I looked yesterday when I heard about it. She was unable to recall everything exactly. She stated she knew she signed it, but she missed it somehow. She stated if she had caught it, for labs sensitive like that, normally she would ask for a replacement lab that day. By that time, the lab value was two weeks old. Then adjust medications and redraw them two weeks later. She stated with his history of seizures and his levels being low like that, she definitely would have ordered to redraw labs. She stated the seizures could have been prevented. During an interview with MD B on [DATE] at 2:36 p.m., he stated he lowered the dosage due to a critically high phenytoin level. He stated he did not decrease it that much. He changed phenytoin from 250 mg to 200 mg which is 1/3 of the dosage and he stated it should have minimal change. He increased lab draws from every three months to every two months. He stated, The first recheck was 5 something. He stated it was on the low side. It should be somewhere around 10. He stated the NP missed the lab; he was not sure how that happened. MD B stated the seizures could have any other cause such as stress or a urinary tract infection. He did not recall if he was notified about this specific lab value. He stated the levels could be off due to timing of the labs. He stated there was no reason to do anything else at the time because there were no symptoms. He stated he wouldn't just chase the numbers. During an interview on [DATE] at 3:19 p.m., ADON C stated when the NP came to the building, she rounded at that time. She pulled all the labs that have not been reviewed. She stated she did not specifically look at each lab herself. She printed them and gave them to the NP. The NP read through them while she was standing there, signed them, and gave them back to her. ADON C documented any orders or if there were no orders in the EHR, then the signed labs were given to medical records to be scanned and uploaded into the EHR. This was part of the normal lab practice for all the labs that came into the entire facility. During an interview on [DATE] at 3:26 p.m., LVN D stated she notified the NP of the lab results. She did not confirm or deny that she informed the NP specifically about the phenytoin level. She stated she knew she would notify the doctor if any lab values were off. She stated she received a text back, no new orders from the NP. She stated she knew she put in the progress notes that she contacted the NP regarding the labs. During an interview on [DATE] at 9:15 a.m., the DON stated the lab value was low, not critical. The DON stated the NP was contacted twice regarding the labs. The Administrator was present during this interview, she added the NP was contacted twice, what else are we supposed to do? The Administrator asked, Isn't it the NP's responsibility to let the doctor know? She stated, the NP was under his license, so she should do that. The DON stated it was beyond the nurse's scope to question the NP's response. She stated we followed the orders, drew the labs, and contacted the NP and followed her recommendations. She stated she would not answer any other questions until she contacted her VP. An attempt to interview the hospital neurologist on [DATE] at 9:26 a.m. was made, no return call was received. During an interview on [DATE] at 1:08 p.m., MD F stated the phenytoin lab was at 5.6, which is low, it can change quickly. He stated all doctors should probably schedule labs monthly if they are changing something (like medication dosages) or if the lab value was changing rapidly, the labs should be drawn weekly. He stated, oh no, can't make changes based off old labs. He stated new labs should have been done, before changes to the medications were made, lab draws should be within a couple days. He stated the lab values were subtherapeutic, you can't say for sure. (it caused seizures) but it didn't help. The DON was emailed regarding a related lab policy on [DATE], she replied at 1:30 p.m., there was no specific policy for labs, they followed the doctor's orders. Review of the facility's policy, Notifying the Physician of Changes in Status, no date, reflected The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. This facility utilizes the INTERACT tool, Change in Condition - When to Notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician. 1. The nurse will notify the physician or their delegated nurse practitioner or physician assistant with change in status. The nurse will document signs and symptoms of significant change, time/date of callto physician, and interventions that were implemented in the resident's clinical record. 2. Before the physician is contacted, the nurse will gather and organize resident information. Applicable information will include current medications, vital signs, signs and symptoms initiating call, current laboratory information, and interventions that have currently been implemented.4. If the physician does not return the call within a reasonable amount of time, the nurse will attempt to contact the physician a second time. If the situation is an emergency, and the physician does not callback within a reasonable amount of time, the nurse will contact the Medical Director or the nearest ambulance service for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record.11. Abnormal lab, x-ray and other diagnostic reports require physician notification. An IJ was identified on [DATE]. The Administrator and the DON were notified of the IJ on [DATE] at 11:20 a.m. and a plan of removal to remove the immediacy was requested at that time. Review of the facility's Plan of Removal, dated [DATE], reflected the following: Date: 2.26.26Plan of Removal: F684 - Quality of CareThe facility failed to follow up after notifying the NP twice regarding Resident #1's phenytoin lab value of 5.6 on [DATE] and no intervention or assessments were put in place.Interventions:Resident #1 was transferred to the hospital on [DATE] for treatment of status epilepticus and subtherapeutic Dilantin level. The resident remains in the hospital as of 2.26.26. On 2.26.26 DON, ADON, or Designee completed a 100% audit of: anticonvulsant to ensure therapeutic lab values. Any abnormal findings will be communicated to the Attending Physician. Completed 2.26.26. One abnormal lab on resident, provider notified, awaiting for any new orders. Resident has no s/s of symptoms of seizures. The DON and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following in-services. Completed 2.26.26.Provider notification of abnormal labs values to include the NP, MD, and Medical Director. The charge nurse will notify the provider and document communication and orders.Documentation of provider notification for changes of condition including changes in condition as a result of abnormal lab values.Escalation: when the charge nurse notices that the NP doesn't address non-therapeutic labs values, then the nurse will call the attending physician. if the attending physician doesn't address non-therapeutic labs values, then the charge nurse will call the medical director.Abuse and neglect- Failure to intervene on abnormal lab values could be considered neglect. The Medical Director was notified of the Immediate Jeopardy on 2.26.26 by the DON. An ADHOC QAPI meeting was completed by the interdisciplinary team to include the Medical Director on 2.26.26 In-services:The following in-services were initiated on [DATE] for all charge nurses by the DON, ADON, and/or Regional Compliance Nurse in person and/or via phone. All staff not present for in-servicing will not be permitted to work their assignment until in-serviced. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior to working their floor assignment. Completed [DATE].Provider notification of abnormal labs values to include the NP, MD, and Medical Director. The charge nurse will notify the provider and document communication and orders.Documentation of provider notification for changes of condition including changes in condition as a result of abnormal lab values.Escalation: when the charge nurse notices that the NP doesn't address non-therapeutic labs values, then the nurse will call the attending physician. if the attending physician doesn't address non-therapeutic labs values, then the charge nurse will call the medical director.Abuse and neglect- Failure to intervene on abnormal lab values could be considered neglect. On [DATE] the facility wide anti-convulsant audit was reviewed, the documentation of Resident #2's follow up to their abnormal lab was reviewed, and the in-service documentation for the ADON, DON, and all staff were reviewed. Any in-services that have not bee completed, will be done before their next shift. On [DATE] individual staff interviews were conducted with LVN A, ADON C, RN G, LVN H, LVN I, LVN J, LVN K, LVN L, LVN M, and LVN N from 9:15 a.m. to 12:00 p.m. Staff represented all three shifts including weekends and PRN staff. Staff were asked to describe the training they had received. All employees interviewed were able to correctly answer questions and described all types of lab results that would be reported to the DON, MD, and family. On [DATE] at 12:00 p.m. the Administrator was informed the IJ was removed. While the IJ was removed the facility remained out of compliance at a severity level of no actual harm that was not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor to ensure the implementation and effectiveness of their plan of removal.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, which included injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials, which included the State Survey Agency, in accordance with State law through established procedures for 1 of 6 residents (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to report the sexual abuse allegation, after the allegation was made by Resident #1 and CNA A did not report to the abuse coordinator for approximately 2 weeks. The allegation of sexual abuse was not reported to HHSC, investigated timely, and no interventions were initiated to prevent further sexual abuse for Resident #1. This failure could place residents at risk for sexual abuse due to not reporting, investigating and protecting when there was an allegation of abuse within the allocated timeframes. Findings included: 1.Record review of an admission record, dated 10/06/25, indicated Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Alzheimer disease (progress disorder that affects memory, thinking and behavior), high blood pressure (a condition where the force of the blood against the artery walls is consistently too high) and insomnia (common sleep disorder that can make it hard to fall asleep or stay asleep). Record review of Resident #1's physician's orders dated October 2025 indicated an order to admit to the secure unit related to elopement risk with a start date of 04/21/2025. Record review of the quarterly assessment MDS dated [DATE] indicated Resident #1 had a BIMS score of 02 which indicated she was severely impaired cognitively. She had no verbal, physical or sexual behaviors indicated during the last 7 days prior to this assessment. The MDS indicated she wandered 1 to 3 days in the past 7 days prior to the assessment. Record review of Resident #1's care plan dated 08/22/25 indicated she had impaired cognitive function/dementia or impaired thought processes related to dementia. 2. Record review of an admission record, dated 10/06/25, indicated Resident #2 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of which included dementia (a group of conditions that causes decline in memory, thinking reasoning and problems solving), high blood pressure (a condition where the force of the blood against the artery walls is consistently too high) and insomnia (common sleep disorder that can make it hard to fall asleep or stay asleep). Record review of Resident #2's physician's orders dated October 2025 indicated an order to admit to the secure unit related to elopement risk with a start date of 07/31/2025. Record review of the quarterly assessment MDS dated [DATE] indicated Resident #2 had a BIMS score of 04 which indicated he was severely impaired cognition. He had no verbal, physical or sexual behaviors indicated during the last 7 days prior to this assessment. The MDS indicated he wandered every day in the past 7 days prior to the assessment. Record review of Resident #2's care plan dated 09/30/2025 indicated he had a potential to demonstrate physical behaviors related to his dementia and poor impulse control. Resident #2 was hit by another resident. During a confidential phone interview on 10/06/25, a non-staff person said wished to remain anonymous. The anonymous non-staff person said Resident #1 said that a man touched her breast and pointed at Resident #2 in front of the nurses. The anonymous non-staff person was unable to say exactly when this happened, unable to name staff and denied witnessing the event. The anonymous non-staff person denied reporting to the Administrator or the DON, said he didn't report that to the Administrator. The anonymous non-staff person said they just talked about the food being late and needing more staff in the kitchen that day. During an observation and interview during initial rounds on 10/06/25 at 9:30 a.m., Resident #1 was in the dining room, and she said she was ok. Her speech was clear and easy to understand. During an interview on 10/06/25 at 11:00 a.m., Resident #1 said some man touched her breast, but she pushed him away and he left her alone after that. She then pointed to Resident #2 across the dining room and said it was him. She said she got mad but was not afraid. She said he never did anything else to her. She was unable to say when this happened. She was unable to say what staff knew about it. During an interview on 10/06/25 at 2:15 p.m., CNA A said she overheard Resident #1 tell her family member that another resident touched her breast and said she pushed him away. CNA A said she had been trained on abuse and reporting abuse to the administrator and DON immediately. She denied knowing what date this happened, what date she overheard the conversation or if it happened. She stated, I reported to my charge nurse and the surveyor asked which nurse she had reported to. CNA A stated I did not report to the charge nurse, Administrator or the DON. I just thought Resident #1 was just confused. She said she over heard the conversation last week or a couple of weeks ago. CNA A said she should have reported it, and she will be in trouble. She said she had been trained to report to the Abuse coordinator which was the Administrator or to the DON. CNA A said since she didn't report what she overheard it could happened again or to another resident. During an interview on 10/07/25 at 10:00 a.m., Resident #2 denied touching anyone's breast. He said he had never touched breasts here. He said that it would be wrong if not married. Record review of the Provider Investigation Report, dated 10/06/25, indicated the incident on unknown shift and was reported to HHSC on 10/06/25 and the facility was still investigating and monitoring at the time of exit. During an interview on 10/07/25 at 9:40 a.m., the Administrator said there had not been an allegation of abuse reported which involved Resident #1 and Resident #2. He said this was not reported until surveyor intervention. The facility reported this allegation of abuse yesterday (10/06/25). The staff had been retrained about reporting allegations of abuse. The Administrator said all staff were responsible for reporting allegations of abuse immediately and had been trained on hire and annually before this incident. He said the facility was continuing to investigate this allegation and had increased monitoring. He said if he had been informed of this allegation he would have immediately reported, increased monitoring and investigated. During an interview on 10/07/25 at 11:30 a.m., the DON said she was not notified of the incident involving Resident #1 and Resident #2 until yesterday after surveyor intervention. She said all staff were trained on abuse on hire and retrained on abuse again since an allegation of sexual abuse occurred. She said her expectation was for the staff to report allegations of abuse to the DON and the Administrator immediately. She said the facility would have immediately reported, increased monitoring and investigated the sexual abuse allegation. Record review of the undated facility policy titled Abuse/Neglect indicated The resident has right to be free of abuse, neglect . It is each individual's responsibility to recognize, report and promptly investigate actual or alleged abuse . E. Reporting Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse . must report this to the DON, administrator, state, and or adult protective services. Facility employees must report all allegations of: abuse, . a. If the allegations involves abuse or results in serious bodily injury, the report is to be made within 2 hours of the allegation.

Based on observation, interview, and record review, the facility failed to properly store, prepare, distribute, and serve food in accordance with the professional standards for food service safety 1 of 1 kitchen reviewed for safety requirements. 1. The facility failed to ensure food items in Icebox #1 were labeled, dated, sealed, and not expired. 2. The facility failed to ensure the floor in Icebox #2 was free from standing water spills and unpackaged food. 3. The facility failed to ensure Activity Aide B, Dietary Aide G, and Dietary [NAME] H's hair was completely contained with an effective hair restraint. 4.The facility failed to ensure the left wall in the milk-box cooler - was free of ice build-up and accumulation of food crumbs and debris. 5.The facility failed to ensure food items in the dry pantry were labeled, dated, sealed, and not expired and failed to ensure dented cans were not stored and co-mingled with non-dented food cans ready for use. 6.The facility failed to ensure the flat sheet pans and stock pots were free of black and brown cooked on build-up. These failures could place residents, who received food and beverages from the kitchen, at risk for health complications, foodborne illnesses, and decreased quality of life. Finding included: During an observation and interview on [DATE] at 8:30 a.m., in Icebox #2 there were two cases of ,d+[DATE] gallon cartons of milk, wet from exposure to half-inch to 1-inch deep of standing water. The DM confirmed the milk cartons were sitting in water and were wet on the bottom. During an observation and interview on [DATE] at 8:35 a.m. of Icebox #1 with the DM indicated there were: - a gray bin labeled Yoplait yogurt with two small 6-ounce clear cups with lids not labeled and not dated of orange-colored pieces of a substance. The DM said they were cantaloupe slices and she put them in a large gray bin of peaches. Also, in the gray bin (labeled Yoplait) were 2 more small 6-ounce clear cups with lids of a yellow pudding substance. The DM said those were super pudding used for medication pass. - 1-container pint of [NAME] small tomatoes not dated. - 1-large bag of broccoli undated, unlabeled, ripped open from the seam exposing the broccoli to the elements. The DM said the bag was opened and exposing the broccoli to air. The DM said the count of broccoli were 8-heads that were left from Friday's meal. - 1-gallon Ziploc bag of sliced tomatoes with a white coating on them in 2inch height of pink tinged slimy liquid. The DM confirmed the tomatoes were losing their color and had a white coating. During an observation on [DATE] at 8:45 a.m., Dietary [NAME] H was in the kitchen, near the food preparation table. She had a hairnet on with approximately ,d+[DATE] inches of hair in the nape (back of her head) and wisps of her hair (around front profile of face) not covered with the hair net. She was standing at the prep table preparing canned beans in a pot. During an observation on [DATE] at 9:00 a.m., Dietary Aide G was in the kitchen, near the food preparation table. She had a hairnet on with approximately ,d+[DATE] inches of hair in the nape (back of her head) and wisps of her hair (around front profile of face) not covered with the hair net. She was standing at the prep table. During an observation on [DATE] at 12:00 p.m., Activity Aide B was in the kitchen, near the food preparation table. She had a hairnet on with approximately ,d+[DATE] inches of hair Bang (front of her head), in the nape (back of her head) and wisps of her hair (around side profile of face) not covered with the hair net. She was standing at the prep table preparing shredded cheese. During an observation and interview on [DATE] at 8:50 a.m., the milk box cooler had clear ice build-up approximately 2-inches thick to the left wall in the milk box and along the rubber gasket seal weather strip was an accumulation of brown-tinged grime, dirt and crumbs. The DM confirmed the ice on the wall of the milk box and build-up of dirt and crumbs to the rubber seal. During an observation and interview on [DATE] at 9:05 a.m. of the pantry with the DM indicated there were: - 20, 4-ounce containers of thickened cranberry cocktail juice in their original container with a manufacturer expiration date of [DATE]. The DM said she would remove them from the pantry and discard. She said if used, residents could get sick. - Two, 6-pound cans of [NAME] Farms Sliced Peaches heavy syrup dented cans co-mingled with non-dented food cans ready for use. One can had a large dent in the middle of the can and the other had a large dent at the bottom seam. The DM place the dented cans in the dented can section of the pantry and said using dented cans could contaminate food. - 1 opened and used folded down bag of vanilla wafers that was folded down on itself, not sealed and exposed to the elements. The DM said not being sealed the wafers could get stale. - On the shelf of the ready to use foods was an expired jar of Zatarain's Prepared Horseradish 5.25-ounce, manufacturer expiration date [DATE] and instructions to refrigerate after opening. The DM said she thought she threw that away, and it could cause food illness. During an interview on [DATE] at 09:33 a.m., Dietary [NAME] H said she received orientation training on different types of meals to include how to serve plates, menus, reading the meal ticket, hair nets, glove use, hand hygiene, using scoops for serving food, and many other topics. She said without a date, she would not know when it had been placed in the refrigerator and would discard the food to ensure it was safe for residents and not make them sick. Dietary [NAME] H said she was not aware of her hair sticking out. During an observation and interview on [DATE] at 9:05 a.m . of the storage area for pots and pans with DM indicated there were: - 5, large cooking pans with build-up of a cooked on black and brown substance. - 2, large cake sheet pans with build-up of baked on black and brown substance - 4, large flat cooking sheet pans had baked on build-up of a brown substance. - 1, large stock pot with build-up cooked on black and brown substance. During an interview on [DATE] at 2:20 p.m., the DM confirmed the cans of peaches contained dents and should have been stored separate from non-dented cans. The DM said hair restraints should be worn at all times while in the kitchen, including bangs and little hairs around the face. She said hairnets prevent cross contamination and foodborne illnesses from getting in the food. The DM said she was responsible for making sure staff in the kitchen were following the facility policy, checking the pantry, refrigerator, and freezer for expired or spoiled foods at the end of each week, and cleaning the kitchen and pot and pans. The DM said she could not explain why the expired or spoiled foods had not been removed from the refrigerator, freezer or why the weekly schedule for cleaning the pots and pans was not done. The DM said she was purchasing new pots and pans. The DM said the Maintenance Supervisor was aware of Icebox #2 having standing water on the floor, but she could not remember when she notified him. She said all kitchen staff completed the required food preparation and food storage trainings. The DM said the potential harm to residents would be food poisoning, diarrhea, sickness, and bacteria on food. The DM said the failure occurred due to staff not paying attention. During an interview on [DATE] at 2:40 p.m., the Administrator said if any staff entered the kitchen, they were expected to wear a hair net. He also said if a staff's hair was not completely covered, the risk would be hair getting in the resident's food, and he had no complaints of hair in the food. The Administrator said he was not aware of the ice and water build up and told the Maintenance Supervisor that day ([DATE]) he found out to check the equipment. The Administrator said his expectation was all products in the kitchen be labeled and dated correctly. The Administrator said if residents were served out of date food products it could result in stomach aches, diarrhea, causing them to get sick. The Administrator said it was the responsibility of the DM to ensure all products were labeled correctly and equipment in the kitchen was cleaned regularly and in good working condition. During an interview on [DATE] at 3:00 p.m., the Maintenance Supervisor said he checked the milk box cooler and Icebox #1 in the kitchen and there was nothing needed to be repaired. He said the ice was from the rubber seal needed cleaning, which caused a slightly opened area and caused ice to buildup on the left side of the milk box cooler. The Maintenance Supervisor said the water was because the drain was clogged in the Icebox #1, and he unclogged it. He said the milk box cooler and Icebox #1 was in good working order. The Maintenance Supervisor said he was made aware of what equipment needs repair from the morning meetings and from checking his phone notifications about it. He said he learned how to use the facility electronic reporting system about a couple weeks ago. The Maintenance Supervisor said requests were entered but he could not retrieve them from the electronic reporting system and did not know how to do it. The Maintenance Supervisor said that he was not aware of the kitchen equipment needing repair until [DATE] when the Administrator told him to check it. The Maintenance Supervisor said the risk to residents could be food spoilage and cause them to get sick. During an interview on [DATE] at 3:32 p.m., Activity Aide B said she did not work in the kitchen and said she was just preparing cheese for the dining room resident's appetizers. She said she had been trained on how to properly wear a hair net, covering the entire hair. She said the reason she was supposed to wear a hairnet is because it keeps the hair out of the food. Record review of the facility's policy titled, Food Storage and Supplies, dated 2012, read: Procedure: .4. Opened packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened . Record review of the facility's policy titled, Equipment Sanitation, dated 2012, read: : Procedure: .6. Pots and Pans: .b. Prior to washing, all utensils and equipment shall be pre-scraped or pre-flushed and when necessary, pre-soaked to remove gross waste . Record review of the facility's policy titled, Infection Control, revised [DATE], read: : Procedure: .1. Clean hair is required. It is to be covered with an effective hair restraint. Review of the Food and Drug Administration Food Code, dated 2022, reflected, XXX,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food ,d+[DATE].11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 1 of 1 activity aide (Activity Aide B) and 1 of 5 dietary aides (Dietary Aide L) reviewed for qualified dietary staff. The facility failed to ensure Activity Aide B and Dietary Aide L had their Texas Food Handler's License. This failure could place residents at risk of not having their nutritional needs met and place them at risk for food born illnesses. Findings included: During an observation on [DATE] at 12:00 p.m., Activity Aide B was standing at the prep table preparing shredded cheese. Record review of Activity Aide B's personnel file indicated a hire date of [DATE]. No prior or current food handler certificate was found. Record review of Dietary Aide L personnel file indicated a hire date of [DATE] no prior or current food handler certificate was found. During an interview on [DATE] at 9:00 a.m., DM said Activity Aide B and Dietary Aide L did not have current food handler certificate and she could not locate any prior food handler certifications for Activity Aide B or Dietary Aide L. She said not having a current certification places the residents at risk of not having food prepared correctly. During an interview on [DATE] at 2:40 P.M., the Administrator said it was important for anyone who prepared or cooked in the kitchen to have their food handler's license to ensure everyone knew the best practices across the board. He said they needed to know to follow the rules and regulations, ensure proper sanitation, and how to not cross-contaminate. He said the certification was normally done 30-days after hire and when expired, and the DM was responsible for ensuring they were completed. He said that obviously, some were missed, and the facility did not have a policy on Food Handler Certifications. During an interview on [DATE] at 3:32 p.m., Activity Aide B said she had a food handler certification, but it was expired. She said on [DATE] she was in the kitchen getting shredded cheese for the residents' appetizers. She said on [DATE] she retook the food handler's certification. She said not having a current certification put the residents at risk of not having best practice followed when preparing their food. Dietary Aide L was unavailable for interview via phone. After surveyor intervention: Record review of the Activity Aide B Texas Food Handler Training Program certification, reflected the effective date as [DATE]. Record review of and Dietary Aide L Texas Food Handler Training Program certification, reflected the effective date as [DATE]. Record review of the facility's policy titled, Infection Control, revised [DATE], read: Procedure: .4.b. The facility will follow all state and local regulations concerning initial hire and annual health examinations for dietary associates. C. the Dietary Service Manager should use the following guidelines concerning health examinations and documentation. If required, post a valid food handler's card for each dietary associate in the department at all times, keep current examination documentation and food handler's cards in personnel file on all department associates .

Based on interview and record review, the facility failed to consult with the physician regarding a change in condition for 2 of 20 residents reviewed for physician notification. (Residents #5 and #17) The facility failed to consult physician when Resident #5 consistently had above normal blood glucose levels. The facility failed to consult physician when Resident #17's medications were held due to patterns of low heart rate. This failure could place residents at increased risk for complications due to delayed physician intervention. Findings included: 1. Record review of Resident #5's face sheet indicated a [AGE] year-old male admitted to facility on 02/11/25 with diagnoses including diabetes and dementia. Record review of the Quarterly MDS dated [DATE] indicated Resident #5's BIMS score was 03, which indicated severe impairment of cognitive abilities. Record review of Resident #5's care plan dated 07/09/18 indicated a diagnosis of diabetes. Interventions included diabetes medication as ordered by the doctor. Monitor/document for side effects and effectiveness. Review of Resident #5's physician orders dated 05/20/25 included Lantus insulin 16 units subcutaneously one time per day related to diabetes (in the evening). Resident #5's blood glucose level was checked twice daily prior to receiving prescribed dosages of insulin. There were no physician orders to notify the MD of any results outside a parameter. Record review of a May 2025 MAR indicated on the following dates, Resident #5's blood glucose levels were elevated: *05/03/25 - BS was 222; *05/04/25 - BS was 276; *05/05/25 - BS was 184; *05/07/25 - BS was 184; *05/09/25 - BS was 219; *05/10/25 - BS was 200; *05/13/25 - BS was 197; *05/14/25 - BS was 191; *05/15/25 - BS was 304; *05/16/25 - BS was 214; and *05/18/25 - BS was 246. During an interview on 05/21/25 at 9:40 a.m., LVN L said sliding scale insulin usually has parameters to administer when blood glucose level is between 150 - 400. She said the physician should have been notified of Resident #5's abnormal levels when the readings were high on these dates. LVN L said Resident #5 needed an order for sliding scale insulin to help bring glucose levels back to normal ranges. During an interview on 05/21/25 at 1:45 p.m., the DON Resident #5's blood glucose levels bottom out easily in the mornings (drop levels drastically). She said her expectations were to notify physician each time abnormal elevated blood glucose level. She stated, Obviously he should have had an order for sliding scale insulin to control levels. 2. Record review of Resident #17's face sheet indicated a [AGE] year-old female admitted to facility on 02/03/25 with diagnoses including congestive heart failure (chronic condition in which the heart does not pump blood as well as it should) and hypertension (high blood pressure). Record review of the quarterly MDS dated [DATE] indicated Resident #17's BIMS score was 14, which indicated she was cognitively intact. Resident #17 required moderate to maximum assist with most activities of daily living. Record review of Resident #17's care plan dated 07/28/21 indicated a diagnosis of heart failure. Interventions included report to physician if pulse falls below 60 or rises above 110 or detect skipped beats or other changes in rhythm. Review of Resident #17's physician orders dated 05/20/25 included Digox tablet 125 mcg - give one tablet by mouth one time per day. Hold if heart rate is below 60. Notify physician if above 100. (Digox is used to improve the strength and efficiency of the heart, or to control the rate and rhythm of the heartbeat). Record review of a May 2025 MAR indicated on the following dates, Resident #17's Digox 125 mcg was held: *05/01/25, heart rate was 58; *05/06/25, heart rate was 55; *05/11/25, heart rate was 52; *05/12/25, heart rate was 50; *05/13/25, heart rate was 58; and *05/14/25, heart rate was 48. Record review of Progress Notes dated 05/01/25 through 05/19/25 gave no indication Resident #17's physician was consulted regarding the resident's patterns of low heart rate, and of Digox 125 mcg being held six of 20 opportunities. During an interview on 05/21/25 at 09:30 a.m., LVN L said nursing staff were to document in progress notes anytime a physician was consulted. She said the physician should have been consulted regarding Resident #17's pattern of low heart rate and of medication being held. LVN L said not notifying the physician could affect Resident #17's overall health. During an interview on 05/21/25 at 09:55 a.m., MA M said anytime medications were held for any reason, the charge nurse was to be notified. She said if a resident's heart rate or blood pressure was outside parameters, she would recheck vital signs prior to notifying the charge nurse. MA M said the charge nurses would then assess residents and should notify physicians, especially if a pattern of being held was noted. During an interview on 05/21/25 at 1:45 p.m., the DON said her expectations were to make notifications to physician when vital signs were outside physician ordered parameters and to document notification and results in the resident's electronic medical record. A policy titled medication Administration and General Guidelines labeled as v3-2025 indicated the following: . Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and 2. Medications are administered in accordance with written orders of the attending physician. 12. The physician must be notified when a dose of medication has not been given.

47879 Based on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the abuse coordinator for immediate intervention for 1 of 4 residents (Resident #1) reviewed for abuse and failed to ensure that all alleged violations involving abuse were reported no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or neglect resulting in serious bodily injury, to the State Survey Agency, for 2 of 15 residents (Resident #4, Resident #6) reviewed for reporting allegations of abuse. 1. The facility failed to report a verbal abuse allegation immediately to the Abuse Coordinator. CNA A alleged she witnessed LVN B verbally abuse Resident #1 on 10/22/24 at approximately 8:00 p.m. CNA A immediately reported the verbal abuse incident to ADON C and ADON D on 10/22/2024 at 8:30 p.m. ADON C and ADON D did not report the Verbal Abuse allegation immediately to the Administrator who was the Abuse Coordinator. An Immediate Jeopardy (IJ) was identified on 01/28/2025. The IJ Template was provided to the facility on [DATE] at 5:26 p.m. While the IJ was removed on 01/29/2025 at 5:33 p.m., the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. 2. The facility failed to report allegation of abuse to the State Agency within 2 hours when it was reported on 8/22/2024 that Resident #5 hit Resident #4 with a soft plastic urinal. 3. The facility failed to report allegations of abuse to the State Agency within 2 hours when it was reported on 07/5/2024 that Resident #6 was verbally abused by CNA F. The failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of the admission record dated 01/29/2025 indicated Resident #1 was admitted on [DATE], she was [AGE] years old with Alzheimer's disease, anxiety, and heart failure. Record review of quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 5 and was cognitively impaired. She was able to make herself understood and understood others. No behaviors were noted. Resident #1 had psychotic disorder, anxiety, and depression. Resident #1 had received medication last 7 days of antipsychotic, antianxiety and antidepressant. During an interview on 01/28/2025 at 8:00 a.m., CNA A said on 10/22/2024 around 8:00 p.m., she found Resident #1 on the floor and asked LVN B to check on Resident #1 and assist her to place Resident #1 back in bed. CNA A said she heard LVN B say loudly to Resident #1 you need to keep your fat ass off the floor, and she did not come to work to throw her back out picking your fat ass off the floor. CNA A said Resident #1 said You should not work here then. CNA A said all of that happened while they were putting the resident back in the bed. CNA A said she stepped between the nurse and the resident and said she had it from there. She said she reported the incident to both ADON C and ADON D, who were in their office on the computers, around 8:30 p.m. CNA A said the ADONs sent her to lunch to cool down and she said she was really upset. She said after that she made her rounds and went home after the shift ended. She said the next day she was asked to write her witness statement on the proper form by the human resource department and the administrator. She said the night before she had written her witness statement on notebook paper. During an interview and observation on 01/28/25 at 9:30 a.m., Resident #1 was lying in her bed, well-groomed with no foul odors noted. She said she did not recall any facility staff cursing at her or mistreating her. Record review of Resident #1's skilled nurses' notes dated 10/22/2024 did not indicate any falls or any concerns. Record Review of Resident #1's medical records did not indicate an incident report or event note was completed the day of the incident, 10/22/2024. Record review of LVN B time sheet indicated she was on duty on 10/22/2024 at 1:37 p.m. to 10:10 p.m. and was on duty on 10/23/2024 from 2:00 p.m. to 4:28 p.m. Record review of a weekly skin assessment dated [DATE] indicated LVN B performed a skin assessment on Resident #1 after the incident was reported to the ADONs on 10/22/2024. During an interview on 01/28/2025 at 8:25 a.m., the Administrator said the allegation of LVN B verbally abusing Resident #1 was not reported to him until 10/23/2024. He said he was made aware of the allegation on 10/23/2024 around 4:00 p.m. and reported to the state thereafter. He said all abuse allegations must be reported to him or designee immediately and reported to the state within 2 hours of the allegation. He said residents were at risk of continued abuse if allegations of abuse were not reported as required. During an interview on 01/28/2025 at 9:05 a.m., ADON C said she thought about it more and remembered CNA A had reported to herself and ADON D an allegation of LVN B telling Resident #1 to keep her fat ass off the floor. ADON C said they sent CNA A to go on lunch break. ADON C said they both went to the halls, and she checked on another matter and ADON D went to check on Resident #1. ADON C said herself and ADON D were both working that evening on the halls, and both were responsible for reporting to the Administer/Abuse Coordinator. She stated I thought ADON D had reported the event to the Administer because he was the Abuse Coordinator. She said residents were at risk of continued abuse if allegations of abuse were not reported as required. During an interview and record review on 01/28/2025 at 2:03 p.m., the Administrator said he was not notified of the verbal incident with Resident #1 on 10/22/2024. The State Surveyor reviewed CNA A's witness statement dated 10/23/2024 with the Administrator and identified that the CNA had notified ADON C and ADON D regarding the incident. He said he had not seen that CNA A had reported this allegation to the ADONs on 10/22/2024 when he read CNA A's witness statement originally. He said he had not seen the last sentence about CNA A indicating she reported this event to the ADONs until now. He said the ADONs should have called him immediately and LVN B should have been suspended until the investigation was completed. He said LVN B was suspended on 10/23/2024 at 4:30 p.m. He said the ADONs should have been interviewed during the investigation and disciplined for not reporting the incident immediately. During an interview on 1/28/2025 at 2:37 p.m., ADON D denied that CNA A reported the allegation of LVN B verbally abusing Resident #1 to her. She said she knew the Administrator was investigating the allegation. She said she and ADON C worked that night (10/22/2024), but no one had reported abuse to her, or she would have called the Administrator immediately. Record review on LVN B's personnel file indicated her date of hire was 09/19/2024 and last day worked was 10/23/2024. LVN B was terminated on 10/25/2024 for misconduct. This was determined to be an Immediate Jeopardy (IJ) on 01/28/2025 at 5:26 p.m. The facility's Administrator, the ADO, and the Regional Compliance Nurses were notified. The Administrator was provided with the IJ template on 01/28/2025 at 5:26 p.m. The following POR was accepted on 01/29/2025 at 9:53 a.m.: Interventions 1.Resident #1 was assessed for emotional distress by the DON on 01/28/2025. A trauma informed care assessment was completed on 01/28/2025 by the DON. No additional emotional distress was noted. 2.LVN B was terminated on 10/25/2024 and ADON D resigned. Both are no longer employed at the facility as of 01/28/2025. 3.The Administrator, DON, and ADON C were in-serviced 1:1 by the Area Director of Operations and Regional Compliance Nurse on following topics below. Completed on 01/28/2025. a. Abuse and Neglect- The administrator is the Abuse Coordinator. Inservice includes that abuse and neglect should be reported immediately to the abuse coordinator. The Abuse coordinator will immediately suspend all alleged perpetrators. Staff named in the allegation(s) are not allowed to continue working. The abuse coordinator will report to HHS immediately but no later than two hours after the event. The abuse coordinator will thoroughly investigate the allegation. The abuse coordinator will delegate responsibilities to start the investigation in the event he is not available. In the event the Administrator can't be reached, the DON will be notified immediately. The alleged perpetrator will not return to work until approved by the abuse coordinator. 4.The medical director was informed of the immediate jeopardy citation on 01/28/2025 by DON. 5.An ADHOC QAPI meeting was held on 01/28/2025 to include the interdisciplinary team and medical director to discuss the immediate jeopardy citation and plan of removal. In-services: On 01/28/2025, All staff will be in-serviced on the following topics below by the Administrator, Regional Compliance Nurse, DON, and ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. Completion date 01/29/2025. a. Abuse and Neglect- The administrator is the Abuse Coordinator. Inservice includes that abuse and neglect should be reported immediately to the abuse coordinator. The Abuse coordinator will immediately suspend all alleged perpetrators. Staff named in the allegation(s) are not allowed to continue working. The abuse coordinator will report to HHS immediately but no later than two hours after the event. The abuse coordinator will thoroughly investigate the allegation. The abuse coordinator will delegate responsibilities to start the investigation in the event he is not available. In the event the Administrator cannot be reached, the DON will be notified immediately. The alleged perpetrator will not return to work until approved by the abuse coordinator. The surveyors monitored the POR on 01/29/2025 as followed: During interviews on 01/29/2025 from 10:00 a.m. - 2:00 p.m. 8 CNAs (CNA GG, CNA II, CNA LL, CNA NN, CNA OO, CNA SS, CNA YY, and CNA DDD), 4 LVN's (LVN E, LVN HH, LVN QQ, and ADON C), 1 LVN/treatment nurse (LVN/Treatment AAA), 1 MA (MA HHH), 2 MDS Nurses ( MDS JJ and MDS KK), 2 Laundry staff (Laundry CC and Laundry GGG), 3 Dietary staff ( Dietary EE, Dietary EEE, and Dietary FFF), 2 Housekeeping staff (HSK RR and HSK CCC), 2 Activities staff (Activities TT and Activities Asst VV), 2 Physical Therapists (PT MM and PT WW), 1 Speech Therapist (ST FF), 1 Certified Occupational therapist assistant (COTA BBB), 1 Business office staff (BO DD), 1 Admission Clerk (Admission ZZ), 1 Human Resource staff (HR XX), 1 Medical Records (MR UU), 1 Maintenance Supervisory (Maintenance PP) (from the A.M. shift) all said they were in-serviced before starting their shift on 01/29/2025 and then given questionnaires to complete to verify their knowledge. All were able to state that their abuse coordinator was the Administrator, and if he was not available, they were to notify the DON. They were all able to give examples of physical, verbal, and emotional abuse. All expressed the importance of reporting alleged abuse immediately when they first saw or heard it. All knew where the corporate compliance hotline number was posted and knew when to contact if needed. During interviews on 01/29/2024 from 3:55p.m.- 4:20p.m. with 6 alert and oriented residents indicated they recently had communication with management regarding their satisfaction with living at the facility and they had no concerns about their safety, about the staff who provided their daily care, or the management at the facility. During interviews on 01/29/2025 from 2:30p.m. -5:20 p.m. 8 CNAs (CNA LLL, CNA MMM, CNA NNN, CNA OOO, CNA QQQ, CNA RRR, CNA SSS, and CNA TTT), 3 LVNs (LVN III, LVN KKK, and LVN PPP), and 1 MA (MA JJJ) (from 2 p.m.-10 p.m. and 10 p.m. - 6 a.m. shifts) all said they were in-serviced before starting their shift on 01/28/2025 and 1/29/2025 and then given questionnaires to complete to verify their knowledge. All were able to state that their abuse coordinator was the Administrator, if he were not available, they were to notify the DON. They were all able to give examples of physical, verbal, and emotional abuse. All expressed the importance of reporting alleged abuse immediately when they first saw or heard it. All knew where the corporate compliance hotline number was posted and knew when to contact if needed. During an interview on 01/29/2025 at 12:15 p.m., ADON C said she was given one-on-one in-service with the ADO (Area Director of Operations) and the Regional Compliance Nurses regarding reporting alleged abuse to the abuse coordinator immediately (if abuse coordinator was not available or was unreachable, then they would report to the DON ), the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and she was to begin investigating alleged allegations immediately if delegated by the abuse coordinator or the DON to do so. She said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. During an interview on 01/29/2025 at 12:45 p.m., the DON said she was given one-on-one in-service with the ADO (Area Director of Operations) and the Regional Compliance Nurses regarding reporting alleged abuse allegations to the abuse coordinator immediately (if abuse coordinator was not available or was unreachable, then staff would report to her), the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and she was to begin investigating alleged allegations immediately if delegated by the abuse coordinator do so. She said if abuse was reported to her in the absence of the abuse coordinator that she would report the alleged allegation to HHSC within 2 hours of the alleged incident. She said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. During an Interview on 01/29/2025 at 1:00 p.m., the Administrator said he was in-serviced one-on-one with the ADO (Area Director of Operations) and the Regional Compliance Nurses regarding the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and that he was to begin investigating alleged allegations immediately and if he was not available, he was to delegate investigation responsibilities to the DON and/or management staff. He said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. The Administrator said 95% of the active employees had been in-serviced and the remaining employees would be in-serviced before the start of their next shift. The Administrator said all new hires would receive training on abuse, neglect, and timely reporting prior to providing any resident care. Record Review of Resident #1's chart included the Trauma Informed PRN Assessment which was completed on 01/28/2025 at 6:49 p.m. and indicated Resident: #1 did not have any major trauma since she was young. The Administrator, the ADO, and the Regional Compliance Nurses were informed the Immediate Jeopardy was removed on 01/29/2025 at 5:33 p.m. The facility remained out of compliance at a severity level of potential for more than minimal harm, that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 2. Record review of Resident #4's Admission Record dated 01/27/2025 indicated he was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses which included intracranial injury with loss of consciousness of unspecified duration (injury to the brain caused by an external force such as a violent blow to the head, resulting in loss of consciousness), aphasia (inability to understand or produce speech, as a result of brain disease or damage), dysphagia (difficulty swallowing), hemiplegia (paralysis of one side of the body), muscle weakness, abnormal gait and mobility, protein malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), and depression (mental illness that negatively affects how you feel, the way you think and how you act). Record review of Resident #4's admission MDS assessment, dated 08/25/2024, indicated a BIMS score of 03 which indicated he was severely impaired cognitively and he was sometimes able to make himself understood and sometimes understood others. He was always incontinent of bowel and bladder. The Functional Status reflected he required total assistance with his ADLs. Resident #1's Mobility Assessment reflected he required total assistance with chair/bed transfers. Record review of Resident #4's care plan, dated 05/15/2024, indicated he had a communication problem related to traumatic brain injury and he was the receiver of physical behaviors. Interventions included demonstrate effective coping skills, evaluation, general assessment, cognitive assessment, trauma informed care assessment, room change, skin assessment, and pain assessment. Record review of Resident #4's event nurses' note authored by DON J (the previous DON) indicated on 08/22/2024 at 9:46 p.m., Event location: Resident Room, Description of the event: Resident was being hit with urinal by roommate. Resident statement related to event: Resident unaware of situation. Intervention: Resident moved to another room. Reportable to state. Unable to interview Resident #4 as he no longer resided at the facility. Record review of Resident #5's Admission Record dated 01/27/2025 indicated he was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included Gastro-Esophageal Reflux Disease/GERD (stomach contents leak backward from the stomach into the esophagus (food pipe)), blindness one eye and low vision in other eye, diabetes (chronic condition in which the pancreas produces little or no insulin), cerebral ischemia (condition that occurs when there isn't enough blood flow to the brain to meet metabolic demand), and personal history of malignant neoplasm of skin. Record review of Resident #5's quarterly MDS, dated [DATE], indicated a BIMS score of 13 which indicated he was cognitively intact and was able to make himself understood and usually understood others. He was always continent of bowel and bladder. Functional Status reflected he required supervision or touching assistance with his IADL/ADLs except eating and oral care required setup or clean-up assistance. Record review of Resident #5's care plan, dated 08/22/2024, indicated he had demonstrated physical behaviors. He had interventions for staff to analyze of key times, places, circumstances, triggers, and what de-escalates, assess and address for contributing sensory deficits, assess and anticipate resident's needs: food, thirst, Toileting needs, comfort level, body positioning, pain etc. He had interventions for communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated, intervene to protect the residents involved and call for assistance and if intervening would be unsafe, call out for staff assistance immediately, and when the resident becomes agitated: intervene before agitation escalates; Guide away from source of distress; engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Notify the charge nurse of any physically abusive behaviors. Monitor/ document/report to MD of danger to self and others. Record review of Resident #5's event nurses' note authored by DON J indicated on 08/22/2024 at 8:28 p.m., Event location: Resident Room, Description of the event: Nurse reported that CNA reported Resident was seen on the side of his roommate's bed hitting him with urinal. Intervention: Stat labs and Psych consult ordered. Record review of the Provider Investigation Report dated 08/30/2024 indicated on 08/22/2024 at 8:45 p.m., A CNA witnessed Resident #5 hitting Resident #4 with a bedside urinal. The Agency's Immediate Response indicated the residents were separated and neurological checks were started on Resident #4. Skin assessments and monitoring were ordered for both residents. The medical director and the residents' families were notified. Labs were drawn on Resident #5. The Social Worker was notified, and interviews were performed on the residents. Trauma informed care was provided. Staff were in-serviced on abuse, neglect, resident rights, and timely reporting. The Investigation Summary indicated there were no injuries noted to either resident. The Social Worker interviewed Resident #5, in which he confessed that he thought someone was in his bed and upon trying to wake them up he heard what he thought was a growling noise. Resident #5 was almost completely blind, and his roommate Resident #4, spoke in a low audible voice that could be misinterpreted as a growl. After the incident, Resident #5 asked if his roommate was OK and that if he would have realized it was his roommate, he would not have hit him. Resident #5 had no other behaviors or outburst since this occurrence. The Investigation Findings indicated it was inconclusive. The Agency Action Post-Investigation included room changes made would remain permanent, psych evaluations performed for both residents, trauma informed care given, and in-service performed on all staff on abuse and neglect, resident rights, and timely reporting. The date and time reported to HHSC was on 08/23/2024 at 8:50 a.m. (12 hours after the incident was initially reported). During an interview on 01/27/2025 at 2:15 p.m., Resident #5 said on 08/22/2024 around 8:40 p.m. he was up in the bathroom emptying his urinal and when he was returning to get in bed, he saw something moving in his bed and heard a growling sound, so he swatted at the object with his plastic urinal. Resident #5 said a CNA entered the room and then a nurse came in the room and explained to him that was not his bed and that was his roommate in the bed. Resident #5 said that staff checked him out, did labs, and monitored him after the incident. Resident #5 said he has poor vision and got turned around in the room and was trying to get in the wrong bed and when he heard the growling noise he swatted at the object. Resident #5 said he had requested to be moved to the opposite side of the room prior to incident and must have forgot when he was returning to bed. Resident #5 said he was upset about hitting his roommate (Resident #4) and did not intentionally harm him, he was just defending himself from the growling object. During an interview on 01/27/2025 at 4:51 p.m. ADON C said on 08/22/2024 she was the charge nurse for Hall 100 and around 8:45 p.m., the CNA reported to her that she witnessed Resident #5 hit Resident #4 with a soft plastic urinal. ADON C said she and the CNA separated the residents and verified all residents involved in the incident were safe and reported the incident to the active DON (DON J) and was directed to start the resident-to-resident altercation protocol. ADON C said she immediately reported the incident to the DON and thought the DON would report the incident to the abuse coordinator. During an interview on 01/28/2025 at 10:15 a.m., the Administrator said he was the abuse coordinator and he investigated or designated staff to investigate allegations of abuse or neglect with serious body injury. The Administrator said he was aware that all abuse or neglect allegations with serious bodily injury must be reported to the state within 2 hours of the alleged incident. The Administrator said he reported abuse allegations within 2 hours of him being notified. He said they provided in-services to all the facility staff regarding timely reporting when he identified that the staff were not reporting the incidents timely when he first took the administrator/abuse coordinator role back on 07/30/2024. He said residents were at risk of continued abuse if allegations of abuse were not reported as required. 3. Record review of Resident #6's Admission Record dated 01/27/2025 indicated she was an [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses including encephalopathy (disease in which the functioning of the brain is affected by some agent or condition), diabetes (chronic condition in which the pancreas produces little or no insulin), protein malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and depression (mental illness that negatively affects how you feel, the way you think and how you act). Record review of Resident #6's admission MDS assessment, dated 06/17/2024, indicated a BIMS score of 10 which indicated she was moderately impaired cognitively and she was able to make herself understood and sometimes understood others. She was always incontinent of bowel and bladder. The Functional Status indicated she required set up or clean-up assistance with her IADL/ADLs except eating which she was independent. The Mobility Status indicated she required maximum to moderate assistance with bed mobility, transfers, and ambulation. She used a manual wheelchair for mobility. Record review of Resident #6's care plan, dated 01/31/2024, indicated she had a communication problem related to encephalopathy. The interventions included staff were to anticipate and meet the resident's needs and to monitor for/record confounding problems. Record review of Resident #6's event nurses' note authored by DON J indicated on 07/06/2024 at 2:41 p.m., Event location: Nurses station, Description of the event: CNA F at nurses' station was rude to Resident #6 when she came to nurses' station to request assistance. Allegation reported to DON and administrator. Other information: Reported to state. Record review of Resident #6's weekly skin assessment, dated 07/06/2024 indicated no new skin impairments found during skin assessment. Record review of Resident #6's weekly skin assessment, dated 07/09/2024 indicated no new skin impairments found during assessment. Record review of the Provider Investigation Report dated 07/12/2024 indicated on 07/05/2024 at 10:00 p.m., A CNA spoke rudely to Resident #6 when she requested to be changed. The Agency's Immediate Response indicated the CNA was suspended and Resident #6 was assessed with no injuries. Resident #6 was assisted back to bed and was provided care by assigned CNAs and CN. The Investigation Findings indicated Resident #6 had been very happy about the care she received, except the night of 07/05/2024 when CNA F was rude to her. Facility staff intervened during the incident and removed Resident #6 from the situation and took her back to her room and provided requested care. The Agency Action Post-Investigation included trauma informed care given, and in-service performed on all staff on abuse and neglect. The date and time reported to HHSC was on 07/06/2024 at 4:30 p.m. (>16 hours after the incident was initially reported). Record review of timesheets for facility staff working 07/04/2024 and 07/05/2024 did not indicate CNA F clocked in or worked on 07/05/2024. Unable to interview Resident #6 as she no longer resides at the facility. During an interview on 01/27/2025 at 4:55 p.m., ADON C said on 07/05/2024 she was the outgoing charge nurse for Hall 100 and around 10:00 p.m., she heard CNA F speak rudely to Resident #6 regarding her call light not being on because the call system was not working. ADON C said she intervened, and she and Resident #6's assigned CNA assisted Resident #6 back to her room and provided the requested care. ADON C said that she verified that Resident #6 was safe, and no injuries or distress were noted during providing care and she reported the incident to the oncoming CN and the active DON (DON J). She said residents were at risk of continued abuse if allegations of abuse were not reported as required. Attempted to call DON J on 01/27/2025 at 4:50 p.m. and 5:50 p.m. via telephone for interview, unsuccessful with no answer or returned call. During an interview on 01/28/2025 at 10:15 a.m., the Administrator said he was the abuse coordinator and he investigated or designated staff to investigate allegations of abuse. The Administrator said he was aware that all abuse allegations must be reported to the state within 2 hours of the alleged incident. The Administrator said he reported abuse allegations within 2 hours of him being notified. He said they provided in-services to all the facility staff regarding timely reporting when he identified that the staff were not reporting the incidents timely when he first took the administrator/abuse coordinator role back on 07/30/2024. He said residents were at risk of continued abuse if allegations of abuse were not reported as required. Record review of the facility's policy Abuse/Neglect, date revised 09/09/2024, indicated .Reporting 1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons. 2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. 3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 2024-14 dated 8/29/2024. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.

47879 Based on observations, interviews, and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated and/or prevent further potential abuse for 1 of 4 resident (Resident #1) reviewed for abuse and neglect. The facility failed to conduct a thorough investigation when CNA A reported to ADON C and ADON D an allegation of verbal abuse of LVN B to Resident #1 on 10/22/2024 at 8:30 p.m. The facility failed to protect Resident #1 from further alleged/potential verbal abuse by allowing LVN B to work in the facility on 10/22/2024 after the allegation and to work on 10/23/2024 until 4:30 p.m. An Immediate Jeopardy (IJ) was identified on 01/28/2025. The IJ Template was provided to the facility on [DATE] at 5:26 p.m. While the IJ was removed on 01/29/2025 at 5:33 p.m., the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. The failures could place residents at risk of undetected abuse, trauma, and/or decline in feelings of safety and well-being and psychosocial harm. Findings included: 1. Record review of the admission record dated 01/29/2025 indicated Resident #1 was admitted on [DATE], she was [AGE] years old with Alzheimer's disease, anxiety, and heart failure. Record review of quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 5 and was cognitively impaired. She was able to make herself understood and understood others. No behaviors were noted. Resident #1 had psychotic disorder, anxiety, and depression. Resident #1 had received medication last 7 days of antipsychotic, antianxiety and antidepressant. During an interview on 01/28/2025 at 8:00 a.m., CNA A said on 10/22/2024 around 8:00 p.m., she found Resident #1 on the floor and asked LVN B to check on Resident #1 and assist her to place Resident #1 back in bed. CNA A said she heard LVN B say loudly to Resident #1 you need to keep your fat ass off the floor, and she did not come to work to throw her back out picking your fat ass off the floor. CNA A said Resident #1 said You should not work here then. CNA A said all of that happened while they were putting the resident back in the bed. CNA A said she stepped between the nurse and the resident and said she had it from there. She said she reported the incident to both ADON C and ADON D, who were in their office on the computers, around 8:30 p.m. CNA A said the ADONs sent her to lunch to cool down and she said she was really upset. She said after that she made her rounds and went home after the shift ended. She said the next day she was asked to write her witness statement on the proper form by the human resource department and the administrator. She said the night before she had written her witness statement on notebook paper. During an interview and observation on 01/28/25 at 9:30 a.m., Resident #1 was lying in her bed, well-groomed with no foul odors noted. She said she did not recall any facility staff cursing at her or mistreating her. Record review of Resident #1's skilled nurses' notes dated 10/22/2024 did not indicate any falls or any concerns. Record Review of Resident #1's medical records did not indicate an incident report or event note was completed the day of the incident, 10/22/2024. Record review of LVN B time sheet indicated she was on duty on 10/22/2024 at 1:37 p.m. to 10:10 p.m. and was on duty on 10/23/2024 from 2:00 p.m. to 4:28 p.m. Record review of a weekly skin assessment dated [DATE] indicated LVN B performed a skin assessment on Resident #1 after the incident was reported to the ADONs on 10/22/2024. During an interview on 01/28/2025 at 8:25 a.m., the Administrator said the allegation of LVN B verbally abusing Resident #1 was not reported to him until 10/23/2024. He said he was made aware of the allegation on 10/23/2024 around 4:00 p.m. and reported to the state thereafter. He said all abuse allegations must be reported to him or designee immediately and reported to the state within 2 hours of the allegation. He said residents were at risk of continued abuse if allegations of abuse were not reported as required. During an interview on 01/28/2025 at 9:05 a.m., ADON C said she thought about it more and remembered CNA A had reported to herself and ADON D an allegation of LVN B telling Resident #1 to keep her fat ass off the floor. ADON C said they sent CNA A to go on lunch break. ADON C said they both went to the halls, and she checked on another matter and ADON D went to check on Resident #1. ADON C said herself and ADON D were both working that evening on the halls, and both were responsible for reporting to the Administer/Abuse Coordinator. She stated I thought ADON D had reported the event to the Administer because he was the Abuse Coordinator. She said residents were at risk of continued abuse if allegations of abuse were not reported as required. She said that she should have verified that the allegations of abuse were reported to the abuse coordinator immediately. She said not reporting the abuse allegation to the abuse coordinator could delay the investigation of the allegation and place residents at risk for continued abuse. During an interview and record review on 01/28/2025 at 2:03 p.m., the Administrator said he was not notified of the verbal incident with Resident #1 on 10/22/2024. The State Surveyor reviewed CNA A's witness statement dated 10/23/2024 with the Administrator and identified that the CNA had notified ADON C and ADON D regarding the incident. He said he had not seen that CNA A had reported this allegation to the ADONs on 10/22/2024 when he read CNA A's witness statement originally. He said he had not seen the last sentence about CNA A indicating she reported this event to the ADONs until now. He said the ADONs should have called him immediately and LVN B should have been suspended until the investigation was completed. He said LVN B was suspended on 10/23/2024 at 4:30 p.m. He said the ADONs should have been interviewed during the investigation and disciplined for not reporting the incident immediately. He said not investigating the allegation of abuse thoroughly could place the residents at risk for undetected or continued abuse, and/or a decline in feeling safe at the facility. During an interview on 1/28/2025 at 2:37 p.m., ADON D denied that CNA A reported the allegation of LVN B verbally abusing Resident #1 to her. She said she knew the Administrator was investigating the allegation. She said she and ADON C worked that night (10/22/2024), but no one had reported abuse to her, or she would have called the Administrator immediately. Record review on LVN B's personnel file indicated her date of hire was 09/19/2024 and last day worked was 10/23/2024. LVN B was terminated on 10/25/2024 for misconduct. This was determined to be an Immediate Jeopardy (IJ) on 01/28/2025 at 5:26 p.m. The facility's Administrator, the ADO, and the Regional Compliance Nurses were notified. The Administrator was provided with the IJ template on 01/28/2025 at 5:26 p.m. The following POR was accepted on 01/29/2025 at 9:53 a.m.: Interventions 1.Resident #1 was assessed for emotional distress by the DON on 01/28/2025. A trauma informed care assessment was completed on 01/28/2025 by the DON. No additional emotional distress was noted. 2.LVN B was terminated on 10/25/2024 and ADON D resigned. Both are no longer employed at the facility as of 01/28/2025. 3.The Administrator, DON, and ADON C were in-serviced 1:1 by the Area Director of Operations and Regional Compliance Nurse on following topics below. Completed on 01/28/2025. a. Abuse and Neglect- The administrator is the Abuse Coordinator. Inservice includes that abuse and neglect should be reported immediately to the abuse coordinator. The Abuse coordinator will immediately suspend all alleged perpetrators. Staff named in the allegation(s) are not allowed to continue working. The abuse coordinator will report to HHS immediately but no later than two hours after the event. The abuse coordinator will thoroughly investigate the allegation. The abuse coordinator will delegate responsibilities to start the investigation in the event he is not available. In the event the Administrator can't be reached, the DON will be notified immediately. The alleged perpetrator will not return to work until approved by the abuse coordinator. 4.The medical director was informed of the immediate jeopardy citation on 01/28/2025 by DON. 5.An ADHOC QAPI meeting was held on 01/28/2025 to include the interdisciplinary team and medical director to discuss the immediate jeopardy citation and plan of removal. In-services: On 01/28/2025, All staff will be in-serviced on the following topics below by the Administrator, Regional Compliance Nurse, DON, and ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. Completion date 01/29/2025. a. Abuse and Neglect- The administrator is the Abuse Coordinator. Inservice includes that abuse and neglect should be reported immediately to the abuse coordinator. The Abuse coordinator will immediately suspend all alleged perpetrators. Staff named in the allegation(s) are not allowed to continue working. The abuse coordinator will report to HHS immediately but no later than two hours after the event. The abuse coordinator will thoroughly investigate the allegation. The abuse coordinator will delegate responsibilities to start the investigation in the event he is not available. In the event the Administrator cannot be reached, the DON will be notified immediately. The alleged perpetrator will not return to work until approved by the abuse coordinator. The surveyors monitored the POR on 01/29/2025 as followed: During interviews on 01/29/2025 from 10:00 a.m. - 2:00 p.m. 8 CNAs (CNA GG, CNA II, CNA LL, CNA NN, CNA OO, CNA SS, CNA YY, and CNA DDD), 4 LVN's (LVN E, LVN HH, LVN QQ, and ADON C), 1 LVN/treatment nurse (LVN/Treatment AAA), 1 MA (MA HHH), 2 MDS Nurses ( MDS JJ and MDS KK), 2 Laundry staff (Laundry CC and Laundry GGG), 3 Dietary staff ( Dietary EE, Dietary EEE, and Dietary FFF), 2 Housekeeping staff (HSK RR and HSK CCC), 2 Activities staff (Activities TT and Activities Asst VV), 2 Physical Therapists (PT MM and PT WW), 1 Speech Therapist (ST FF), 1 Certified Occupational therapist assistant (COTA BBB), 1 Business office staff (BO DD), 1 Admission Clerk (Admission ZZ), 1 Human Resource staff (HR XX), 1 Medical Records (MR UU), 1 Maintenance Supervisory (Maintenance PP) (from the A.M. shift) all said they were in-serviced before starting their shift on 01/29/2025 and then given questionnaires to complete to verify their knowledge. All were able to state that their abuse coordinator was the Administrator, and if he was not available, they were to notify the DON. They were all able to give examples of physical, verbal, and emotional abuse. All expressed the importance of reporting alleged abuse immediately when they first saw or heard it. All knew where the corporate compliance hotline number was posted and knew when to contact if needed. During interviews on 01/29/2024 from 3:55p.m.- 4:20p.m. with 6 alert and oriented residents indicated they recently had communication with management regarding their satisfaction with living at the facility and they had no concerns about their safety, about the staff who provided their daily care, or the management at the facility. During interviews on 01/29/2025 from 2:30p.m. -5:20 p.m. 8 CNAs (CNA LLL, CNA MMM, CNA NNN, CNA OOO, CNA QQQ, CNA RRR, CNA SSS, and CNA TTT), 3 LVNs (LVN III, LVN KKK, and LVN PPP), and 1 MA (MA JJJ) (from 2 p.m.-10 p.m. and 10 p.m. - 6 a.m. shifts) all said they were in-serviced before starting their shift on 01/28/2025 and 1/29/2025 and then given questionnaires to complete to verify their knowledge. All were able to state that their abuse coordinator was the Administrator, if he were not available, they were to notify the DON. They were all able to give examples of physical, verbal, and emotional abuse. All expressed the importance of reporting alleged abuse immediately when they first saw or heard it. All knew where the corporate compliance hotline number was posted and knew when to contact if needed. During an interview on 01/29/2025 at 12:15 p.m., ADON C said she was given one-on-one in-service with the ADO (Area Director of Operations) and the Regional Compliance Nurses regarding reporting alleged abuse to the abuse coordinator immediately (if abuse coordinator was not available or was unreachable, then they would report to the DON ), the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and she was to begin investigating alleged allegations immediately if delegated by the abuse coordinator or the DON to do so. She said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. During an interview on 01/29/2025 at 12:45 p.m., the DON said she was given one-on-one in-service with the ADO (Area Director of Operations) and the Regional Compliance Nurses regarding reporting alleged abuse allegations to the abuse coordinator immediately (if abuse coordinator was not available or was unreachable, then staff would report to her), the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and she was to begin investigating alleged allegations immediately if delegated by the abuse coordinator do so. She said if abuse was reported to her in the absence of the abuse coordinator that she would report the alleged allegation to HHSC within 2 hours of the alleged incident. She said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. During an Interview on 01/29/2025 at 1:00 p.m., the Administrator said he was in-serviced one-on-one with the ADO (Area Director of Operations) and the Regional Compliance Nurses regarding the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and that he was to begin investigating alleged allegations immediately and if he was not available, he was to delegate investigation responsibilities to the DON and/or management staff. He said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. The Administrator said 95% of the active employees had been in-serviced and the remaining employees would be in-serviced before the start of their next shift. The Administrator said all new hires would receive training on abuse, neglect, and timely reporting prior to providing any resident care. Record Review of Resident #1's chart included the Trauma Informed PRN Assessment which was completed on 01/28/2025 at 6:49 p.m. and indicated Resident: #1 did not have any major trauma since she was young. Record review of the facility's policy Abuse/Neglect, date revised 09/09/2024, indicated .F. Investigation: Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated . 6. The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incident(s). A copy of the written report will accompany any personnel action deemed necessary. If a personnel action occurs, a copy of all pertinent documents will be placed in the employee's personnel file. The Administrator, the ADO, and the Regional Compliance Nurses were informed the Immediate Jeopardy was removed on 01/29/2025 at 5:33 p.m. The facility remained out of compliance at a severity level of potential for more than minimal harm, that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

47879 Based on observation, interview, and record review, the facility failed to ensure the resident's environment remained free of accident hazards and the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #2) reviewed for accidents and supervision. The facility failed to ensure adequate supervision for Resident #2 with two staff members for bed mobility during pressure ulcer treatment to prevent a fall with injury on 10/29/2024. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 10/29/24 and ended on 10/29/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for injury and harm due to the lack of supervision provided by the facility. Findings included: Record review of the face sheet for Resident #2 indicated she was admitted on [DATE], was [AGE] years old with diagnosis of high blood pressure, kidney disease, stroke, and morbid obesity. Record review of the physician orders October 2024 for Resident #2 indicated she had an order for Acetaminophen Tablet 325 mg, give 650 mg by mouth every 4 hours as needed for pain give two 325mg tabs to give 650mg with start date of 11/16/2020. Record review of the MDS state optional assessment dated [DATE] indicated Resident #2 required 2 staff members for bed mobility. Her BIMS indicated severe cognitive impairment with score of 6. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #2 was able to understand and make her needs known. She required substantial/ maximal assistance with the helper doing more than half the effort. Her BIMS indicated severe cognitive impairment with score of 6. Record review of the care plan dated 09/09/2024 indicated Resident #2 had an ADL self-care performance deficit. Resident #2 required 2 staff for assistance with bed mobility, with start date of 11/23/2020. Record review of the Kardex dated 10/22/2024 indicated Resident #2 required 2 staff for bed mobility. Record review of the nurse progress notes for Resident #2 indicated on 10/29/2024 at 11:00 a.m., LVN H was performing a treatment while Resident #2 was rolled over holding onto the P rail. The resident she rolled off onto the floor. Resident #2 had a small skin tear to her right upper arm and small scratch to her left arm. LVN H cleaned both areas and applied a bandage to the resident's right arm skin tear. LVN H said the resident did not hit her head and the fall was witnessed. She assisted the resident back into the bed with a mechanical lift. Record review of the hospital records dated 10/30/2024 indicated Resident #2 had no fractures or head injuries. Resident #2 did have bruises to the side of the face and to the abdomen and bruises with skin tear on right upper arm. She was transferred back to the facility with no new orders. Record review of the nurse progress notes for Resident #2 indicated on 10/30/2024 at 1:04 a.m., the resident was back in facility after she was sent to the local hospital related to the fall. A CT was done of her head and X-rays were done of her knees and ankles. No fractures or abnormalities shown. Record review of the MAR for October 2024 indicated Resident #2 received 2 doses of Tylenol 325 mg 2 tablets on 10/29/2024 and 10/30/2024 for abdomen pain and it was effective. Record review of an in-service training dated 10/29/2024 indicated LVN H was retrained on bed mobility for Resident #2, the use of Kardex and documenting falls. The training documents indicated where in the Kardex the staff could locate bed mobility and how many staff were required. Record review of an in-service dated 10/29/2024 at 6:30 p.m. indicated nursing staff were retrained on the use of the Kardex system and documenting falls. The training documents indicated where in the Kardex the staff could locate bed mobility and how many staff were required. Record review of the Kardex dated 10/30/2024 indicated Resident #2 required 2 staff for bed mobility. During an interview on 01/27/2025 at 9:05 a.m., Resident #2 said the day she fell , LVN H was doing a treatment with no one helping her. Resident #2 stated I told her she needed someone to help turn me and the nurse said she could not find anyone to help. She stated, the nurse turned me towards my right side, and I fell out of the bed. During an interview on 01/27/2025 at 1:28 p.m., LVN H said she had not been oriented about the Kardex system until after the incident with Resident #2. LVN H said she thought she could do the treatment by herself because she could not find someone who could help her turn the resident. She stated, When I turned the resident towards her right side, she fell off the bed onto the floor. She said the bed was not against the wall and there was a small gap and that was where Resident #2 fell to the floor. LVN H denied the resident told her to get help. She said the resident was assessed for serious injuries and placed back in the bed and then sent to the hospital. During an interview 01/27/2025 at 10:30 a.m., ADON C said she had orientated LVN H when she was hired and told the nurse about the Kardex system. ADON C said all nursing staff were retrained on 10/29/24 following the incident with Resident #2, on the use of the Kardex system and to check how many staff were required for turning, transfer, toileting and eating. During an interview on 01/27/2025 at 10:12 a.m., the DON said LVN H was not terminated due to the incident; however, she had since been terminated. The DON said all the nursing staff were retrained on the Kardex system to ensure all staff knew about the residents who needed 2 staff for bed mobility. The DON said her expectation was for the staff to get help in turning the residents who required 2 staff members per Kardex. Record review of the personnel file record for LVN H indicated she was hired 10/24/2024. She was suspended on 10/29/2024 for the incident involving Resident #2 and after the investigation, she was provided additional training related to the Kardex system. She was terminated on 11/19/24 was for a different reason. During an interview on 01/27/2025 at 10:05 a.m., LVN E said Resident #2 had always been 2 staff with turning her and for her treatment. She said Resident #2 required 2 staff for transfer. During an interview on 01/27/2025 at 11:01 a.m., LVN III said when you reposition Resident #2 must use 2 staff. During an interview on 01/27/2025 at 11:30 a.m., CNA A said she knew to use 2 staff with Resident #2. She said when giving incontinent care or transfer must us 2 staff. During an interview on 01/27/2025 at 11:30 a.m., CNA SS said Resident #2 required 2 for bed mobility and 2 for transfer. During an interview on 01/27/2025 at 11:50 a.m., LVN AAA said Resident #2 required assistance when she performed Resident 2's treatment to hold the resident. She said Resident #2 was unable to balance self on her side. During an observation on 01/27/2025 12:00 p.m., LVN E and CNA A repositioned Resident #2 on her back and pulled her up in the bed to prepare for lunch. During interviews on 01/27/2025 at 1:30 to 4:30 p.m., 8 CNAs (CNA GG, CNA II, CNA LL, CNA NN, CNA OO, CNA SS, CNA YY, and CNA DDD), 4 LVNs (LVN E, LVN HH, LVN QQ, and ADON C), 1 LVN/treatment nurse (LVN/Treatment AAA), 1 MA (MA HHH), 2 MDS Nurses ( MDS JJ and MDS KK), 2 Physical Therapists (PT MM and PT WW), 1 Speech Therapist (ST FF), 1 Certified Occupational therapist assistant (COTA BBB). All the staff were retrained on the Kardex system and said the program indicated how many staff was required for eating, transfer, bed mobility and ambulation. During an interview on 01/27/2025 at 430 p.m., the Administrator said he expected the staff to use the Kardex system and get help when help is needed or required. The facility policy dated 12/30/2005 titled Safe Patient Handling indicated The facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment, and interventions to provide a comfortable, safe transfer, repositioning and resident movement. 1.Nurses will identify residents in need of transfer, repositioning, or movement assistance. 2.Nurses will assess the risks associated with lifting, transferring, repositioning or movement assistance. 3.Nurses will be educated in the identification, assessment, and control of risks of injury to resident and nurses during patient handling. 4.Resident will be evaluated on admission and as needed for alternative means of lifting, transferring, repositioning and other movement to minimize risk of injury. 1. Nurses will be educated regarding correct safe handling procedures, to report concerns or the inability to perform resident handling or movement that the nurse believes in good faith will expose a resident or nurse to an unacceptable risk of injury. 2. Facility staff will report to supervisor the inability to complete resident lifting, transfer, or repositioning if they feel it will either endanger the resident or cause injury to staff. The undated Comprehensive care plan policy indicated The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Comprehensive care plans may include but are not limited to resident Kardex records, baseline care plans, and task listings. On 02/10/2025 at 10:22 a.m., the Administrator was informed of the Immediate Jeopardy. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 10/29/2024 and ended on 10/29/2024. The facility had corrected the noncompliance before survey began.