DFW Nursing & Rehab

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to be from abuse for 1 of 4 residents (Residents #1) reviewed for abuse. <BR/>The facility failed to protect Residents #1 from a physical and verbal altercation on 01/22/25 with the Administrator. The Administrator pushed Resident#1, causing Resident#1 to fall. The incident was not reported or documented until after surveyor intervention on 01/23/25.The Administrator was not suspended until 01/23/25 at approximately 11:30 AM. <BR/>An IJ was identified on 01/23/25. The IJ template was provided to the facility on [DATE] at 5:15 PM. While the IJ was removed on 01/25/25, the facility remained out of compliance at a scope of Isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems .<BR/>This failure placed residents at risk of subsequent abuse, mental anguish, and emotional distress. <BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 01/23/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizophrenia (Serious mental health condition that affects how people think, feel and behave), Type 2 Diabetes Mellitus with Diabetic, Unspecified Psychosis not due to substance or known major depressive disorder.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 10/28/24, reflected Resident #1 had a BIMS of 12, which indicated cognition moderate impaired. <BR/>Record review of Resident #1's care plan, revised 09/20/24, revealed the resident at risk for altered status due to a traumatic life experience while at a previous group home or [Nursing Facility]. Certain male figures in authority positions, with similar physical attributes or appearance at times trigger him. Interventions in place included: Administer medication as ordered, approach resident from the front and speak in a calm, unhurried manner .Identify cause/trigger for behavior and reduce factors that may provoke resident .Call [Family Member#1] if need to calm down or get him to comprehend the situation]<BR/> .<BR/>Record review of Record review of Psychological Services Progress Note, dated 10/08/24and completed by Psy services reflected, Resident#1 was negative for Trauma Informed Care. <BR/>Record review revealed no incident/accident report was completed about the incident on 01/22/25.<BR/>Record review of Resident#1 progress noted dated, 11/01/23 to 01/22/25 reflected: Resident#1 had other incidents with other staff but not the Administrator. <BR/>Record review of Resident#1 progress notes revealed no documentation about the incident on 01/22/25.<BR/>Record review of Resident#1 assessments revealed no documentation about incident on 01/22/25.<BR/>Record review of Resident#1 incident provided to surveyor on 01/25/25 reflected: it was initiated on 01/22/25 with no completed/ locked date on the incident report. Incident description section reflected: This [LVN K] was notified by staff after the incident that [Resident#1] slapped [MA N] and physically attacked Administrator and [Resident#1] fell to the floor. Resident description reflected: [Resident#1] stated he was approached by Administrator, in what he felt was an aggressive manner so I just swung on his . Immediate action taken section reflected: [Resident#1] assessed for injuries. None noted, denied pain or any discomfort. Physician notified, In the agencies/people notified section reflected: no notification found,<BR/>An interview on 01/23/25 at 10:20 AM Family Member#1 approached surveyor at the facility and stated the Administrator fought [Resident#1] last night. Family Member#1 stated that was wrong and he is elderly. Family Member#1 stated the Administrator was always picking on him when Resident#1 wanted to play his piano. Resident#1 did not speak to the Administrator when the Administrator would try to speak to him <BR/>An in-person interview on 01/23/25 at 10:45 AM, the Administrator and MA N entered the conference room to explain the incident on 01/22/25. The administrator stated Resident#1 assaulted a medication aide around 7pm on 01/22/25. The Administrator stated the medication aide and himself went to Resident#1s room. Resident#1 was asked why he hit the medication aide. The Administrator stated Resident#1 started punching and kicking the Administrator and made threats. The Administrator stated he put his hands up to protect himself. The Administrator stated Resident#1 tripped over his own leg and fell. The Administrator stated [CNA J], [CNA L] and [LVN P] intervened and pulled Resident#1 away. The Administrator stated he was told by Resident#1 and Family member that he reminded Resident#1 of males from his past that made fun of him and were aggressive towards him because he was gay. The Administrator stated it did not have to be reported because it was an altercation between staff and a resident.<BR/>An interview on 01/23/25 at 10:45 AM, MA N stated Resident#1 took snacks off the snack tray and hit MA N's face when she asked him what he was doing. MA N immediately reported to the Administrator who went to Resident#1 to ask what happened and Resident#1 hit the Administrator. <BR/>An interview on 01/23/25 at 11:00 AM, the DON stated she was not made aware of the incident until after 10:15 AM on 01/23/25 when Resident#1 family member came into her office. The DON immediately called her nurse consultant and informed her of the situation. <BR/>An interview and observation on 01/23/25 at 11:05 AM of the camera in the Administrator office with the PD revealed, Resident was punching and kicking the Administrator. The Administrator open hand pushed Resident#1 face area and caused Resident#1 to fall. Observed a linen cart pushed between the Administrator and Resident#1. Observation of additional staff stepped in between Resident#1 and Administrator. Staff were observed holding the Administrator back and grabbing Resident#1. PD stated an incident would be put on file but no arrest or charges because the resident started the altercation. Surveyor did not recall observing a date and time on the footage. <BR/>An interview on 01/23/25 at 11:30 AM, Ombudsmen stated she had not been notified about the physical altercation between the Administrator and Resident#1.<BR/>An over the phone interview on 01/23/25 at 1:30 PM the Corporate Operations Manager and Nurse Consultant stated they were not made aware of the abuse allegation until 1/23/25 at approximately 10:30 AM. The Administrator (Abuse coordinator) was asked to go home until the investigation was completed. Both stated it did not have to be reported to State since there was not an allegation of abuse at the time of the incident. Operations Manager stated that is the company policy for all that when an investigation of abuse had been reported the staff member would be suspended until the investigation was completed. Corporate Operations Manager and Nurse Consultant both stated the Administrator was suspended until the investigation was completed. Both stated there was no risk to residents, as soon as they found out about the incident the facility took immediate action. <BR/>An interview with Resident#1 on 01/23/25 at 2:15 PM he stated he would not feel safe in the facility if the Administrator returned. Resident#1 stated the Administrator hit him and he hit him back.<BR/>An interview on 01/23/25 at 4:11PM CNA J stated it was chaos in the hallway and he did not see how the incident started. CNA J stated he saw Resident#1 kicking and hitting the Administrator. CNA J stated he tried to intervene but did not want to get hit by Resident#1 so, he pushed a linen cart between them. CNA J stated he did not see how the resident fell. CNA J stated he grabbed Resident#1 and took him outside to smoke. <BR/>An interview on 01/23/25 at 4:20 PM LVN P stated he witnessed Resident#1 swinging both of his arms towards the Administrator LVN P stated they separated Resident#1 and the Administrator. <BR/>An interview on 01/24/25 at 4:30 PM CNA L stated Resident#1 was kicking and hitting the Administrator in the hallway. CNA L stated he did not see how Resident#1 fell but, he jumped back up and continued to attack the Administrator. CNA L stated the Administrator and Resident#1 were separated. <BR/>An interview on 01/24/25 at 4:50 PM DON stated the Administrator who is the abuse coordinator is responsible for completing and reporting investigation to corporate and State office. DON stated while the Administrator was suspended, she would be responsible. <BR/>Record review of facility policy titled; Usual Occurrence Reporting revised 12/07 reflected: H. Other occurrences that interfere with facility operations band affect welfare, safety, or health of residents, employees or vistors.2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations.<BR/>Record review of facility policy titled; Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigating revised 09/22 reflected: <BR/>All reports of resident abuse . Are reported to local state and federal agencies add (current regulations) is thoroughly investigated by facility management . findings of all investigations are documented and reported . Policy interpretation and inflammation reporting allegations to the administrator and authorities upon receiving any allegations of abuse the administrator is responsible for determining what actions (if any) are needed for protection of residents . Investigation allegations 1. all allegations are thoroughly investigated the administrative initiates investigations any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete . 9. the investigator notifies the ombudsman that in abuse investigation is being conducted the ombudsman is invited to participate in the review process B. the ombudsman is notified of the result of the investigations as well as any corrective measures taken . follow up report #1 within 5 business days of the incident the administrator will provide a follow-up investigation report direct action number one all relevant professional and licensing boards are notified when an employee is found to have committed abuse #2 if the investigation reveals that the allegations of abuse are founded the employee is terminated #3 any allegations of its view in our files in the huge employees personal records along with any statement by the employee disputing the allegation if the employee chose make one .<BR/>The Director of Nursing was notified that an Immediate Jeopardy situation was identified and record review request of ANE policy due to the above failure and provided with the Immediate Jeopardy template on 1/23/25 at 5:15 PM. A Plan of Removal was requested.<BR/>The facility's Plan of Removal was accepted on 1/24/2025 at 1:50 PM and included: <BR/>Plan of Removal:<BR/>1. <BR/>Immediate action(s) taken for the resident(s) found to have been affected include:<BR/>Resident # 1 was assessed by the Nurse on 1/22/25 . A thorough investigation was initiated by the Corporate Office and Director of Nursing Services.<BR/>The Medical Director was notified by the DON at 3:33pm and The DON called and left a message for the Ombudsman 1/23/25, at 5:30PM. The RP was notified on 1/22/25 by the Administrator. The accused Team Member was placed on Administrative Leave pending investigation. The Police Department was called and arrived at the facility. The Incident Report was completed on 1/23/25. The SIMS was initiated on 1/23/25 at 2:30pm.<BR/>In-services have been done by the DON for: Completing Incident reports, Notifications to MD/Ombudsman, Reporting Abuse/Neglect, Abuse Policy including timeline for reporting and What to do When a Team Member is accused (investigation requires for Team Member to be placed on Administrative Leave until the investigation is concluded). De-escalation of aggressive behaviors and resident to staff altercations. <BR/>The Post Test will be administered by the DON/designee after education is completed. Staff are required to pass at least 80%. Staff who do not achieve 80% passing rate will be re-educated and will retake the test.<BR/>TEXAS Abuse hotline number, [PHONE NUMBER] posted in strategic areas within the facility, staff made aware of postings.<BR/>2. <BR/>Identification of other residents having the potential to be affected was accomplished by:<BR/>The facility has determined that all residents have the potential to be affected. Supervisor Rounds have been started and will be completed by 1/24/25 to interview residents for issues related to care, respect and dignity. The rounding will be done by the Supervisors and the monitoring will be completed on the Supervisor Daily Rounds form.<BR/>3. <BR/>Actions taken/systems put into place to reduce the risk of future occurrence include:<BR/>An in-service education program was conducted by the Director of Nursing Services and the Assistant Director of Nursing with all staff addressing circumstances that require reporting including appropriate timeframes, reporting to the Corporate Office, reporting to the Ombudsman, timely completion of Incident Reports and SIMS reports and policy regarding Team Member involvement will be completed by 1/24/25. <BR/>The Corporate Nurse Team will conduct a Zoom meeting at 10 am on 1/24/25 with [Facility] Director of Nursing. The purpose of the in-service is to provide education for the following areas:<BR/>Our Abuse/Neglect Policy as it relates to Reporting Timelines to Corporate/State/Law Enforcement/Ombudsman/Medical Director<BR/>Steps to take when a Team Member is involved or is allegedly involved-Contact Corporate HR and place on Administrative Leave pending investigation of Abuse.<BR/>Conducting Education and Training with all Departments<BR/>Follow up and Monitoring that is required such as Rounding on Halls, Talking with Residents and Staff, Re-education with Staff to help Ensure There is No Breakdown in Communication<BR/>Five day follow up with the State Office<BR/>4. <BR/>How the corrective action(s) will be monitored to ensure the practice will not reoccur:<BR/>The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any incidents or injuries are identified, properly investigated and reported to the appropriate entities. <BR/>Findings of this audit will be reviewed in the Resident Council meetings.<BR/>This plan of correction will be monitored at the monthly Quality Assurance meeting until such time the IDT determines consistent substantial compliance has been met. <BR/>On 1/25/25 beginning at 3:00 PM the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of pre/posttest had been completed by1st, 2nd and 3rd shift nursing staff on ANE. <BR/>Record review of Director of Nursing in-services by the Nurse on ANE <BR/>Record review of the Administrator profile reflected, the Administrator was hired on 11/27/23 and terminated on 01/24/25.<BR/>An observation of the facility on 01/25/25 at 2:00 PM revealed 1-800 HHSC hotline number for abuse was posted at the entry of the facility, social workers door, display board in hallway and employees break room. <BR/>All staff were able to provide competency regarding in-service over ANE. All staff were able to provide policy, procedure, protocols, appropriate interventions, and when and who to report abuse to. All staff were to provide an example of ANE. <BR/>Staff interviewed on 01/24/25 between 9:00 AM to 2:00 PM CNA A, CNA B, LVN C (overnight shift) and CNA G, CNA H, LVN I (1st shift) and CNA J, CNA L LVN K, RN O, LVN P (2nd shift).<BR/>Staff interviewed on 01/25/25 3:40 AM to 3:00 PM: CNA D, CNA E, LVN F, RN N (Weekend shift) and laundry aide M.<BR/>An interview on 01/25/25 at 3:45PM the Director of Nursing stated she was in-serviced by the Corporate Nurse on 01/24/25 at 10:00 AM. The Director of Nursing stated she is currently the abuse coordinator. The Director of Nursing stated staff have been in-service and pre/posttest have been completed. <BR/>The Director of Nursing was informed the Immediate Jeopardy was removed on 01/25/25 at 3:00 PM the facility remained out of compliance at a scope of potential of minimum harm and a severity level of isolated, due to the facility's need to evaluation the effectiveness of the corrective systems. <BR/>An interview on 02/12/25 at 9:30 AM, Resident#1 stated that he was doing good and did not have any concerns and wanted to stay at the facility.<BR/>An over the phone interview on 02/12/24 at 9:52 AM Family member stated she was going by what [Resident#1] told her (Previous admin would tell him to stop playing his piano and pick on him that way.). Family member stated the previous Administrator [Current facility] favored someone from [Resident#1] past, but the sister did not know exactly who and people in general would make fun of [Resident#1] because he was gay. Family member stated he was previously, in a group home and wanted to stay there but, he could not care for himself. Since, previous admin is gone there has not been any more issues. Family Member stated he came from a group home, and he was happy there and did not want to leave. <BR/>Attempted to call PCP on 02/13/24 at 9:27 AM<BR/>Attempted to call Psy services on 02/13/24 at 9:52 AM<BR/>An observation and interview on 02/13/25 at 11:30 AM Resident#1 stated [Name] the Administrator hit him last week and he did not know why. Surveyor asked Resident#1 if he knew the previous Administrator name at the current facility that he stayed at and he said that was [Name] Resident#1 stated he felt safe and did not have any concerns.<BR/>Record review of Psy Subsequent assessment dated [DATE] and completed by Psy services reflected, <BR/>The provider asked the patient to tell him what transpired since the last few days. The patient replied nothing happened. The provider reframed the question and asked the patient if he had any altercation with anyone in the facility a few days ago. He replied someone pushed me. The provider asked the patient how the incident happened or what prompted the altercation. He replied, I do not know . <BR/>Record review of Psychological Services Progress notes dated ,01/30/25 on Resident#1 completed by Psy services reflected, Resident#1 was negative for Trauma Informed Care.<BR/>The Director of Nursing was informed the Immediate Jeopardy was removed on 01/25/25. The facility remained out of compliance at a scope of actual harm and a severity level of isolated, due to the facility's need to evaluation the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation or mistreatment have evidence that all alleged violations were thoroughly investigated and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for two of eleven residents (Resident #1 and Resident #2) reviewed for abuse, neglect and exploitation. <BR/>1. <BR/>The facility failed to investigate an alleged violation when Resident #1 exhibited sexually inappropriate behaviors to prevent further abuse or neglect towards Resident #1 and others. <BR/>2. <BR/>The facility failed to investigate when Resident #2 obtained and used nonprescription drugs at the facility, was found exhibiting signs of an overdose, and was transported to the local hospital where he tested positive for marijuana .<BR/>This failure could place all residents at an increased risk for abuse and neglect.<BR/>Findings included: <BR/>1.<BR/>Record review of Resident #1's face sheet, dated 5/20/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: dementia (brain disorder that affects memory, thinking, and behavior), metabolic encephalopathy (brain disorder that causes confusion) COPD (lung disease), type II diabetes (inability to regulate blood sugar levels), chronic respiratory failure (lack of oxygen), end-stage renal failure (kidney disease), and hypertension (high blood pressure). <BR/>Record review of Resident #1's admission MDS assessment, dated 4/08/25, reflected his BIMS score was 10, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required partial to moderate assistance with most ADLs, used a walker, and was independent with most mobility tasks. The MDS Assessment under Section E-Behaviors, reflected Resident #1 did not have any physical or verbal behaviors. <BR/>Record review of Resident #1's care plan, revised 4/23/25, reflected the resident had a history of socially inappropriate behaviors: sexually inappropriate behavior. Interventions included: administering medication as ordered, eliciting family input for best approaches, praising the resident for demonstrating desired behavior, providing all care with another staff member, and removing the resident from public area when behavior was disruptive and/or unacceptable. Further review of this document reflected Resident #1 was not care planned for sexually inappropriate behaviors upon admission.<BR/>Record review of Resident #1's clinical notes, dated 3/21/25 and signed by the MD, from previous nursing facility reflected in part the following:<BR/>HPI: <BR/>LTC on therapy <BR/>Today: <BR/> . [Resident #1] has had multiple complaints and issues regarding inappropriate sexual behavior with staff and residents, He currently has a sitter, Psychiatry also following, Vitals stable. I believe patient is no longer safe to remain at the facility given sexual aggression towards other residents. I believe patient would be more appropriate to reside in a male only locked unit given behaviors.<BR/> .<BR/>Record review of Resident #1's progress note, dated 4/23/25 at 9:34 AM by the SSD, reflected the following:<BR/>[SSD] contacted [RP] to make her aware of [Resident #1's] behavior and what all took place during the activity with the high school students. [RP] shared that [Resident #1] had already told her he spanked a high [NAME] on the butt.<BR/>Record review of Resident #1's progress note, dated 4/23/25 at 9:53 AM by the DON, reflected the following:<BR/>[DON] was notified by [Activity Director] that [Resident #1] has inappropriately touched a student that was in facility for a activity. [Activity Director] stated that another student told him but didn't say who the student was. [DON] asked if police was made aware, was told that they have already gone, [DON] told director to notify abuse coordinator. Nursing placed [Resident #1] on Q15 min monitoring, until alternate placement can be made, immediate discharge to be given, MD made aware.<BR/>Record review of Resident #1's progress note, dated 4/23/25 at 10:12 AM by the SSD, reflected the following:<BR/>[Resident #1's] [RP] reached out and shared that she won't be able to properly care for [Resident #1]so she is not able to pick him up. [SSD] informed [RP] that she will be sending over clinical information to several nursing homes and facilities.<BR/>Record review of documents provided by the DON titled Resident 15 Minute Checks, dated 4/23/25-5/04/25, reflected Resident #1 remained on Q15 monitoring during this time. <BR/>Record review of documents provided by the DON titled [Nursing Facility] Resident Safe Survey Questionnaire for Staff, dated 4/23/25, reflected 30 residents were surveyed regarding abuse and neglected from staff with no concerns. Further review of this document reflected there were no questions directly regarding concerns for sexual abuse by staff or other residents. <BR/>Record review of Resident #1's active consolidated physician orders, dated 5/20/25, reflected in part the following:<BR/>-Estradiol Oral Tablet 2 mg; give 1 tablet by mouth one time a day for hypersexuality. Start Date: 5/15/25. <BR/>Further review of this document reflected Resident #1 did not have an order for psychological/psychiatric services.<BR/>Attempted interview on 5/16/25 at 10:30 AM with Resident #1 was unsuccessful due to the resident being away from the facility at the dialysis clinic. <BR/>In an interview on 5/16/25 at 12:35 PM with the DON and Administrator, the DON denied knowing Resident #1 had a history of exhibiting sexually inappropriate behaviors. The Administrator stated the facility did not have a policy that required the facility to check a resident's background or the sex offender registry prior to admission. The DON stated per regional managers, the facility did not discriminate against residents regarding criminal background. The Administrator and DON failed to mention Resident #1 was involved in an incident on 4/23/25 where he exhibited sexually inappropriate behavior by touching a student visitor during this interview. <BR/>In an interview on 5/16/25 at 1:35 PM, Resident #3 stated she felt uncomfortable around Resident #1, who she called a sex offender, because he always stared at her while making sexual gestures. Resident #3 stated a lot of female residents were uncomfortable around Resident #1 and it was reported to the Administrator and the DON, and they never did anything about it. Resident #3 stated students from the local high school used to visit and paint the female residents' fingernails; however, they stopped after Resident #1 touched one of the students inappropriately last month. She denied ever being touched by Resident #1. <BR/>In an interview on 5/16/25 at 2:15 PM, Resident #11 stated Resident #1 was creepy because he would come up to her room door and stick his tongue out, wink, and blow kisses at her. Resident #11 stated Resident #1 did that to a lot of other female residents, and they were all uncomfortable around him. Resident #11 stated she reported this to her nurse ; however, Resident #1's behavior did not stop. Resident #11 denied ever being touched by Resident #1 but stated he touched a student while they were visiting the facility to participate in activities with the residents. Resident #11 stated after the incident Resident #1 had 1 to 1 supervision and that stopped the behaviors, but he was not on it long. <BR/>In an interview on 5/16/25 at 4:20 PM with the Administrator and DON, the DON stated she was aware of Resident #1 touching a student visitor inappropriately. The DON stated she did not know the state surveyor was referring to that incident during the earlier interview. The DON stated the Activity Director reported to her the students were in the dining room areas doing an activity with the residents when one of the students ran out upset and another student reported she was touched inappropriately by Resident #1. The DON stated Resident #1 was placed on Q 15-minute supervision and issued an immediate discharge notice; however, they were unable to find placement and Resident #1's RP stated she could not care for the resident. The DON stated she was responsible for reviewing clinical notes before admitting a resident; however, she did not remember seeing in Resident #1's clinical notes that he had a history of exhibiting sexually inappropriate behaviors or that it was recommended he be placed on an all-male secured unit. The DON stated if she saw the recommendation, she probably would not have admitted Resident #1, or she would have put appropriate interventions in place. The DON stated the MD recently placed Resident #1 on medication for his hypersexual behaviors and he was care planned to have 2 staff when care was being provided. The Administrator stated he was aware of the incident and after reviewing the camera footage he was unable to determine exactly what happened due to a pole blocking the view. He stated he only saw the student jump back then get up and run from the area. The Administrator stated since he could not determine what happened from the footage, he did not proceed with a full investigation or report it to the state agency. The Administrator stated it was the facility's policy to investigate and report abuse and neglect; however, he did not think he needed to investigate or report the incident based on the information he had. He stated the risk of not investigating and reporting incidents of alleged abuse or neglect could place the residents at risk of being harmed. <BR/>In an interview on 5/16/25 at 4:40 PM, the Ombudsman stated she had an open case for Resident #1 regarding the resident being sexually inappropriate with a student who was visiting the facility. The Ombudsman stated Resident #1's RP called her because the facility was trying to discharge the resident to a group home which was inappropriate for his level of care. The Ombudsman stated the RP informed that Resident #1 was unaware of his actions and the consequences of it due to his dementia and did not feel it was right for him to be punished. The Ombudsman stated she never received a discharge notice Resident #1. She stated she visited the facility to investigate and felt the facility should have reported the incident to the state agency. The Ombudsman stated she reviewed Resident #1's clinical notes from the previous facility and found that it was recommended the resident be placed on a male secured unit. The Ombudsman stated Resident #1 should not have been admitted to the current nursing facility if they could not accommodate his care needs as they did not have a male secured unit. The Ombudsman expressed deep concerns that the incident was not reported, and the facility had considered discharging the resident to a group home. <BR/>In an interview on 5/20/25 at 1:25 PM, CNA C stated she worked with Resident #1 and he was always sexually inappropriate with staff. She stated Resident #1 would grab at her breast and thighs while she was showering him, and it made her very uncomfortable. CNA C stated she reported this to the DON, and she placed the resident on 2-person assist with care but there was not always an extra staff to help when needed. CNA C stated she was aware of the incident that happened on 4/23/25 when Resident #1 touched a student inappropriately. CNA C stated later that evening, a man who said he was the student's father came to the facility and asked to speak to someone about the incident. CNA C stated that made the staff concerned for the safety of everyone in the facility. CNA C stated it was reported to the Administrator and DON . <BR/>2.<BR/>Record review of Resident 2's face sheet, dated 5/16/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: COPD (lung disease), multiple sclerosis (nerve disorder), bipolar disorder (mood disorder), and legal blindness. <BR/>Record review of Resident #2's Quarterly Minimum Data Set (MDS) assessment, dated 5/02/25, reflected he had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #2 required partial to moderate assistance with most ADLs. The MDS Assessment under Section N-Medications, reflected Resident #2 was prescribed medication under the high-risk drug class that included an antidepressant, diuretic, and anticonvulsant. <BR/>Record review of Resident #2's care plan, dated 2/20/25, did not reflect a care plan for the resident's behavior related to substance abuse.<BR/>Record review of Resident #2's progress notes, dated 2/06/25 at 10:01 AM by the SSD reflected the following:<BR/>[Social Worker] reached out to [Resident #2's] Parole Officer to inform her that he is bringing drugs into the building to sell to other residents.<BR/>Record review of Resident #2's progress notes, dated 2/11/25 at 2:36 PM by the SSD reflected the following:<BR/>[Resident #2] 30 day discharge notice was issued and signed due to lack of facility compliance.<BR/>Record review of Resident #2's progress notes, dated 2/13/25 at 3:01 PM by the SSD reflected the following:<BR/>[SSD] spoke with [Resident #2's] [PO]. [PO] shared she would be help to his discharge process and help<BR/>him look for housing.<BR/>Record review of Resident #2's progress notes, dated 2/15/25 at 8:00 AM by LVN A reflected the following:<BR/>[LVN A] was notified by staff that [Resident #2] is not acting like himself. This nurse assessed [Resident #2] and observed resident with the following symptoms: Weakness abnormal from baseline with moments of limpness noted to both sides of body, pinpoint pupils, Confusion, difficulty talking and supporting self on the side of the bed. [Resident #2] asked by staff if he's taken any new medications or anything not prescribed by current MD, resident shook his head no. MD notified new order to send resident out to ER for further evaluation. This nurse attempted to contact RP and LVM [sic]. [Resident #2] transferred to [local hospital] MD aware.<BR/>Record review of Resident #2's hospital records, dated 2/15/25, reflected in part the following:<BR/>Today's Visit (continued) <BR/>Reason for Visit: Drug / Alcohol Assessment <BR/>Diagnosis: Bladder infection<BR/> .<BR/>Labs:<BR/>Marijuana (Cannabinoid)- Positive<BR/> .<BR/>Record review of Resident #2's progress notes, dated 2/17/25 at 9:57 AM by the SSD reflected the following:<BR/>[SSD] reached out to [Resident #2's] [PO] to inform her of his resent drug overdose hospital visit.<BR/>Record review of Resident #2's consolidated physician orders, dated 5/20/25, reflected in part the following:<BR/>-Gabapentin Capsule 300 mg-give 3 capsule by mouth three times a day for nerve pain give (3) 300 mg caps to equal 90 mg. Start date: 5/16/25.<BR/>-Hydrocodone-Acetaminophen Tablet 7.5-325 mg-give 1 tablet by mouth three times a day for pain. Start date: 5/15/25.<BR/>-Tylenol Oral Tablet 325 mg (Acetaminophen)-give 2 tablets by mouth three times a day for pain.<BR/>Further review of this document reflected Resident #2 did not have an order for medical marijuana. <BR/>Interview on 5/16/25 at 11:45 AM, Resident #10 stated he was the Resident Council President at the facility. He stated there was a lot of talk going around the facility about residents bringing in drugs to use and give to other residents. Resident #10 stated it was never said which resident was bringing drugs into the facility. Resident #10 stated he often smelled marijuana in the facility. He stated the Administrator and DON were aware of this problem.<BR/>In an interview on 5/16/25 at 12:35 PM with the Administrator and DON, they both stated being aware of concerns the residents were using drugs in the facility. The Administrator stated during a smoke break about a week ago there was a smell of marijuana, and he gave staff permission to stop the smoke break that day, and there had been other reports of marijuana being smelled . The Administrator stated he had never seen marijuana in the facility and the smell could be coming from anywhere in the area. The DON stated there was a day a package arrived at the facility for Resident #3 that had to be signed for, and Resident #3 admitted there was THC in the package, but it was for her family. The DON stated the package was not accepted at the facility and it was not opened to confirm if it was THC. The Administrator stated Resident #3 used a vape that she was very protective of and would become verbally aggressive towards staff when questioned about it. The Administrator stated he did not know what was in the vape and could not violate Resident #3's rights by searching her belongings . The Administrator and DON both stated they were not aware of any concerns for staff using or bringing illegal drugs into the facility. The Administrator stated all staff were drug tested upon hire. They stated if there were drugs in the facility, they were unsure how it was getting in. The Administrator stated they had several residents who went out into the community. The DON stated if residents showed any obvious s/sx of drug use they would be sent out to the hospital for a drug screening. The Administrator stated he did not initiate an investigation or report to the state agency when marijuana was smelled during the smoke break or when Resident #3 admitted to having THC delivered to the facility. He could not state why he did not investigate or report these incidents.<BR/>In an interview on 5/16/25 at 1:35 PM, Resident #3 stated she had concerns about residents using drugs in the facility that was being brought in by staff and other residents. She stated the Administrator and DON were aware and were not doing anything about it. Resident #3 stated she had a meeting with the Administrator, DON, and SSD on 5/12/25 where she expressed all her concerns, which included the drugs in the facility, and nothing had been done yet. She stated she had a package delivered to the facility that contained THC that she ordered from a local smoke shop, but it was not for her. Resident #3 stated she was going to visit family and was going to give it to them, but the facility did not allow her to get the package. She stated she knew it was wrong to have the package delivered to the facility, but they allowed everything else. She stated she would not order THC to the facility again. <BR/>In an interview on 5/16/25 at 2:15 PM, Resident #11 stated there was always the smell of marijuana in the facility and residents would do other drugs like methamphetamines. Resident #11 stated she could tell by the smell what type of drug was being used. Resident #11 stated it mostly happened during smoke breaks and sometimes in resident rooms, and she just tried to stay away from it. Resident #11 stated she reported her concerns to the DON; however, it was still going on. She stated the residents were supposed to be drug tested if they were suspected of using, but they would refuse, and the nurses would not force them to do it and would just let it go. <BR/>Further interview on 5/19/25 at 3:00 PM with the Administrator and DON, the DON stated she was aware of Resident #2 being sent out to the local hospital after showing signs of drug use and failing his drug screening. The DON stated the MD discontinued all of Resident #2's pain medication and put in a standing order to drug screen any resident who exhibited s/sx of drug use. The DON stated she did not drug test any residents the day it smelled like marijuana during the smoke break and could not state why. She also stated staff were not in-serviced on recognizing s/sx of drug use and reporting it after the incidents. The Administrator stated the facility was waiting on Resident #2's PO to find placement for him. He stated the PO informed he was either going to find another facility or Resident #2 would go back to jail. The Administrator stated the facility was waiting on the PO to find something since the incident happened on 2/15/25. The Administrator stated not addressing the concerns for drug use at the facility or implementing effective interventions could place residents at risk of being able to obtain and use drugs at the facility that could cause serious harm .<BR/>Record review of the facility's policy titled Abuse Prevention Program, revised January 2011, reflected in part the following:<BR/>Policy Statement:<BR/>Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. <BR/> .15. Investigate and report any allegations of abuse within timeframes as required by federal requirements <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure complete and accurate incident/accident report for 1 (Resident#1) of 4 residents reviewed for incident reports.<BR/>The facility failed to ensure Resident#1's incident report was completed on 01/22/25, which involved a verbal and physical altercation between Resident#1 and Administrator by LVN C.<BR/>This failure could place residents at risk of inaccurate or incomplete information, resulting in the risk of abuse or neglect by staff. <BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 01/23/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizophrenia (serious mental condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) Type 2 Diabetes Mellitus with Diabetic, Unspecified Psychosis not due to substance or known major depressive disorder.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 10/28/24, reflected Resident #1 had a BIMS of 12, which indicated cognition moderate impaired. <BR/>Record review of Resident #1's care plan, revised 09/20/24, revealed the resident at risk for altered status due to a traumatic life experience while at a previous group home or [Nursing Facility]. Certain male figures in authority positions, with similar physical attributes or appearance at times trigger him. Interventions in place included: Administer medication as ordered, approach resident from the front and speak in a calm, unhurried manner .Identify cause/trigger for behavior and reduce factors that may provoke resident .Call [Family Member#1] if need to calm down or get him to comprehend the situation]<BR/> .<BR/>Record review revealed no incident/accident report was completed about Resident#1 incident on 01/22/25.<BR/>Record review of Resident#1 progress notes revealed no documentation about the incident on 01/22/25.<BR/>Record review of Resident#1 assessments revealed no documentation of completed assessment on 01/22/25.<BR/>Record review of Resident#1 incident provided to surveyor on 01/25/25 reflected: it was initiated on 01/22/25 with no completed/ locked date on the incident report. Incident description section reflected: This [LVN K] was notified by staff after the incident that [Resident#1] slapped [MA N] and physically attacked Administrator and [Resident#1] fell to the floor. Resident description reflected: [Resident#1] stated he was approached by Administrator, in what he felt was an aggressive manner so I just swung on his . In the agencies/people notified section no notification found,<BR/>An interview on 12/23/24 at 2:30 PM, LVN K stated she did not witness the incident between the Administrator and the Resident#1 that happened on 01/22/25 at 7:00 PM. LVN K stated she was told about the incident after it happened. LVN K stated she did the incident report on 01/23/25 after the DON D told her to complete it. LVN K stated the incident and accident report should have been completed in the EHR under the resident's name the same day of the incident before she left for the day. <BR/>An interview on 12/23/24 at 3:30 PM, the DON stated the nurse who is over the resident was responsible for doing the incident/accident report. The DON stated the incident and accident report should be completed immediately after the incident or before staff leaves for the day. DON stated Resident could have delay treatment if there were injuries and/or abuse. DON stated no specific policy on documentation of incident reports in residents 'medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to be from abuse for 1 of 4 residents (Residents #1) reviewed for abuse. <BR/>The facility failed to protect Residents #1 from a physical and verbal altercation on 01/22/25 with the Administrator. The Administrator pushed Resident#1, causing Resident#1 to fall. The incident was not reported or documented until after surveyor intervention on 01/23/25.The Administrator was not suspended until 01/23/25 at approximately 11:30 AM. <BR/>An IJ was identified on 01/23/25. The IJ template was provided to the facility on [DATE] at 5:15 PM. While the IJ was removed on 01/25/25, the facility remained out of compliance at a scope of Isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems .<BR/>This failure placed residents at risk of subsequent abuse, mental anguish, and emotional distress. <BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 01/23/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizophrenia (Serious mental health condition that affects how people think, feel and behave), Type 2 Diabetes Mellitus with Diabetic, Unspecified Psychosis not due to substance or known major depressive disorder.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 10/28/24, reflected Resident #1 had a BIMS of 12, which indicated cognition moderate impaired. <BR/>Record review of Resident #1's care plan, revised 09/20/24, revealed the resident at risk for altered status due to a traumatic life experience while at a previous group home or [Nursing Facility]. Certain male figures in authority positions, with similar physical attributes or appearance at times trigger him. Interventions in place included: Administer medication as ordered, approach resident from the front and speak in a calm, unhurried manner .Identify cause/trigger for behavior and reduce factors that may provoke resident .Call [Family Member#1] if need to calm down or get him to comprehend the situation]<BR/> .<BR/>Record review of Record review of Psychological Services Progress Note, dated 10/08/24and completed by Psy services reflected, Resident#1 was negative for Trauma Informed Care. <BR/>Record review revealed no incident/accident report was completed about the incident on 01/22/25.<BR/>Record review of Resident#1 progress noted dated, 11/01/23 to 01/22/25 reflected: Resident#1 had other incidents with other staff but not the Administrator. <BR/>Record review of Resident#1 progress notes revealed no documentation about the incident on 01/22/25.<BR/>Record review of Resident#1 assessments revealed no documentation about incident on 01/22/25.<BR/>Record review of Resident#1 incident provided to surveyor on 01/25/25 reflected: it was initiated on 01/22/25 with no completed/ locked date on the incident report. Incident description section reflected: This [LVN K] was notified by staff after the incident that [Resident#1] slapped [MA N] and physically attacked Administrator and [Resident#1] fell to the floor. Resident description reflected: [Resident#1] stated he was approached by Administrator, in what he felt was an aggressive manner so I just swung on his . Immediate action taken section reflected: [Resident#1] assessed for injuries. None noted, denied pain or any discomfort. Physician notified, In the agencies/people notified section reflected: no notification found,<BR/>An interview on 01/23/25 at 10:20 AM Family Member#1 approached surveyor at the facility and stated the Administrator fought [Resident#1] last night. Family Member#1 stated that was wrong and he is elderly. Family Member#1 stated the Administrator was always picking on him when Resident#1 wanted to play his piano. Resident#1 did not speak to the Administrator when the Administrator would try to speak to him <BR/>An in-person interview on 01/23/25 at 10:45 AM, the Administrator and MA N entered the conference room to explain the incident on 01/22/25. The administrator stated Resident#1 assaulted a medication aide around 7pm on 01/22/25. The Administrator stated the medication aide and himself went to Resident#1s room. Resident#1 was asked why he hit the medication aide. The Administrator stated Resident#1 started punching and kicking the Administrator and made threats. The Administrator stated he put his hands up to protect himself. The Administrator stated Resident#1 tripped over his own leg and fell. The Administrator stated [CNA J], [CNA L] and [LVN P] intervened and pulled Resident#1 away. The Administrator stated he was told by Resident#1 and Family member that he reminded Resident#1 of males from his past that made fun of him and were aggressive towards him because he was gay. The Administrator stated it did not have to be reported because it was an altercation between staff and a resident.<BR/>An interview on 01/23/25 at 10:45 AM, MA N stated Resident#1 took snacks off the snack tray and hit MA N's face when she asked him what he was doing. MA N immediately reported to the Administrator who went to Resident#1 to ask what happened and Resident#1 hit the Administrator. <BR/>An interview on 01/23/25 at 11:00 AM, the DON stated she was not made aware of the incident until after 10:15 AM on 01/23/25 when Resident#1 family member came into her office. The DON immediately called her nurse consultant and informed her of the situation. <BR/>An interview and observation on 01/23/25 at 11:05 AM of the camera in the Administrator office with the PD revealed, Resident was punching and kicking the Administrator. The Administrator open hand pushed Resident#1 face area and caused Resident#1 to fall. Observed a linen cart pushed between the Administrator and Resident#1. Observation of additional staff stepped in between Resident#1 and Administrator. Staff were observed holding the Administrator back and grabbing Resident#1. PD stated an incident would be put on file but no arrest or charges because the resident started the altercation. Surveyor did not recall observing a date and time on the footage. <BR/>An interview on 01/23/25 at 11:30 AM, Ombudsmen stated she had not been notified about the physical altercation between the Administrator and Resident#1.<BR/>An over the phone interview on 01/23/25 at 1:30 PM the Corporate Operations Manager and Nurse Consultant stated they were not made aware of the abuse allegation until 1/23/25 at approximately 10:30 AM. The Administrator (Abuse coordinator) was asked to go home until the investigation was completed. Both stated it did not have to be reported to State since there was not an allegation of abuse at the time of the incident. Operations Manager stated that is the company policy for all that when an investigation of abuse had been reported the staff member would be suspended until the investigation was completed. Corporate Operations Manager and Nurse Consultant both stated the Administrator was suspended until the investigation was completed. Both stated there was no risk to residents, as soon as they found out about the incident the facility took immediate action. <BR/>An interview with Resident#1 on 01/23/25 at 2:15 PM he stated he would not feel safe in the facility if the Administrator returned. Resident#1 stated the Administrator hit him and he hit him back.<BR/>An interview on 01/23/25 at 4:11PM CNA J stated it was chaos in the hallway and he did not see how the incident started. CNA J stated he saw Resident#1 kicking and hitting the Administrator. CNA J stated he tried to intervene but did not want to get hit by Resident#1 so, he pushed a linen cart between them. CNA J stated he did not see how the resident fell. CNA J stated he grabbed Resident#1 and took him outside to smoke. <BR/>An interview on 01/23/25 at 4:20 PM LVN P stated he witnessed Resident#1 swinging both of his arms towards the Administrator LVN P stated they separated Resident#1 and the Administrator. <BR/>An interview on 01/24/25 at 4:30 PM CNA L stated Resident#1 was kicking and hitting the Administrator in the hallway. CNA L stated he did not see how Resident#1 fell but, he jumped back up and continued to attack the Administrator. CNA L stated the Administrator and Resident#1 were separated. <BR/>An interview on 01/24/25 at 4:50 PM DON stated the Administrator who is the abuse coordinator is responsible for completing and reporting investigation to corporate and State office. DON stated while the Administrator was suspended, she would be responsible. <BR/>Record review of facility policy titled; Usual Occurrence Reporting revised 12/07 reflected: H. Other occurrences that interfere with facility operations band affect welfare, safety, or health of residents, employees or vistors.2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations.<BR/>Record review of facility policy titled; Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigating revised 09/22 reflected: <BR/>All reports of resident abuse . Are reported to local state and federal agencies add (current regulations) is thoroughly investigated by facility management . findings of all investigations are documented and reported . Policy interpretation and inflammation reporting allegations to the administrator and authorities upon receiving any allegations of abuse the administrator is responsible for determining what actions (if any) are needed for protection of residents . Investigation allegations 1. all allegations are thoroughly investigated the administrative initiates investigations any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete . 9. the investigator notifies the ombudsman that in abuse investigation is being conducted the ombudsman is invited to participate in the review process B. the ombudsman is notified of the result of the investigations as well as any corrective measures taken . follow up report #1 within 5 business days of the incident the administrator will provide a follow-up investigation report direct action number one all relevant professional and licensing boards are notified when an employee is found to have committed abuse #2 if the investigation reveals that the allegations of abuse are founded the employee is terminated #3 any allegations of its view in our files in the huge employees personal records along with any statement by the employee disputing the allegation if the employee chose make one .<BR/>The Director of Nursing was notified that an Immediate Jeopardy situation was identified and record review request of ANE policy due to the above failure and provided with the Immediate Jeopardy template on 1/23/25 at 5:15 PM. A Plan of Removal was requested.<BR/>The facility's Plan of Removal was accepted on 1/24/2025 at 1:50 PM and included: <BR/>Plan of Removal:<BR/>1. <BR/>Immediate action(s) taken for the resident(s) found to have been affected include:<BR/>Resident # 1 was assessed by the Nurse on 1/22/25 . A thorough investigation was initiated by the Corporate Office and Director of Nursing Services.<BR/>The Medical Director was notified by the DON at 3:33pm and The DON called and left a message for the Ombudsman 1/23/25, at 5:30PM. The RP was notified on 1/22/25 by the Administrator. The accused Team Member was placed on Administrative Leave pending investigation. The Police Department was called and arrived at the facility. The Incident Report was completed on 1/23/25. The SIMS was initiated on 1/23/25 at 2:30pm.<BR/>In-services have been done by the DON for: Completing Incident reports, Notifications to MD/Ombudsman, Reporting Abuse/Neglect, Abuse Policy including timeline for reporting and What to do When a Team Member is accused (investigation requires for Team Member to be placed on Administrative Leave until the investigation is concluded). De-escalation of aggressive behaviors and resident to staff altercations. <BR/>The Post Test will be administered by the DON/designee after education is completed. Staff are required to pass at least 80%. Staff who do not achieve 80% passing rate will be re-educated and will retake the test.<BR/>TEXAS Abuse hotline number, [PHONE NUMBER] posted in strategic areas within the facility, staff made aware of postings.<BR/>2. <BR/>Identification of other residents having the potential to be affected was accomplished by:<BR/>The facility has determined that all residents have the potential to be affected. Supervisor Rounds have been started and will be completed by 1/24/25 to interview residents for issues related to care, respect and dignity. The rounding will be done by the Supervisors and the monitoring will be completed on the Supervisor Daily Rounds form.<BR/>3. <BR/>Actions taken/systems put into place to reduce the risk of future occurrence include:<BR/>An in-service education program was conducted by the Director of Nursing Services and the Assistant Director of Nursing with all staff addressing circumstances that require reporting including appropriate timeframes, reporting to the Corporate Office, reporting to the Ombudsman, timely completion of Incident Reports and SIMS reports and policy regarding Team Member involvement will be completed by 1/24/25. <BR/>The Corporate Nurse Team will conduct a Zoom meeting at 10 am on 1/24/25 with [Facility] Director of Nursing. The purpose of the in-service is to provide education for the following areas:<BR/>Our Abuse/Neglect Policy as it relates to Reporting Timelines to Corporate/State/Law Enforcement/Ombudsman/Medical Director<BR/>Steps to take when a Team Member is involved or is allegedly involved-Contact Corporate HR and place on Administrative Leave pending investigation of Abuse.<BR/>Conducting Education and Training with all Departments<BR/>Follow up and Monitoring that is required such as Rounding on Halls, Talking with Residents and Staff, Re-education with Staff to help Ensure There is No Breakdown in Communication<BR/>Five day follow up with the State Office<BR/>4. <BR/>How the corrective action(s) will be monitored to ensure the practice will not reoccur:<BR/>The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any incidents or injuries are identified, properly investigated and reported to the appropriate entities. <BR/>Findings of this audit will be reviewed in the Resident Council meetings.<BR/>This plan of correction will be monitored at the monthly Quality Assurance meeting until such time the IDT determines consistent substantial compliance has been met. <BR/>On 1/25/25 beginning at 3:00 PM the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of pre/posttest had been completed by1st, 2nd and 3rd shift nursing staff on ANE. <BR/>Record review of Director of Nursing in-services by the Nurse on ANE <BR/>Record review of the Administrator profile reflected, the Administrator was hired on 11/27/23 and terminated on 01/24/25.<BR/>An observation of the facility on 01/25/25 at 2:00 PM revealed 1-800 HHSC hotline number for abuse was posted at the entry of the facility, social workers door, display board in hallway and employees break room. <BR/>All staff were able to provide competency regarding in-service over ANE. All staff were able to provide policy, procedure, protocols, appropriate interventions, and when and who to report abuse to. All staff were to provide an example of ANE. <BR/>Staff interviewed on 01/24/25 between 9:00 AM to 2:00 PM CNA A, CNA B, LVN C (overnight shift) and CNA G, CNA H, LVN I (1st shift) and CNA J, CNA L LVN K, RN O, LVN P (2nd shift).<BR/>Staff interviewed on 01/25/25 3:40 AM to 3:00 PM: CNA D, CNA E, LVN F, RN N (Weekend shift) and laundry aide M.<BR/>An interview on 01/25/25 at 3:45PM the Director of Nursing stated she was in-serviced by the Corporate Nurse on 01/24/25 at 10:00 AM. The Director of Nursing stated she is currently the abuse coordinator. The Director of Nursing stated staff have been in-service and pre/posttest have been completed. <BR/>The Director of Nursing was informed the Immediate Jeopardy was removed on 01/25/25 at 3:00 PM the facility remained out of compliance at a scope of potential of minimum harm and a severity level of isolated, due to the facility's need to evaluation the effectiveness of the corrective systems. <BR/>An interview on 02/12/25 at 9:30 AM, Resident#1 stated that he was doing good and did not have any concerns and wanted to stay at the facility.<BR/>An over the phone interview on 02/12/24 at 9:52 AM Family member stated she was going by what [Resident#1] told her (Previous admin would tell him to stop playing his piano and pick on him that way.). Family member stated the previous Administrator [Current facility] favored someone from [Resident#1] past, but the sister did not know exactly who and people in general would make fun of [Resident#1] because he was gay. Family member stated he was previously, in a group home and wanted to stay there but, he could not care for himself. Since, previous admin is gone there has not been any more issues. Family Member stated he came from a group home, and he was happy there and did not want to leave. <BR/>Attempted to call PCP on 02/13/24 at 9:27 AM<BR/>Attempted to call Psy services on 02/13/24 at 9:52 AM<BR/>An observation and interview on 02/13/25 at 11:30 AM Resident#1 stated [Name] the Administrator hit him last week and he did not know why. Surveyor asked Resident#1 if he knew the previous Administrator name at the current facility that he stayed at and he said that was [Name] Resident#1 stated he felt safe and did not have any concerns.<BR/>Record review of Psy Subsequent assessment dated [DATE] and completed by Psy services reflected, <BR/>The provider asked the patient to tell him what transpired since the last few days. The patient replied nothing happened. The provider reframed the question and asked the patient if he had any altercation with anyone in the facility a few days ago. He replied someone pushed me. The provider asked the patient how the incident happened or what prompted the altercation. He replied, I do not know . <BR/>Record review of Psychological Services Progress notes dated ,01/30/25 on Resident#1 completed by Psy services reflected, Resident#1 was negative for Trauma Informed Care.<BR/>The Director of Nursing was informed the Immediate Jeopardy was removed on 01/25/25. The facility remained out of compliance at a scope of actual harm and a severity level of isolated, due to the facility's need to evaluation the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to notify the ombudsman of the transfer or discharge before transferring or discharging the resident for 1 of 1 resident (Resident #1) reviewed for Discharge Rights.The facility failed to notify the ombudsman in writing of the transfer/ discharge of Resident #1 to a behavioral hospital, the reason for the transfer/discharge, and the right to appeal. This failure could affect the residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings included: Record review of Resident #1's face sheet dated 10/14/2025 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 was discharged to hospital for a behavioral evaluation on 09/28/2025. Resident's diagnosis included Schizophrenia, Unspecified (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania ); Unspecified Psychosis Not Due to a Substance or Known Psychological Condition (used when psychotic symptoms are present but a specific cause, like drugs, other mental disorders, or a medical condition hasn't been identified or confirmed yet); and Major Depressive Disorder, Recurrent, Unspecified (used when a person has significant symptoms of depression that cause distress or impairment, but they do not meet the full diagnostic criteria for a more specific depressive disorder, or there is not enough information to provide one).Record review of Resident #1's MDS assessment dated [DATE], noted his BIMS Score to be 12 which reflected moderate cognitive impairment. Resident #1 Review of Resident #1's progress notes reflected that on 09/28/2025, the facility initiated a referral to transfer the resident to the hospital for a psychological evaluation due to the resident having an increase in his verbal, physical, and violent behavior towards the staff. Family member notified by phone concerning Resident #1's transfer. Resident #1 was his own responsible party. Record review on 09/29/2025 of social services notes revealed that SW spoke with Resident #1's family member about how his behavior had not gotten better since giving him the 30-day notice before. SW informed family member about Resident #1 threatening staff. Family member stated she has never known Resident #1 threaten to kill anyone and that the staff are triggering him. DSS said this was done after staff redirected him while breaking rules. Resident #1 was contacted by SW that he was being provided an immediate discharge from the facility r/t his violent behavior towards the staff and other residents in the facility. Resident #1 refused to give verbal consent by phone. SW planned for Resident #1 to move to a residential group home in the community upon discharge from hospital. Resident #1 was transferred to a group home and has adjusted well to the move. On 10/13/2025 at 1:12 p.m., an interview with the family member revealed that Resident #1 had not been at the facility for some time. Family member could not give the specific time he was discharged to hospital for a psychological evaluation. Family member stated that Resident #1 is now in another place but cannot remember the name of the group home he moved to. Resident #1 has his own room, is stable, and happy. Family member stated Resident #1 had schizophrenia and did not understand he could not smoke anytime he wanted when he was at the facility. When he acted up at the facility, the staff would contact the family member to come to the facility to calm him down. Family member stated she told the staff it was their job to take care of him. Family member stated that Resident #1 is glad he is no longer at that facility because the staff stated he was threatening to kill others and kill himself. Family member did not believe what they told her. Family member did not state if she was aware of the 30-day notice. On 10/14/2025 at 2:32 p.m., an interview with SW revealed that she contacted the Ombudsman (person who acts as an independent and neutral intermediary to help resolve complaints and disputes fairly between individuals and an organization or government agency) and left a message concerning Resident #1's immediate discharge. SW did not document that a message was left on Ombudsman's voicemail and could not provide a date when she left the message. SW could not provide a copy of the first 30-day notice that was given to Resident #1 and could not provide the date. SW provided a copy of the immediate discharge notice given to Resident #1. Record review of an email conversation with the Ombudsman on 10/14/2025 at 4:33 p.m. revealed she did not receive a phone call or email r/t a notification before or after Resident #1's discharge on [DATE]. On 10/14/2025 at 4:17 p.m., an interview with DON revealed that Resident #1 exhibited behaviors that placed residents' and staff's safety at risk. He was non-compliant with facility smoking rules, would go out to the laundry, take staff's food from the employee breakroom, and verbally threaten to harm the employees. Resident #1 threatened to kill other staff and himself. Resident #1's family member was informed of his behavior, but she thought the staff were not telling the truth. The family member was verbally aggressive towards staff when she was informed by phone of Resident #1's behaviors. DON stated she was not aware the Ombudsman was not notified of Resident #1's discharge. On 10/14/2025 at 4:55 p.m., an interview with the ADM revealed that Resident #1 had to be given an immediate discharge for the safety of the other residents and staff. Resident #1 was non-compliant with the smoking rules and verbally aggressive towards other residents and staff. Resident #1 was discharged to the hospital for a psychiatric evaluation and SW planned for transfer to a group home. Resident #1's family member came into the facility to pick up his belongings and began cursing staff. The ADM was not aware that the Ombudsman had not been notified by SW r/t Resident #1's immediate discharge. The ADM expectations are for the SW to contact the Ombudsman concerning all discharges from the building and document in SS notes of notification.Record review of the facility's admission and Discharge including AMA, Against Medical Advice Policy dated March 2017, reflected, It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility, except in limited circumstances. a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide behavioral health services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #2) of five residents reviewed for behavioral health services. The facility failed to ensure Resident #2 received a psychology consultation or assessment after three incidents (5/24/2025, 08/17/2025, 10/03/2025) of resident-to-resident abuse where Resident #2 was the victim. This failure could place residents at risk for not receiving behavioral health services and a decline in quality of life. Findings included:Record review of an undated admission Record revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had the admitting diagnoses of Alzheimer's Disease, Unspecified (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), Type 2 Diabetes Mellitus without Complications (chronic condition where persistently high blood sugar levels are caused by the pancreas not being able to make enough insulin), Dementia in other Diseases Classified Elsewhere, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (dementia where the specific cause is unknown and the person does not exhibit behavioral issues like agitation or aggression), Major Depressive Disorder, Recurrent, Unspecified (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), Cerebral Infarction, Unspecified (a stroke where the exact cause and location of the brain damage are unknown), Chronic Obstructive Pulmonary Disease, Unspecified (a group of lung diseases that cause airflow obstruction and breathlessness), Chronic Respiratory Failure, Unspecified (condition where there is not enough oxygen or too much carbon dioxide is in the body), and Presence of Cerebrospinal Fluid Drainage Device (long term device, or shunt, that allows excess fluid from the brain to drain to another part of the body relieving pressure). Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 03 indicating Severe Cognitive Impairment. Resident #2 was documented as having no (zero) behavioral symptoms. Resident #2 showed to be independently ambulatory with no functional limitations in range of motion. Record Review of Resident #2's Care Plan, dated 08/30/2025, revealed a focus added on 03/15/2023 of resident having a history of intruding on others privacy with interventions and tasks of place in area where frequent observation was possible, redirect when wandering into other resident rooms, and monitor and document behavior. Focus added on 01/14/2024 of displays socially inappropriate/ disruptive behavior due to known for taking personal items from her roommate and other peers that do not belong to her. When she is called out on this disruptive behavior, she curses at staff and peers, calls everyone names and refuses to listen to staff due to her cognitive status, Psych. diagnosis with interventions and tasks of administer medication as ordered, discuss options for appropriate channeling of anger, talk in calm voice when behavior is disruptive, Social Services to evaluate and visit routinely, and monitor and document behavior. Focus of at risk of being taken advantage of r/t impaired cognition updated on 10/03/2025 when Resident #3 slapped Resident #2 after she took his cup with interventions and tasks of allow Resident #2 to express concerns about safety, anticipate Resident #2's needs, encourage Resident #2 to sit in common areas that are well populated, observe Resident #2 frequently throughout the day, psych services are available as needed, and on 10/03/2025 added intervention of place Resident #2 on 1:1 monitoring until alternate placement is found. Record Review of Resident #3's undated admission Record revealed Resident #3 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had the admitting diagnoses of Bipolar Disorder, Unspecified (psychological condition that causes dramatic changes in a person's mood, ability to think clearly, and energy; involves periods of mania and depression; unspecified is diagnosed when symptoms do not meet the criteria for other types), Depression, Unspecified (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), Anxiety Disorder, Unspecified (repeated episodes of sudden feelings of intense anxiety, and fear or terror that reach a peak within minutes), Impulse Disorder, Unspecified (group of behavioral conditions that make it difficult to control your actions or reactions), Mild Intellectual Disabilities (neurodevelopment disorder characterized by significant limitations in intellectual and adaptive functioning), Cerebral Infarction, Unspecified (a stroke where the exact cause and location of the brain damage are unknown), Other Specified Disorders Of Brain (group of conditions that do not fall into specific diagnostic categories that can affect various aspects of brain function including cognitive abilities, movement, and consciousness) and Epileptic Seizures Related to External Causes, not Intractable, without Status Epilepticus (epileptic seizures caused by external factors, such as head trauma or substance abuse, that are not difficult to treat and are considered provoked by a single external factor meaning there are clear, identifiable causes). Record review of Resident #3's annual MDS, dated [DATE], revealed a BIMS score of 03 indicating severe cognitive impairment. Signs and Symptoms of Delerium was ranked at a 2 for both Inattention (difficulty focusing attention, being easily distracted, or having difficulty keeping track of what was said) and Disorganized Thinking (thinking was disorganized or incoherent, rambling or irrelevant conversation, unclear or illogical flow of ideas, startled easily to any sound or touch). Behavioral Symptoms for Resident #3 were listed at zero (Behavior not exhibited) for Physical Behavioral Symptoms directed towards others (e.g. hitting, pushing, kicking, scratching, grabbing other than sexually and zero for Verbal behavioral symptoms directed towards others (e.g. threatening others, screaming at others, cursing at others). Resident #3 was documented to have had no functional limitation in range of motion and did not utilize any assistive devices for mobility. Record review of Resident #3's care plan, dated 09/05/2025, revealed a focus area of at risk for behaviors due to impulse control disorder listing the following incidents: 05/24/2025-- resident noted with aggressive behavior, hit another resident (Resident #2), swung chair at nurse, swung chair at meal cart tipping it over, 06/15/2025 Resident increased behaviors, and 10/03/2025-- slapped a resident (Resident #2), after she took his cup. Interventions and tasks included contact to transfer resident to hospital (Geri-Psych) when explosive psychosis is exhibited, Discuss options for appropriate channeling of anger, give all meds as ordered, Give PRN anti-anxiety medication, Notify Psych NP whenever such behaviors are exhibited, psych services as needed, and Seek alternate placement that has less stimuli which could contribute to aggressive, impulsive behavior. On 01/21/2025 the focus area of Resident #3 has a h/o wandering into unsafe situations, Resident packs all belongings and states I'm moving as well as on 10/01/2025 Resident #3 removed his wander guard, and refuses to allow it to be put back on with interventions and tasks of alert staff to wandering behavior, Approach positively and in a calm manner, Check that wander guard is properly working every shift by taking to the door if not properly working notify DON and replace the wander guard, Resident on hourly safety checks, and Monitor and document behavior.Record Review of resident-to-resident assault on 05/24/2025 revealed that when Resident #2 passed Resident #3 in the hallway, Resident #3 hit her on the back of the head with his fist. Resident #2 expressed pain and was sent to the local hospital for evaluation and later returned with no injury diagnosis. Resident #3 was placed on 1:1 monitoring by staff for the remainder of that weekend and both residents were to be kept in eyesight when the other resident was around. Record review of resident-to-resident assault on 8/17/2025 revealed that as Resident #2 walked down a hallway, Resident #3 hit her. Resident #2 was reported to hit Resident #3 back and Resident #2 then fell to the ground after being hit a second time by Resident #3 where he then kicked Resident #3 before staff were able to intervene. Resident #2 did not indicate she was in pain, neither resident was sent to the hospital for evaluation. Resident #3 was placed on 1:1 monitoring for that weekend and referrals began for discharge to new facility for Resident #3. Record review of resident-to-resident assault on 10/03/2025 revealed that Resident #3 quickly charged through the door onto the smoking patio and hit Resident #3 with an open fist. Resident #2 was noted to have bruising, redness, and swelling around her left eye in facility photograph documentation. The facility ordered a facial x-ray which was unremarkable for any fracture. Both Resident #2 and #3 were placed on 1:1 monitoring from staff. Local law enforcement was contacted twice about the assault before arriving to the facility to remove from the facility and transfer Resident #3 to the local hospital for evaluation for his behaviors. Resident #2 remained on 1:1 monitoring for safety.Record review of the facility Investigation Follow-Up, dated effective 10/05/2025, revealed that the incident on 10/03/2025 happened at approximately 11:15am when Resident #3 came out the door like a ranging (raging [sic]) bull and hit Resident #2 upside her head as witnessed by a CNA. When asked why, Resident #3 stated because she (Resident #2) took my cup. Resident #3 was put on 1:1 with staff, then checked every hour. The facility also placed Resident #2 on 1:1 with staff for safety. Notification was made to the QA committee, Medical Director, Resident #2's responsible party, DON, and police. Follow-up with Resident #2's family on revisions to the Care Plan included information that the police has taken Resident #3 to the hospital and he will not be returning to the facility, the medical director had ordered facial bone x-ray to left eye, and that Resident #2 was also put on 1:1 with staff for safety. Record review of Resident #2's Trauma Informed Screening Tool, administered by SW dated 09/09/2025, that the resident, family, and staff participated in revealed positive (yes) responses on questions: Have you ever experienced this kind of event (assault by another resident)? In the past month have you had nightmares about the event when you did not want to? In the past month, have you tried hard not to think about the event or went out of your way to avoid situations that remind you of event? In the past month, have you been constantly guarded, watchful, or easily startled? Record review of Resident #2's Trauma Informed Screening Tool, administered by SW and dated 08/13/2025 and 10/06/2025, indicated that the resident and staff participated; a positive (yes) response on question Have you ever experienced this kind of event? only was given when asked about being assaulted by another resident. Interview on 10/14/2025 at 11:21 AM with LPC A revealed that Resident #2 was not currently being followed by psychological services and had never had a referral for evaluation or services. LPC A verified these findings in their system using Resident #2's name and date of birth searching for all psychology related providers. Observation and interview with Resident #2 on 10/14/2025 at 11:22 AM revealed the resident was still on 1:1 monitoring by staff. Resident #2 was seen in the dining room after observing her during the 11:00 smoke break on the patio. Resident #2 stated that was doing fine and that her face was doing better now. Resident #2 could not be engaged in a detailed conversation. Resident #2 was observed to be calm and kept to herself while smoking and in the dining room. Resident #2 was polite but reserved in her interactions with others. Interview on 10/14/2025 at 11:30 AM with CNA B revealed that she began 1: with Resident #2 at the start of that shift, however the 1:1 was ongoing since the incident with another resident on 10/03/2025. CNA B stated that Resident #2 was at her baseline and appeared to be doing fine from what she could tell. Interview on 10/14/2025 at 2:35 PM with SW revealed that the incident of physical assault on 10/03/2025 between Residents #2 and #3 was the third altercation between the two, with Resident #3 being the aggressor in all three instances. SW stated she had not noticed any effects from incidents of assault as Resident #2 has no real short-term memory from the dementia and that when EMT came in to assess she acted like she did not know what happened but was able to tell her family member in detail a few hours later when Resident #2 called her. The SW stated that the facility has conducted trauma assessments with Resident #2 but no further actions had been taken with that information. When asked about referral for psychological assessment or therapy due to the positive responses on the trauma assessments, the SW responded that she had not made any referrals as Resident #2 was known to refuse services in the past such as dental and vision however family were able to easily get Resident #2 to participate with care from outside providers. SW stated that she had not noticed any change in Resident #2's behaviors since Resident #3 was discharged .Interview on 10/14/2025 at 4:26 PM with the DON revealed that psychology services were offered in facility multiple times a week, however due to Resident #2's advanced dementia they had not referred for an evaluation or services. The DON stated that the SW has done trauma screenings, but no referrals were sent as Resident #2 was difficult to assess. The DON stated that Resident #2 was placed on 1:1 with a staff member so that someone was always with her. The DON indicated that even though Resident #2 may have been targeted by Resident #3, they wanted to keep eye on her for her safety since she has had history of taking things from other residents however has not seen or heard of any negative response from Resident #2 with having the 1:1 monitoring by staff. The DON stated that staff had been informed if Resident #2 asked why she was being followed around they were to inform her it was to keep her company. Interview on 10/14/2025 at 5:05PM with the Administrator revealed he had been employed at the facility since 9/10/2025. The Administrator stated that he felt Resident #2 did not remember the altercation on 10/03/2025, however, a few hours later she was able to call her family member and give details. The Administrator stated he would expect behavioral health services to be offered to residents after they were assaulted by another resident and for staff to follow what was recommended by the mental health providers as they are in the building on Wednesdays every week. The Administrator stated he also expected staff to call on these contracted mental health providers as needed, to alert them to situations that had happened in the facility since their last visit, and to do what was needed or recommended by those providers. Confidential interview with family member #1 revealed Resident #2 became more withdrawn after the incidents of abuse but returned to baseline shortly after. The resident was confused and the family member was frustrated and concerned for Resident #2's safety in the facility. Family member #1 stated they were focused on finding a suitable facility for the resident to relocate to. Resident #2 did not receive any behavioral services after each incident and Resident #3 continued to abuse Resident #2.Review of facility policy Unmanageable Residents, revised April 2010 revealed; Each resident will be provided I. Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately:a. Provide for the safety of all concerned (i.e., move resident, equipment, etc.);b. Notify the resident's Attending Physician for instructions; Review of facility policy Resident Rights, revised December 2016 revealed; Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence;b. be treated with respect, kindness, and dignity;c. be free from abuse, neglect, misappropriation of property, and exploitation;f. communication with and access to people and services, both inside and outside the facility;h. be supported by the facility in exercising his or her rights;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to immediately report failed to report abuse, neglect, exploitation, or critical incidents for 1 of 4 resident (Resident #1) reviewed for reporting.<BR/>The facility failed to report an incident of resident to staff physical aggression/assault to HHSC.<BR/>This failure could place residents at risk for abuse, neglect and incidents.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 01/23/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizophrenia (serious mental condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) Type 2 Diabetes Mellitus with Diabetic, Unspecified Psychosis not due to substance or known major depressive disorder.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 10/28/24, reflected Resident #1 had a BIMS of 12, which indicated cognition moderate impaired. <BR/>Record review of Resident #1's care plan, revised 09/20/24, revealed the resident at risk for altered status due to a traumatic life experience while at a previous group home or [Nursing Facility]. Certain male figures in authority positions, with similar physical attributes or appearance at times trigger him. Interventions in place included: Administer medication as ordered, approach resident from the front and speak in a calm, unhurried manner .Identify cause/trigger for behavior and reduce factors that may provoke resident .Call [Family Member#1] if need to calm down or get him to comprehend the situation]<BR/> .<BR/>Record review revealed no incident/accident report was completed about Resident#1 incident on 01/22/25.<BR/>Record review of Resident#1 progress notes revealed no documentation about the incident on 01/22/25.<BR/>Record review of Texas Unified Licensing Information Portal on 01/23/25 at 12:00 PM reflected, the verbal and physical altercation between Resident#1 and Administrator was not uploaded.<BR/>Record review of Resident#1 incident provided to surveyor on 01/25/25 reflected: it was initiated on 01/22/25 with no completed/ locked date on the incident report. Incident description section reflected: This [LVN K] was notified by staff after the incident that [Resident#1] slapped [MA N] and physically attacked Administrator and [Resident#1] fell to the floor. Resident description reflected: [Resident#1] stated he was approached by Administrator, in what he felt was an aggressive manner so I just swung on his . Immediate action taken section reflected: [Resident#1] assessed for injuries. None noted, denied pain or any discomfort. Physician notified, In the agencies/people notified section reflected: no notification found,<BR/>In an interview on at DON stated she did not find out about the incident until Resident#1 family member came into her office on 01/23/25 at 10:00 AM and stated the Administrator hit Resident#1. DON stated she called the Nurse Consultant to be advised on what to do. <BR/>An interview over the phone on 01/23/25 at 1:30 PM, Nurse Consultant and Operation Manager stated they were not made aware of the incident between Resident#1 and the Administrator until 10:30 AM by the DON. <BR/>An interview on 01/23/25 at 1:15 PM DON stated that she does not do the incident and reports, upload the information in Tulip or contact HHSC. DON stated the Administrator was responsible for doing the incident and accident reports. DON stated no incident or accident report for the incident on 01/22/25 between Resident#1 and the Administrator had been completed. DON stated by this information not do not know what interventions need to be put in place to prevent further abuse. <BR/>An over the phone interview on 01/23/35 at 1:30 PM Nurse Consultant E and Operation Manager stated the Administrator had been suspended pending the investigation. Nurse Consultant stated she will work and trained the DON on how to do the incident reports. <BR/>An observation on 01/23/25 at 7am revealed the Administrator was in the building at 7AM and did not leave the building until 12:00 PM. <BR/>Record review of Administrator profile reflected: Administrator was hired on 11/27/23 and terminated on 01/24/25. <BR/>Record review of the facility policy titled Unusual Occurrence Reports revised 12/07, reflected: Other occurrences that interfere with facility operations and affects the welfare, safety, or health of residents, employees .2. Unusual occurrences shall reported via telephone to appropriate agencies as required by current law and/ or regulations within twenty-four (24) hours of such incidents or as otherwise required by federal and state regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan 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 for one of 5 residents (Resident #2) reviewed for comprehensive resident centered care plans. <BR/>The facility failed to ensure the comprehensive resident centered care plan for Resident #2 was implemented by not putting a fall mat in Resident #2's room. <BR/>This failure could place residents, that are at risk for falls, to be injured by not putting interventions listed in resident's care plan. <BR/>Findings include:<BR/>Record review of Resident's #2s Face Sheet dated 3-5-2024 indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had a primary diagnosis of Hemiplegia (paralysis) and Hemiparesis (loss of strength in limbs) following a cerebrovascular disease (condition affecting blood flow to the brain) affecting the right dominant side, unspecified visual loss, seizures, and dysarthria (difficult or unclear articulation of speech) following cerebral infarction (stroke). <BR/>Record Review of Resident #2's medical record, in Resident #2's MDS, dated [DATE], indicated a Brief Interview Mental Status (BIMS) Score of 10, indicating moderate mental impairment. <BR/>Record Review of Resident #2s Care Plan, dated 2-26-2024, revealed Resident #2 was at risk for falls and at risk for injury due to having a seizure disorder. The care plan stated Resident #2 had a fall on 2-26-2024. Resident #2s care plan revealed that Resident #2 have a fall mat, in his room, while in bed. Record Review of Nursing notes for Resident #2, dated 2-24-2024 thru 3-5-2024, indicated Resident#2 was not offered a fall mat before 3-5-2024. <BR/>In an observation/interview, on 3-5-2024 at 2:20 PM, Resident #2 was observed to be lying on his bed. Resident #2 was observed to be a right leg amputee above the knee. Resident #2 stated he had poor vison and had never been offered a fall mat nor has he ever had a fall mat in his room. <BR/>In an interview on 3-9-2024, with LVN-A, at 1:00 PM, who was the charge nurse for Resident#2s hall, revealed she did not know why Resident #2 did not have a fall mat.<BR/>In an interview with the DON on 3-9-2024, at 3:4 PM, revealed her expectation was for Resident #2 to have what his care plan called for. The DON stated if Resident #2's care plan indicated he should have a fall mat, while in bed, then she expected Resident #2 to have had it in place. The DON did not know why Resident #2 did not have a fall mat in his room. <BR/>In an interview with the Administrator, on 3-9-2024, at 4:10 PM, revealed that he had high expectations that care plans be followed by staff and that the DON is ultimately responsible that care plans are implemented. <BR/>Record Review of the facility's care plan policy dated 12-2016, revealed:<BR/>A comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .#8 the comprehensive, person-centered care plan will (b) describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan 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 for one of 5 residents (Resident #2) reviewed for comprehensive resident centered care plans. <BR/>The facility failed to ensure the comprehensive resident centered care plan for Resident #2 was implemented by not putting a fall mat in Resident #2's room. <BR/>This failure could place residents, that are at risk for falls, to be injured by not putting interventions listed in resident's care plan. <BR/>Findings include:<BR/>Record review of Resident's #2s Face Sheet dated 3-5-2024 indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had a primary diagnosis of Hemiplegia (paralysis) and Hemiparesis (loss of strength in limbs) following a cerebrovascular disease (condition affecting blood flow to the brain) affecting the right dominant side, unspecified visual loss, seizures, and dysarthria (difficult or unclear articulation of speech) following cerebral infarction (stroke). <BR/>Record Review of Resident #2's medical record, in Resident #2's MDS, dated [DATE], indicated a Brief Interview Mental Status (BIMS) Score of 10, indicating moderate mental impairment. <BR/>Record Review of Resident #2s Care Plan, dated 2-26-2024, revealed Resident #2 was at risk for falls and at risk for injury due to having a seizure disorder. The care plan stated Resident #2 had a fall on 2-26-2024. Resident #2s care plan revealed that Resident #2 have a fall mat, in his room, while in bed. Record Review of Nursing notes for Resident #2, dated 2-24-2024 thru 3-5-2024, indicated Resident#2 was not offered a fall mat before 3-5-2024. <BR/>In an observation/interview, on 3-5-2024 at 2:20 PM, Resident #2 was observed to be lying on his bed. Resident #2 was observed to be a right leg amputee above the knee. Resident #2 stated he had poor vison and had never been offered a fall mat nor has he ever had a fall mat in his room. <BR/>In an interview on 3-9-2024, with LVN-A, at 1:00 PM, who was the charge nurse for Resident#2s hall, revealed she did not know why Resident #2 did not have a fall mat.<BR/>In an interview with the DON on 3-9-2024, at 3:4 PM, revealed her expectation was for Resident #2 to have what his care plan called for. The DON stated if Resident #2's care plan indicated he should have a fall mat, while in bed, then she expected Resident #2 to have had it in place. The DON did not know why Resident #2 did not have a fall mat in his room. <BR/>In an interview with the Administrator, on 3-9-2024, at 4:10 PM, revealed that he had high expectations that care plans be followed by staff and that the DON is ultimately responsible that care plans are implemented. <BR/>Record Review of the facility's care plan policy dated 12-2016, revealed:<BR/>A comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .#8 the comprehensive, person-centered care plan will (b) describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident received adequate supervision and interventions for 3 of 6 residents (Resident #1, Resident #3, and Resident #5) reviewed for supervision and interventions.<BR/>1.The facility failed to use a Hoyer sling that was in good condition for Resident #1.<BR/>2. The facility failed to ensure Resident #3's wheelchair was in good condition.<BR/>3. The facility failed to safely supervise and transport Resident #5 to the facility at admission.<BR/>These failures could place residents at risk for accidents and injury.<BR/>Findings included:<BR/>1. Record review of Resident #1's admission record, dated 01/12/2024, revealed a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included cerebral infarction (stroke), vascular dementia, mixed receptive-expressive language disorder (difficulty understanding and using language) and hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) affecting right dominant side.<BR/>Record review of Resident #1's annual MDS, dated [DATE], revealed BIMS was not conducted and Resident #1 had moderate impaired cognitive skills for daily decision making. <BR/>Record review of Resident #1's care plan, dated 08/16/2016 and revised on 11/02/2021, revealed Resident #1 required extensive/total assist with ADL's, r/t hx of CVA, right flaccid with intervention of transfers with support x2 (Hoyer lift).<BR/>Observation on 01/11/2024 at 1:17 p.m., revealed Resident #1 sitting in his wheelchair, with a Hoyer sling underneath him. The green middle loops on both upper straps were broken and the purple and blue loops appeared undamaged. <BR/>Interview on 01/11/2024 at 1:17 p.m., LVN D stated he assisted the aides to get Resident #1 up and they used the purple or blue loops on the sling. He stated the green loops were broken and the straps looked worn. LVN D stated the sling should be inspected before each use for safety. He said residents could fall or worse. He stated the DON just ordered 12 new slings so each resident that required a Hoyer lift will have a personal sling. He said on his side 6 or 7 residents needed to use the Hoyer lift and about 12-13 residents for the whole building. <BR/>Interview on 01/12/2024 at 1:45 pm, the DON stated they just ordered slings earlier in the week. She stated she did not know the loops were broken on Resident #1's sling. She said the staff did not use the green loop but should not have used that sling at all because they had other slings. The DON stated the plan was for each resident to have their own sling [that required one], and two extra slings at the nurse's station. She said the night shift will wash and distribute them. The DON stated the slings must be inspected before use, and if frayed or broken, they would not be used. She stated the CNA should look at the sling to see if it was broken. She said she did not expect laundry to inspect the slings, but if the sling was falling apart, they would let them know because they have done that before. She said if slings were not inspected the resident could be injured. <BR/>Record review of census list dated 01/12/2024, provided by the facility revealed 13 residents required the use of Hoyer lift for transfers.<BR/>Record review of invoice dated 01/10/2024 revealed a purchase order for 11 large sized lift slings and 2 bariatric sized lift slings.<BR/>Observation on 01/12/2024 at 1:16 pm, revealed 12 residents had slings that appeared to be in good condition or new.<BR/>2. Record review of Resident #3's admission record, dated 01/12/2023, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of metabolic encephalopathy (brain dysfunction).<BR/>Record review of Resident #3's admission MDS, dated [DATE], revealed a BIMS of 9, indicating moderate cognitive impairment. <BR/>Observation and interview on 01/11/2024 at 12:56 p.m., revealed the backrest upholstery of the wheelchair appeared torn on Resident #3's left side. Resident #3 said the backing of his wheelchair came off and has been that way for about a week. He stated it was going to get replaced next week. Resident #1 stated he thought it was because of a bag he used on the back of the wheelchair to carry his belongings. <BR/>Interview on 01/12/2024 at 1:45 p.m., the DON stated Resident #3's wheelchair was not safe at all. She said she thought the wheelchair was brought with him and he was very protective of his wheelchair. The DON stated she did not know the wheelchair looked like that and said Resident #3 could fall out, the chair could flip over, and he could be injured. The DON stated Resident #3 was on therapy caseload and would ensure the wheelchair was functioning.<BR/>3. Record review of Resident #5's admission record, dated 01/12/2024, revealed an [AGE] year-old male who admitted on [DATE] with a diagnosis of dementia.<BR/>Record review of Resident #5's Nurse's Note, dated 11/2/2023 at 2:00 p.m., revealed Resident received in room [number], MD notified of new admission, medications verified, and placed on EMAR.<BR/>Record review of Resident #5's Discharge summary, dated [DATE] at 11:20 p.m., revealed Family wanted to take [him] home as they said that they did not approve for the resident to be in this facility.<BR/>Interview on 01/12/2024 at 9:31 a.m., with the Marketer revealed he and the Housekeeping Supervisor brought Resident #5 over because he was just across the street and the other facility's van was busy. He stated Resident #5 was in a wheelchair and had just one bag. <BR/>Interview on 01/12/2024 at 12:13 p.m., the Administrator stated the SW had just briefed him about Resident #5. He stated [facility name] was their next-door neighbor and he was not here at that time, or aware of how Resident #5 was transported. He stated the previous Administrator only came in on the weekends and that was a time when they did not have a daily administrator. He said that the Housekeeping Supervisor was not normally involved in the admission process that way. He stated the facility did not have its own facility van. He said Resident #5 should have been transported by facility van or transport should have been set up with outside companies the facility has a contract with. <BR/>Interview on 01/12/2024 at 1:45 p.m., the DON stated before a resident admits and they come from the hospital, the Marketer gives them the list of contracted transportation companies. If a resident came from another facility, he would give them the name of the company they contract with and tell that facility to contact them to schedule transportation. The DON stated she did not know why the staff members went over to get Resident #5 and expected that transportation be arranged or have the proper personnel from the transferring facility bring the resident. She stated it could have been potential harm, anything could have happened to Resident #5. <BR/>Record review of the facility's policy titled Assistive Devices and Equipment revised July 2017, reflected, in part: Our facility provides, maintains, trains and supervises the use of assistive devices and equipment for residents .1. Devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include but are not limited to: a. Wheelchairs (manual and powered); b. Walkers; and c. Canes .5. The following factors will be addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment .c. Device condition - devices and equipment will be maintained on schedule and according to manufacturer's instructions. Defective or worn devices will be discarded or repaired.<BR/>Record review of the facility's policy titled Admissions Policies, revised 2006, reflected, in part: 1. The primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility. The policy did not reflect guidelines for resident transportation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to be from abuse for 1 of 4 residents (Residents #1) reviewed for abuse. <BR/>The facility failed to protect Residents #1 from a physical and verbal altercation on 01/22/25 with the Administrator. The Administrator pushed Resident#1, causing Resident#1 to fall. The incident was not reported or documented until after surveyor intervention on 01/23/25.The Administrator was not suspended until 01/23/25 at approximately 11:30 AM. <BR/>An IJ was identified on 01/23/25. The IJ template was provided to the facility on [DATE] at 5:15 PM. While the IJ was removed on 01/25/25, the facility remained out of compliance at a scope of Isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems .<BR/>This failure placed residents at risk of subsequent abuse, mental anguish, and emotional distress. <BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 01/23/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizophrenia (Serious mental health condition that affects how people think, feel and behave), Type 2 Diabetes Mellitus with Diabetic, Unspecified Psychosis not due to substance or known major depressive disorder.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 10/28/24, reflected Resident #1 had a BIMS of 12, which indicated cognition moderate impaired. <BR/>Record review of Resident #1's care plan, revised 09/20/24, revealed the resident at risk for altered status due to a traumatic life experience while at a previous group home or [Nursing Facility]. Certain male figures in authority positions, with similar physical attributes or appearance at times trigger him. Interventions in place included: Administer medication as ordered, approach resident from the front and speak in a calm, unhurried manner .Identify cause/trigger for behavior and reduce factors that may provoke resident .Call [Family Member#1] if need to calm down or get him to comprehend the situation]<BR/> .<BR/>Record review of Record review of Psychological Services Progress Note, dated 10/08/24and completed by Psy services reflected, Resident#1 was negative for Trauma Informed Care. <BR/>Record review revealed no incident/accident report was completed about the incident on 01/22/25.<BR/>Record review of Resident#1 progress noted dated, 11/01/23 to 01/22/25 reflected: Resident#1 had other incidents with other staff but not the Administrator. <BR/>Record review of Resident#1 progress notes revealed no documentation about the incident on 01/22/25.<BR/>Record review of Resident#1 assessments revealed no documentation about incident on 01/22/25.<BR/>Record review of Resident#1 incident provided to surveyor on 01/25/25 reflected: it was initiated on 01/22/25 with no completed/ locked date on the incident report. Incident description section reflected: This [LVN K] was notified by staff after the incident that [Resident#1] slapped [MA N] and physically attacked Administrator and [Resident#1] fell to the floor. Resident description reflected: [Resident#1] stated he was approached by Administrator, in what he felt was an aggressive manner so I just swung on his . Immediate action taken section reflected: [Resident#1] assessed for injuries. None noted, denied pain or any discomfort. Physician notified, In the agencies/people notified section reflected: no notification found,<BR/>An interview on 01/23/25 at 10:20 AM Family Member#1 approached surveyor at the facility and stated the Administrator fought [Resident#1] last night. Family Member#1 stated that was wrong and he is elderly. Family Member#1 stated the Administrator was always picking on him when Resident#1 wanted to play his piano. Resident#1 did not speak to the Administrator when the Administrator would try to speak to him <BR/>An in-person interview on 01/23/25 at 10:45 AM, the Administrator and MA N entered the conference room to explain the incident on 01/22/25. The administrator stated Resident#1 assaulted a medication aide around 7pm on 01/22/25. The Administrator stated the medication aide and himself went to Resident#1s room. Resident#1 was asked why he hit the medication aide. The Administrator stated Resident#1 started punching and kicking the Administrator and made threats. The Administrator stated he put his hands up to protect himself. The Administrator stated Resident#1 tripped over his own leg and fell. The Administrator stated [CNA J], [CNA L] and [LVN P] intervened and pulled Resident#1 away. The Administrator stated he was told by Resident#1 and Family member that he reminded Resident#1 of males from his past that made fun of him and were aggressive towards him because he was gay. The Administrator stated it did not have to be reported because it was an altercation between staff and a resident.<BR/>An interview on 01/23/25 at 10:45 AM, MA N stated Resident#1 took snacks off the snack tray and hit MA N's face when she asked him what he was doing. MA N immediately reported to the Administrator who went to Resident#1 to ask what happened and Resident#1 hit the Administrator. <BR/>An interview on 01/23/25 at 11:00 AM, the DON stated she was not made aware of the incident until after 10:15 AM on 01/23/25 when Resident#1 family member came into her office. The DON immediately called her nurse consultant and informed her of the situation. <BR/>An interview and observation on 01/23/25 at 11:05 AM of the camera in the Administrator office with the PD revealed, Resident was punching and kicking the Administrator. The Administrator open hand pushed Resident#1 face area and caused Resident#1 to fall. Observed a linen cart pushed between the Administrator and Resident#1. Observation of additional staff stepped in between Resident#1 and Administrator. Staff were observed holding the Administrator back and grabbing Resident#1. PD stated an incident would be put on file but no arrest or charges because the resident started the altercation. Surveyor did not recall observing a date and time on the footage. <BR/>An interview on 01/23/25 at 11:30 AM, Ombudsmen stated she had not been notified about the physical altercation between the Administrator and Resident#1.<BR/>An over the phone interview on 01/23/25 at 1:30 PM the Corporate Operations Manager and Nurse Consultant stated they were not made aware of the abuse allegation until 1/23/25 at approximately 10:30 AM. The Administrator (Abuse coordinator) was asked to go home until the investigation was completed. Both stated it did not have to be reported to State since there was not an allegation of abuse at the time of the incident. Operations Manager stated that is the company policy for all that when an investigation of abuse had been reported the staff member would be suspended until the investigation was completed. Corporate Operations Manager and Nurse Consultant both stated the Administrator was suspended until the investigation was completed. Both stated there was no risk to residents, as soon as they found out about the incident the facility took immediate action. <BR/>An interview with Resident#1 on 01/23/25 at 2:15 PM he stated he would not feel safe in the facility if the Administrator returned. Resident#1 stated the Administrator hit him and he hit him back.<BR/>An interview on 01/23/25 at 4:11PM CNA J stated it was chaos in the hallway and he did not see how the incident started. CNA J stated he saw Resident#1 kicking and hitting the Administrator. CNA J stated he tried to intervene but did not want to get hit by Resident#1 so, he pushed a linen cart between them. CNA J stated he did not see how the resident fell. CNA J stated he grabbed Resident#1 and took him outside to smoke. <BR/>An interview on 01/23/25 at 4:20 PM LVN P stated he witnessed Resident#1 swinging both of his arms towards the Administrator LVN P stated they separated Resident#1 and the Administrator. <BR/>An interview on 01/24/25 at 4:30 PM CNA L stated Resident#1 was kicking and hitting the Administrator in the hallway. CNA L stated he did not see how Resident#1 fell but, he jumped back up and continued to attack the Administrator. CNA L stated the Administrator and Resident#1 were separated. <BR/>An interview on 01/24/25 at 4:50 PM DON stated the Administrator who is the abuse coordinator is responsible for completing and reporting investigation to corporate and State office. DON stated while the Administrator was suspended, she would be responsible. <BR/>Record review of facility policy titled; Usual Occurrence Reporting revised 12/07 reflected: H. Other occurrences that interfere with facility operations band affect welfare, safety, or health of residents, employees or vistors.2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations.<BR/>Record review of facility policy titled; Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigating revised 09/22 reflected: <BR/>All reports of resident abuse . Are reported to local state and federal agencies add (current regulations) is thoroughly investigated by facility management . findings of all investigations are documented and reported . Policy interpretation and inflammation reporting allegations to the administrator and authorities upon receiving any allegations of abuse the administrator is responsible for determining what actions (if any) are needed for protection of residents . Investigation allegations 1. all allegations are thoroughly investigated the administrative initiates investigations any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete . 9. the investigator notifies the ombudsman that in abuse investigation is being conducted the ombudsman is invited to participate in the review process B. the ombudsman is notified of the result of the investigations as well as any corrective measures taken . follow up report #1 within 5 business days of the incident the administrator will provide a follow-up investigation report direct action number one all relevant professional and licensing boards are notified when an employee is found to have committed abuse #2 if the investigation reveals that the allegations of abuse are founded the employee is terminated #3 any allegations of its view in our files in the huge employees personal records along with any statement by the employee disputing the allegation if the employee chose make one .<BR/>The Director of Nursing was notified that an Immediate Jeopardy situation was identified and record review request of ANE policy due to the above failure and provided with the Immediate Jeopardy template on 1/23/25 at 5:15 PM. A Plan of Removal was requested.<BR/>The facility's Plan of Removal was accepted on 1/24/2025 at 1:50 PM and included: <BR/>Plan of Removal:<BR/>1. <BR/>Immediate action(s) taken for the resident(s) found to have been affected include:<BR/>Resident # 1 was assessed by the Nurse on 1/22/25 . A thorough investigation was initiated by the Corporate Office and Director of Nursing Services.<BR/>The Medical Director was notified by the DON at 3:33pm and The DON called and left a message for the Ombudsman 1/23/25, at 5:30PM. The RP was notified on 1/22/25 by the Administrator. The accused Team Member was placed on Administrative Leave pending investigation. The Police Department was called and arrived at the facility. The Incident Report was completed on 1/23/25. The SIMS was initiated on 1/23/25 at 2:30pm.<BR/>In-services have been done by the DON for: Completing Incident reports, Notifications to MD/Ombudsman, Reporting Abuse/Neglect, Abuse Policy including timeline for reporting and What to do When a Team Member is accused (investigation requires for Team Member to be placed on Administrative Leave until the investigation is concluded). De-escalation of aggressive behaviors and resident to staff altercations. <BR/>The Post Test will be administered by the DON/designee after education is completed. Staff are required to pass at least 80%. Staff who do not achieve 80% passing rate will be re-educated and will retake the test.<BR/>TEXAS Abuse hotline number, [PHONE NUMBER] posted in strategic areas within the facility, staff made aware of postings.<BR/>2. <BR/>Identification of other residents having the potential to be affected was accomplished by:<BR/>The facility has determined that all residents have the potential to be affected. Supervisor Rounds have been started and will be completed by 1/24/25 to interview residents for issues related to care, respect and dignity. The rounding will be done by the Supervisors and the monitoring will be completed on the Supervisor Daily Rounds form.<BR/>3. <BR/>Actions taken/systems put into place to reduce the risk of future occurrence include:<BR/>An in-service education program was conducted by the Director of Nursing Services and the Assistant Director of Nursing with all staff addressing circumstances that require reporting including appropriate timeframes, reporting to the Corporate Office, reporting to the Ombudsman, timely completion of Incident Reports and SIMS reports and policy regarding Team Member involvement will be completed by 1/24/25. <BR/>The Corporate Nurse Team will conduct a Zoom meeting at 10 am on 1/24/25 with [Facility] Director of Nursing. The purpose of the in-service is to provide education for the following areas:<BR/>Our Abuse/Neglect Policy as it relates to Reporting Timelines to Corporate/State/Law Enforcement/Ombudsman/Medical Director<BR/>Steps to take when a Team Member is involved or is allegedly involved-Contact Corporate HR and place on Administrative Leave pending investigation of Abuse.<BR/>Conducting Education and Training with all Departments<BR/>Follow up and Monitoring that is required such as Rounding on Halls, Talking with Residents and Staff, Re-education with Staff to help Ensure There is No Breakdown in Communication<BR/>Five day follow up with the State Office<BR/>4. <BR/>How the corrective action(s) will be monitored to ensure the practice will not reoccur:<BR/>The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any incidents or injuries are identified, properly investigated and reported to the appropriate entities. <BR/>Findings of this audit will be reviewed in the Resident Council meetings.<BR/>This plan of correction will be monitored at the monthly Quality Assurance meeting until such time the IDT determines consistent substantial compliance has been met. <BR/>On 1/25/25 beginning at 3:00 PM the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of pre/posttest had been completed by1st, 2nd and 3rd shift nursing staff on ANE. <BR/>Record review of Director of Nursing in-services by the Nurse on ANE <BR/>Record review of the Administrator profile reflected, the Administrator was hired on 11/27/23 and terminated on 01/24/25.<BR/>An observation of the facility on 01/25/25 at 2:00 PM revealed 1-800 HHSC hotline number for abuse was posted at the entry of the facility, social workers door, display board in hallway and employees break room. <BR/>All staff were able to provide competency regarding in-service over ANE. All staff were able to provide policy, procedure, protocols, appropriate interventions, and when and who to report abuse to. All staff were to provide an example of ANE. <BR/>Staff interviewed on 01/24/25 between 9:00 AM to 2:00 PM CNA A, CNA B, LVN C (overnight shift) and CNA G, CNA H, LVN I (1st shift) and CNA J, CNA L LVN K, RN O, LVN P (2nd shift).<BR/>Staff interviewed on 01/25/25 3:40 AM to 3:00 PM: CNA D, CNA E, LVN F, RN N (Weekend shift) and laundry aide M.<BR/>An interview on 01/25/25 at 3:45PM the Director of Nursing stated she was in-serviced by the Corporate Nurse on 01/24/25 at 10:00 AM. The Director of Nursing stated she is currently the abuse coordinator. The Director of Nursing stated staff have been in-service and pre/posttest have been completed. <BR/>The Director of Nursing was informed the Immediate Jeopardy was removed on 01/25/25 at 3:00 PM the facility remained out of compliance at a scope of potential of minimum harm and a severity level of isolated, due to the facility's need to evaluation the effectiveness of the corrective systems. <BR/>An interview on 02/12/25 at 9:30 AM, Resident#1 stated that he was doing good and did not have any concerns and wanted to stay at the facility.<BR/>An over the phone interview on 02/12/24 at 9:52 AM Family member stated she was going by what [Resident#1] told her (Previous admin would tell him to stop playing his piano and pick on him that way.). Family member stated the previous Administrator [Current facility] favored someone from [Resident#1] past, but the sister did not know exactly who and people in general would make fun of [Resident#1] because he was gay. Family member stated he was previously, in a group home and wanted to stay there but, he could not care for himself. Since, previous admin is gone there has not been any more issues. Family Member stated he came from a group home, and he was happy there and did not want to leave. <BR/>Attempted to call PCP on 02/13/24 at 9:27 AM<BR/>Attempted to call Psy services on 02/13/24 at 9:52 AM<BR/>An observation and interview on 02/13/25 at 11:30 AM Resident#1 stated [Name] the Administrator hit him last week and he did not know why. Surveyor asked Resident#1 if he knew the previous Administrator name at the current facility that he stayed at and he said that was [Name] Resident#1 stated he felt safe and did not have any concerns.<BR/>Record review of Psy Subsequent assessment dated [DATE] and completed by Psy services reflected, <BR/>The provider asked the patient to tell him what transpired since the last few days. The patient replied nothing happened. The provider reframed the question and asked the patient if he had any altercation with anyone in the facility a few days ago. He replied someone pushed me. The provider asked the patient how the incident happened or what prompted the altercation. He replied, I do not know . <BR/>Record review of Psychological Services Progress notes dated ,01/30/25 on Resident#1 completed by Psy services reflected, Resident#1 was negative for Trauma Informed Care.<BR/>The Director of Nursing was informed the Immediate Jeopardy was removed on 01/25/25. The facility remained out of compliance at a scope of actual harm and a severity level of isolated, due to the facility's need to evaluation the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for one of eleven residents (Resident #1) reviewed for abuse, neglect, and exploitation. <BR/>-The facility failed to implement policies and procedures to ensure Resident #1 was free from deprivation of goods and services abuse when the facility failed to have effective interventions and services in place to address the resident's inappropriate sexual behaviors and in-service staff on measures to properly handle the behaviors to prevent Resident #1 from sexually abusing others. <BR/>An Immediate Jeopardy (IJ) situation was identified on 5/19/25. While the IJ was removed on 5/20/25, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems . <BR/>These failures could place residents at an increased risk for abuse and neglect.<BR/>Findings include: <BR/>Record review of Resident #1's face sheet, dated 5/20/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: dementia (brain disorder that affects memory, thinking, and behavior), metabolic encephalopathy (brain disorder that causes confusion) COPD (lung disease), type II diabetes (inability to regulate blood sugar levels, chronic respiratory failure (lack of oxygen), end-stage renal failure (kidney disease), and hypertension (high blood pressure). <BR/>Record review of Resident #1's admission MDS assessment, dated 4/08/25, reflected his BIMS score was 10, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required partial to moderate assistance with most ADLs, used a walker, and was independent with most mobility tasks. The MDS Assessment under Section E-Behaviors, reflected Resident #1 did not have any physical or verbal behaviors. <BR/>Record review of Resident #1's care plan, revised 4/23/25, reflected the resident had a history of socially inappropriate behaviors: sexually inappropriate behavior. Interventions included: administering medication as ordered, eliciting family input for best approaches, praising the resident for demonstrating desired behavior, providing all care with another staff member, and removing the resident from public area when behavior was disruptive and/or unacceptable. Further review of this document reflected Resident #1 was not care planned for sexually inappropriate behaviors upon admission.<BR/>Record review of Resident #1's clinical notes, dated 3/21/25 and signed by the MD, from previous nursing facility reflected in part the following:<BR/>HPI: <BR/>LTC on therapy <BR/>Today: <BR/> . [Resident #1] has had multiple complaints and issues regarding inappropriate sexual behavior with staff and residents, He currently has a sitter, Psychiatry also following, Vitals stable. I believe patient is no longer safe to remain at the facility given sexual aggression towards other residents. I believe patient would be more appropriate to reside in a male only locked unit given behaviors.<BR/> .<BR/>Record review of Resident #1's progress note, dated 4/23/25 at 9:34 AM by the SSD, reflected the following:<BR/>[SSD] contacted [RP] to make her aware of [Resident #1's] behavior and what all took place during the activity with the high school students. [RP] shared that [Resident #1] had already told her he spanked a high [NAME] on the butt.<BR/>Record review of Resident #1's progress note, dated 4/23/25 at 9:53 AM by the DON, reflected the following:<BR/>[DON] was notified by [Activity Director] that [Resident #1] has 'inappropriately touched' a student that was in facility for a activity. [Activity Director] stated that another student told him but didn't say who the student was. [DON] asked if police was made aware, was told that they have already gone, [DON] told director to notify abuse coordinator. Nursing placed [Resident #1] on Q15 min monitoring, until alternate placement can be made, immediate discharge to be given, MD made aware.<BR/>Record review of Resident #1's progress note, dated 4/23/25 at 10:12 AM by the SSD, reflected the following:<BR/>[Resident #1's] [RP] reached out and shared that she won't be able to properly care for [Resident #1]so she is not able to pick him up. [SSD] informed [RP] that she will be sending over clinical information to several nursing homes and facilities.<BR/>Record review of documents provided by the DON titled Resident 15 Minute Checks, dated 4/23/25-5/04/25, reflected Resident #1 remained on Q15 monitoring during this time. <BR/>Record review of documents provided by the DON titled [Nursing Facility] Resident Safe Survey Questionnaire for Staff, dated 4/23/25, reflected 30 residents were surveyed regarding abuse and neglected from staff with no concerns. Further review of this document reflected there were no questions directly regarding concerns for sexual abuse by staff or other residents. <BR/>Attempted interview on 5/16/25 at 10:30 AM with Resident #1 was unsuccessful due to the resident being away from the facility at the dialysis clinic. <BR/>Record review of Resident #1's active consolidated physician orders, dated 5/20/25, reflected in part the following:<BR/>-Estradiol Oral Tablet 2 mg; give 1 tablet by mouth one time a day for hypersexuality. Start Date: 5/15/25. <BR/>Further review of this document reflected Resident #1 did not have an order for psychological/psychiatric services.<BR/>In an interview on 5/16/25 at 12:35 PM with the DON and Administrator, the DON denied knowing Resident #1 had a history of exhibiting sexually inappropriate behaviors. The Administrator stated the facility did not have a policy that required the facility to check a resident's background or the sex offender registry prior to admission. The DON stated per regional managers, the facility did not discriminate against residents regarding criminal background. The Administrator and the DON failed to mention Resident #1 was involved in an incident on 4/23/25 where he exhibited sexually inappropriate behavior by touching a student visitor during this interview. <BR/>In an interview on 5/16/25 at 1:35 PM, Resident #3 stated she felt uncomfortable around Resident #1, who she called a sex offender, because he always stared at her while making sexual gestures. Resident #3 stated a lot of female residents were uncomfortable around Resident #1 and it was reported to the Administrator and the DON, and they never did anything about it. Resident #3 stated students from the local high school used to visit and paint the female residents' fingernails; however, they stopped after Resident #1 touched one of the students inappropriately last month. She denied ever being touched by Resident #1. <BR/>In an interview on 5/16/25 at 2:15 PM, Resident #11 stated Resident #1 was creepy because he would come up to her room door and stick his tongue out, wink, and blow kisses at her. Resident #11 stated Resident #1 did that to a lot of other female residents, and they were all uncomfortable around him. Resident #11 stated she reported this to her nurse ; however, Resident #1's behavior did not stop. Resident #11 denied ever being touched by Resident #1 but stated he touched a student while they were visiting the facility to participate in activities with the residents. Resident #11 stated after the incident Resident #1 had 1 to 1 supervision and that stopped the behaviors, but he was not on it long. <BR/>In an interview on 5/16/25 at 4:20 PM with the Administrator and DON, the DON stated she was aware of Resident #1 touching a student visitor inappropriately. The DON stated she did not know the state surveyor was referring to that incident during the earlier interview. The DON stated the Activity Director reported to her the students were in the dining room areas doing an activity with the residents when one of the students ran out upset and another student reported she was touched inappropriately by Resident #1. The DON stated Resident #1 was placed on Q 15-minute supervision and issued an immediate discharge notice; however, they were unable to find placement and Resident #1's RP stated she could not care for the resident. The DON stated she was responsible for reviewing clinical notes before admitting a resident; however, she did not remember seeing in Resident #1's clinical notes that he had a history of exhibiting sexually inappropriate behaviors or that it was recommended he be placed on an all-male secured unit. The DON stated if she saw the recommendation, she probably would not have admitted Resident #1, or she would have put appropriate interventions in place. The DON stated the MD recently placed Resident #1 on medication for his hypersexual behaviors and he was care planned to have 2 staff when care was being provided. The Administrator stated he was aware of the incident and after reviewing the camera footage he was unable to determine exactly what happened due to a pole blocking the view. He stated he only saw the student jump back then get up and run from the area. The Administrator stated since he could not determine what happened from the footage, he did not proceed with a full investigation, report it to the state agency, or notify law enforcement. The Administrator stated it was the facility's policy to investigate and report abuse and neglect; however, he did not think he needed to investigate or report the incident based on the information he had. He stated the risk of not investigating and reporting incidents of alleged abuse or neglect could place the residents at risk of being harmed. <BR/>In an interview on 5/16/25 at 4:40 PM, the Ombudsman stated she had an open case for Resident #1 regarding the resident being sexually inappropriate with a student who was visiting the facility. The Ombudsman stated Resident #1's RP called her because the facility was trying to discharge the resident to a group home which was inappropriate for his level of care. The Ombudsman stated the RP informed that Resident #1 was unaware of his actions and the consequences of it due to his dementia and did not feel it was right for him to be punished. The Ombudsman stated she never received a discharge notice Resident #1. She stated she visited the facility to investigate and felt the facility should have reported the incident to the state agency. The Ombudsman stated she reviewed Resident #1's clinical notes from the previous facility and found that it was recommended the resident be placed on a male secured unit. The Ombudsman stated Resident #1 should not have been admitted to the current nursing facility if they could not accommodate his care needs as they did not have a male secured unit. The Ombudsman expressed deep concerns that the incident was not reported, and the facility had considered discharging the resident to a group home. <BR/>In an interview on 5/19/25 at 9:26 AM, the Activity Director stated students from the local high school would come to the facility twice a month to do activities with the residents. The Activity Director stated on 4/23/25, the students were at the facility doing an activity with the residents in the dining area. He stated a student came up to him visibly upset then pointed at Resident #1 and stated he grabbed one of the student's thighs. The Activity Director stated he saw the student run out of the area but did not know her name and the other students refused to identify her. The Activity Director stated he immediately removed Resident #1 from the area until the students left the facility. He stated he reported the incident to the Administrator and the DON. The Activity Director stated Resident #1 was placed on 1 to 1 supervision for some time, but he was not sure what else was done. He stated the Administrator did not ban the students from the facility because he was still expecting them to show up; however, they never returned. The Activity Director stated he heard Resident #1 was sexually inappropriate with the aides, but he never heard of Resident #1 doing anything to other residents. <BR/>Further interview on 5/19/25 at 3:00 PM with the Administrator and DON, the DON stated after the incident she did not in-service the staff on abuse/neglect and sexually inappropriate behaviors. The DON stated the staff received routine trainings and in-services as needed on abuse and neglect, but she did not know if they received trainings specifically regarding sexual behaviors other than upon hire. The DON stated staff knew to document daily on Resident #1 and the staff who were assigned to do Q 15-miute checks were informed about the incident and knew what to monitor for; however, this was not documented as an in-service. The Administrator stated he had a meeting with management regarding the incident, but it was not documented. The Administrator stated he had a memo typed up that had not been sent out yet because he was waiting to see if the students would return to the facility. He did not state what information was included in the memo . The DON stated not having effective interventions in place, placed residents and visitors at risk of being sexually abused. She stated this also placed Resident #1 at risk of being harmed because he could be sexually inappropriate towards someone who could hurt him.<BR/>In an interview on 5/19/25 at 4:36 PM, Resident #1's RP stated the facility notified her sometime last month to inform her the resident was being discharged to a group home for being sexually inappropriate with a student that was visiting the facility. The RP stated she was aware Resident #1 exhibited sexually inappropriate behaviors from his previous facility; however, he could not help it due to his dementia. The RP stated the last thing she heard from the facility was Resident #1 was placed on 1 to 1 supervision and was told she would have to pay for it to continue. The RP stated she was informed she could not afford to pay, and she also could not bring Resident #1 home with her, and that was the last time she heard from them. <BR/>In an observation and interview on 5/19/25 at 4:52 PM, revealed Resident #1 was sitting in a wheelchair in his room. He was dressed and well-groomed . Resident #1 stated he had just returned to the facility from dialysis and was tired. Resident #1 stated he was fine then refused to answer any other questions. This state surveyor was unable to obtain any information from Resident #1 regarding the incident. <BR/>In an interview on 5/20/25 at 1:25 PM, CNA C stated she worked with Resident #1 and he was always sexually inappropriate with staff. She stated Resident #1 would grab at her breast and thighs while she was showering him, and it made her very uncomfortable. CNA C stated she reported this to the DON, and she placed the resident on 2-person assist with care but there was not always an extra staff to help when needed. CNA C stated she was aware of the incident that happened on 4/23/25 when Resident #1 touched a student inappropriately. CNA C stated later that evening, a man who said he was the student's father came to the facility and asked to speak to someone about the incident. CNA C stated that made the staff concerned for the safety of everyone in the facility. CNA C stated it was reported to the Administrator and DON . <BR/>Record review of the facility's policy titled Abuse Prevention Program, revised January 2011, reflected in part the following:<BR/>Policy Statement:<BR/>Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. <BR/>Policy Interpretation and Implementation:<BR/> As part of the resident abuse prevention, the administration will:<BR/>1. <BR/>Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.<BR/> .<BR/>3. <BR/>Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.<BR/>4. <BR/>Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.<BR/>5. <BR/>Implement measures to address factors that may lead to abusive situations, for example:<BR/> a. <BR/>Provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation.<BR/> b. <BR/>Instruct staff regarding appropriate ways to address interpersonal conflicts; and<BR/>c. <BR/>Help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts.<BR/>6. <BR/>Identify and assess all possible incidents of abuse;<BR/>7. <BR/>Investigate and report any allegations of abuse within timeframes as required by federal requirements;<BR/>8. <BR/>Protect residents during abuse investigations;<BR/>9. <BR/>Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse; and<BR/>10. <BR/>Involve the resident council in monitoring and evaluating the facility's abuse prevention program. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 05/19/25 at 3:22 PM. The Administrator and DON were notified. The Administrator was provided with the IJ template on 05/19/25 at 3:25 PM <BR/>The following Plan of Removal submitted by the facility was accepted on 05/20/25 at 1:32 PM:<BR/>[Nursing Facility]<BR/>1. <BR/>F600 (F607)| Free from Neglect - The facility failed to ensure Resident #1 was free from neglect when he was not provided appropriate good or services to prevent his sexually inappropriate behaviors to potentially cause harm to himself and to others.<BR/>2. <BR/>Identification of Residents Affected or Likely to be Affected: <BR/>The DON, Social Services Director, and designee(s) interviewed/assessed residents all residents for potential abuse by conducting safe surveys on each resident. Concerns were identified. Concerns identified were resident keeps staring at them and touching his privates-3 residents). (Completion Date: 4/23/2025):<BR/>The following actions were taken to prevent Resident # 1 from perpetrating additional abusive behaviors. Resident evaluated by primary care provider on 5/14/25 and provided a medication update. <BR/>Resident will have a psych consult, medication adjustment, and follow-up as needed. Psych referral has been submitted on 5/20/2025. Psyche consult provided (5/23/2025).<BR/>Resident will not be seated near female resident(s) at activities, dining, etc. when at all possible. <BR/>IDT reviewed and revised care plan to identify patterns in resident's behaviors and implement interventions. Care plan revisions and interventions communicated to front line staff caring for resident.<BR/>3. <BR/>Actions to Prevent Occurrence/Recurrence: <BR/>The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 5/20/2025)<BR/>Abuse policies were reviewed/updated to include all sources of abuse, including resident to resident. <BR/>Abuse investigation procedure and documentation process were reviewed and revised. Administrator and DON educated all staff on changes.<BR/>Social Services Director, DON, and Administrator re-educated all staff on facility abuse policies.<BR/>Social Services Director, DON and Administrator re-education all staff on abuse prevention and reporting.<BR/>Corporate will in-service Director of Nursing, Social, Administrator, and ADON on abuse and neglect, by 5/20/2025. Started 5/19/2025.<BR/>DON and designee educated Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director or designee and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form by the Care Plan Coordinator or designee. Started 5/19/2025 Process will be on going.<BR/>In the event of any future allegation of sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. Started 5/19/2025 Process will be on going.<BR/>The DON and/or administrator will in-service the staff on proper interventions of misconduct and abuse and neglect Started 5/19/2025 In-service will be on going.<BR/>QAPI meeting will be held monthly, and findings discussed.<BR/>The DON will monitor the effectiveness of interventions will be ongoing.<BR/>A pre/posttest on abuse and neglect will be on going starting 5/20/2025. Started 5/20/2025.<BR/>The facility is still looking for proper placement of resident.<BR/>Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN, new staff, or staff that has not participated in training.<BR/>Review the following:<BR/>Regulation: F-600 (F607)<BR/>&sect;483.12 Freedom from Abuse, Neglect, and Exploitation<BR/>The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.<BR/>Intent &sect;483.12(a)(1)<BR/>Each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone.<BR/>Highlight the deficient practice and specifics of the citation.<BR/>Facility Policy and Practice <BR/>Facility's Action Plan regarding the deficiency.<BR/>Facility's Policies and Procedures related to the deficiency.<BR/>Facility's Checklists and Monitoring tools used to verify compliance.<BR/>Facility's Abuse investigation procedure and documentation process.<BR/>Record of Training<BR/>Complete Record of In-service Training and Attendance Form. Be sure that all participants sign in.<BR/>Monitoring of the POR included the following:<BR/>Interviews on 5/08/25, 1:20 PM-2:35 PM, conducted with the Administrator, DON, ADON, SSD, MDS Nurse, nurses, CMAs, and CNAs: LVN B (2nd shift), CNC C (1st shift/rotating), LVN E (1st shift), LVN F (1st shift), CNA G (1st shift/rotating), LVN H (3rd shift), RN I (2nd shift), CMA J (2nd shift), CNA K (3rd shift/rotating), LVN L (2nd shift), CNA M (2nd shift), CNA N (2nd shift), and RN O (3rd shift/weekends) indicated they all participated in in-service trainings regarding the facility's policy on abuse/sexual abuse, neglect, and exploitation starting on 5/19/25-5/20/25. All staff were able to identify abuse/sexual abuse, neglect, and exploitation, state when to report it, and who to report it to. All staff were able to state the updated procedure for sexual abuse which included removing any residents who exhibited inappropriate sexual behaviors from the area, placing them on 1 to 1 supervision until further advised, immediately reporting the behaviors to the MD, DON, and family, and following any new orders. The nurses were able to state that all behaviors had to be documented and reported to the DON. The SSD was able to state that she was responsible for monitoring documentation for any changes in residents' behaviors and ensure the care plans were updated and assist in the discharge process as necessary. The Administrator and DON were able to state it was the facility's expectation to identify, report, and investigation any suspected or alleged abuse/sexual abuse, neglect, and exploitation. The Administrator and DON understood it was their responsibility to implement and monitor the effectiveness of interventions put in place. <BR/>Observation, interview, and record review on 5/20/25, 3:00 PM-4:00 PM, of Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11, who were all at risk for abuse, neglect, and exploitation, revealed no further concerns. Record review of residents' EHRs reflected no concerns for changes in physical, mental, or psychosocial status or a lack in necessary goods and services. Observation of the residents revealed no signs of abuse or neglect. Interviews with residents and/or RPs revealed no concerns for abuse, neglect, or exploitation. <BR/>Record review of an in-service titled Abuse and Neglect, dated 5/19/25, reflected all staff were educated on the facility's policy on recognizing and reporting abuse and neglect. <BR/>Record review of an in-service titled Abuse and Neglect, dated 5/19/25, reflected the Administrator, DON, and SSD were educated on implementing the facility's policy to assess, investigate, and report any alleged abuse and neglect. <BR/>Record review of an in-service titled Sexual Assault, dated 5/20/25, reflected all staff were educated on recognizing and reporting any signs of sexual abuse and inappropriate sexual behaviors.<BR/>Record review of documents provided by the Regional Nurse Consultant titled Abuse, Neglect, and Exploitation-Pre/Post Test dated 5/20/25, reflected the DON tested all staff over their knowledge on recognizing and reporting abuse, neglect, and exploitation. <BR/>Record review of a progress note, dated 5/20/25 at 11:25 AM, reflected Resident #1 was connected to psychiatric services to address sexual behaviors.<BR/>Record review of documents provided by the Regional Nurse Consultant titled [Nursing Facility] QAPI/Corrective Action Pla Meeting, dated 5/20/25, reflected a QAPI meeting was held regarding the correction plan for the facility's deficiency in neglect. <BR/>Record review of the facility's policy titled Abuse Prevention Program, revised January 2011, reflected in part the following:<BR/>Policy Statement:<BR/>Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. <BR/>As part of the resident abuse prevention, the administration will:<BR/> .<BR/>3. <BR/>Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.<BR/>The Administrator was informed the Immediate Jeopardy was removed on 05/20/25 at 4:34 PM. The facility remained out of compliance at a scope of pattern and severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to immediately report failed to report abuse, neglect, exploitation, or critical incidents for 1 of 4 resident (Resident #1) reviewed for reporting.<BR/>The facility failed to report an incident of resident to staff physical aggression/assault to HHSC.<BR/>This failure could place residents at risk for abuse, neglect and incidents.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 01/23/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizophrenia (serious mental condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) Type 2 Diabetes Mellitus with Diabetic, Unspecified Psychosis not due to substance or known major depressive disorder.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 10/28/24, reflected Resident #1 had a BIMS of 12, which indicated cognition moderate impaired. <BR/>Record review of Resident #1's care plan, revised 09/20/24, revealed the resident at risk for altered status due to a traumatic life experience while at a previous group home or [Nursing Facility]. Certain male figures in authority positions, with similar physical attributes or appearance at times trigger him. Interventions in place included: Administer medication as ordered, approach resident from the front and speak in a calm, unhurried manner .Identify cause/trigger for behavior and reduce factors that may provoke resident .Call [Family Member#1] if need to calm down or get him to comprehend the situation]<BR/> .<BR/>Record review revealed no incident/accident report was completed about Resident#1 incident on 01/22/25.<BR/>Record review of Resident#1 progress notes revealed no documentation about the incident on 01/22/25.<BR/>Record review of Texas Unified Licensing Information Portal on 01/23/25 at 12:00 PM reflected, the verbal and physical altercation between Resident#1 and Administrator was not uploaded.<BR/>Record review of Resident#1 incident provided to surveyor on 01/25/25 reflected: it was initiated on 01/22/25 with no completed/ locked date on the incident report. Incident description section reflected: This [LVN K] was notified by staff after the incident that [Resident#1] slapped [MA N] and physically attacked Administrator and [Resident#1] fell to the floor. Resident description reflected: [Resident#1] stated he was approached by Administrator, in what he felt was an aggressive manner so I just swung on his . Immediate action taken section reflected: [Resident#1] assessed for injuries. None noted, denied pain or any discomfort. Physician notified, In the agencies/people notified section reflected: no notification found,<BR/>In an interview on at DON stated she did not find out about the incident until Resident#1 family member came into her office on 01/23/25 at 10:00 AM and stated the Administrator hit Resident#1. DON stated she called the Nurse Consultant to be advised on what to do. <BR/>An interview over the phone on 01/23/25 at 1:30 PM, Nurse Consultant and Operation Manager stated they were not made aware of the incident between Resident#1 and the Administrator until 10:30 AM by the DON. <BR/>An interview on 01/23/25 at 1:15 PM DON stated that she does not do the incident and reports, upload the information in Tulip or contact HHSC. DON stated the Administrator was responsible for doing the incident and accident reports. DON stated no incident or accident report for the incident on 01/22/25 between Resident#1 and the Administrator had been completed. DON stated by this information not do not know what interventions need to be put in place to prevent further abuse. <BR/>An over the phone interview on 01/23/35 at 1:30 PM Nurse Consultant E and Operation Manager stated the Administrator had been suspended pending the investigation. Nurse Consultant stated she will work and trained the DON on how to do the incident reports. <BR/>An observation on 01/23/25 at 7am revealed the Administrator was in the building at 7AM and did not leave the building until 12:00 PM. <BR/>Record review of Administrator profile reflected: Administrator was hired on 11/27/23 and terminated on 01/24/25. <BR/>Record review of the facility policy titled Unusual Occurrence Reports revised 12/07, reflected: Other occurrences that interfere with facility operations and affects the welfare, safety, or health of residents, employees .2. Unusual occurrences shall reported via telephone to appropriate agencies as required by current law and/ or regulations within twenty-four (24) hours of such incidents or as otherwise required by federal and state regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation or mistreatment have evidence that all alleged violations were thoroughly investigated and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for two of eleven residents (Resident #1 and Resident #2) reviewed for abuse, neglect and exploitation. <BR/>1. <BR/>The facility failed to investigate an alleged violation when Resident #1 exhibited sexually inappropriate behaviors to prevent further abuse or neglect towards Resident #1 and others. <BR/>2. <BR/>The facility failed to investigate when Resident #2 obtained and used nonprescription drugs at the facility, was found exhibiting signs of an overdose, and was transported to the local hospital where he tested positive for marijuana .<BR/>This failure could place all residents at an increased risk for abuse and neglect.<BR/>Findings included: <BR/>1.<BR/>Record review of Resident #1's face sheet, dated 5/20/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: dementia (brain disorder that affects memory, thinking, and behavior), metabolic encephalopathy (brain disorder that causes confusion) COPD (lung disease), type II diabetes (inability to regulate blood sugar levels), chronic respiratory failure (lack of oxygen), end-stage renal failure (kidney disease), and hypertension (high blood pressure). <BR/>Record review of Resident #1's admission MDS assessment, dated 4/08/25, reflected his BIMS score was 10, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required partial to moderate assistance with most ADLs, used a walker, and was independent with most mobility tasks. The MDS Assessment under Section E-Behaviors, reflected Resident #1 did not have any physical or verbal behaviors. <BR/>Record review of Resident #1's care plan, revised 4/23/25, reflected the resident had a history of socially inappropriate behaviors: sexually inappropriate behavior. Interventions included: administering medication as ordered, eliciting family input for best approaches, praising the resident for demonstrating desired behavior, providing all care with another staff member, and removing the resident from public area when behavior was disruptive and/or unacceptable. Further review of this document reflected Resident #1 was not care planned for sexually inappropriate behaviors upon admission.<BR/>Record review of Resident #1's clinical notes, dated 3/21/25 and signed by the MD, from previous nursing facility reflected in part the following:<BR/>HPI: <BR/>LTC on therapy <BR/>Today: <BR/> . [Resident #1] has had multiple complaints and issues regarding inappropriate sexual behavior with staff and residents, He currently has a sitter, Psychiatry also following, Vitals stable. I believe patient is no longer safe to remain at the facility given sexual aggression towards other residents. I believe patient would be more appropriate to reside in a male only locked unit given behaviors.<BR/> .<BR/>Record review of Resident #1's progress note, dated 4/23/25 at 9:34 AM by the SSD, reflected the following:<BR/>[SSD] contacted [RP] to make her aware of [Resident #1's] behavior and what all took place during the activity with the high school students. [RP] shared that [Resident #1] had already told her he spanked a high [NAME] on the butt.<BR/>Record review of Resident #1's progress note, dated 4/23/25 at 9:53 AM by the DON, reflected the following:<BR/>[DON] was notified by [Activity Director] that [Resident #1] has inappropriately touched a student that was in facility for a activity. [Activity Director] stated that another student told him but didn't say who the student was. [DON] asked if police was made aware, was told that they have already gone, [DON] told director to notify abuse coordinator. Nursing placed [Resident #1] on Q15 min monitoring, until alternate placement can be made, immediate discharge to be given, MD made aware.<BR/>Record review of Resident #1's progress note, dated 4/23/25 at 10:12 AM by the SSD, reflected the following:<BR/>[Resident #1's] [RP] reached out and shared that she won't be able to properly care for [Resident #1]so she is not able to pick him up. [SSD] informed [RP] that she will be sending over clinical information to several nursing homes and facilities.<BR/>Record review of documents provided by the DON titled Resident 15 Minute Checks, dated 4/23/25-5/04/25, reflected Resident #1 remained on Q15 monitoring during this time. <BR/>Record review of documents provided by the DON titled [Nursing Facility] Resident Safe Survey Questionnaire for Staff, dated 4/23/25, reflected 30 residents were surveyed regarding abuse and neglected from staff with no concerns. Further review of this document reflected there were no questions directly regarding concerns for sexual abuse by staff or other residents. <BR/>Record review of Resident #1's active consolidated physician orders, dated 5/20/25, reflected in part the following:<BR/>-Estradiol Oral Tablet 2 mg; give 1 tablet by mouth one time a day for hypersexuality. Start Date: 5/15/25. <BR/>Further review of this document reflected Resident #1 did not have an order for psychological/psychiatric services.<BR/>Attempted interview on 5/16/25 at 10:30 AM with Resident #1 was unsuccessful due to the resident being away from the facility at the dialysis clinic. <BR/>In an interview on 5/16/25 at 12:35 PM with the DON and Administrator, the DON denied knowing Resident #1 had a history of exhibiting sexually inappropriate behaviors. The Administrator stated the facility did not have a policy that required the facility to check a resident's background or the sex offender registry prior to admission. The DON stated per regional managers, the facility did not discriminate against residents regarding criminal background. The Administrator and DON failed to mention Resident #1 was involved in an incident on 4/23/25 where he exhibited sexually inappropriate behavior by touching a student visitor during this interview. <BR/>In an interview on 5/16/25 at 1:35 PM, Resident #3 stated she felt uncomfortable around Resident #1, who she called a sex offender, because he always stared at her while making sexual gestures. Resident #3 stated a lot of female residents were uncomfortable around Resident #1 and it was reported to the Administrator and the DON, and they never did anything about it. Resident #3 stated students from the local high school used to visit and paint the female residents' fingernails; however, they stopped after Resident #1 touched one of the students inappropriately last month. She denied ever being touched by Resident #1. <BR/>In an interview on 5/16/25 at 2:15 PM, Resident #11 stated Resident #1 was creepy because he would come up to her room door and stick his tongue out, wink, and blow kisses at her. Resident #11 stated Resident #1 did that to a lot of other female residents, and they were all uncomfortable around him. Resident #11 stated she reported this to her nurse ; however, Resident #1's behavior did not stop. Resident #11 denied ever being touched by Resident #1 but stated he touched a student while they were visiting the facility to participate in activities with the residents. Resident #11 stated after the incident Resident #1 had 1 to 1 supervision and that stopped the behaviors, but he was not on it long. <BR/>In an interview on 5/16/25 at 4:20 PM with the Administrator and DON, the DON stated she was aware of Resident #1 touching a student visitor inappropriately. The DON stated she did not know the state surveyor was referring to that incident during the earlier interview. The DON stated the Activity Director reported to her the students were in the dining room areas doing an activity with the residents when one of the students ran out upset and another student reported she was touched inappropriately by Resident #1. The DON stated Resident #1 was placed on Q 15-minute supervision and issued an immediate discharge notice; however, they were unable to find placement and Resident #1's RP stated she could not care for the resident. The DON stated she was responsible for reviewing clinical notes before admitting a resident; however, she did not remember seeing in Resident #1's clinical notes that he had a history of exhibiting sexually inappropriate behaviors or that it was recommended he be placed on an all-male secured unit. The DON stated if she saw the recommendation, she probably would not have admitted Resident #1, or she would have put appropriate interventions in place. The DON stated the MD recently placed Resident #1 on medication for his hypersexual behaviors and he was care planned to have 2 staff when care was being provided. The Administrator stated he was aware of the incident and after reviewing the camera footage he was unable to determine exactly what happened due to a pole blocking the view. He stated he only saw the student jump back then get up and run from the area. The Administrator stated since he could not determine what happened from the footage, he did not proceed with a full investigation or report it to the state agency. The Administrator stated it was the facility's policy to investigate and report abuse and neglect; however, he did not think he needed to investigate or report the incident based on the information he had. He stated the risk of not investigating and reporting incidents of alleged abuse or neglect could place the residents at risk of being harmed. <BR/>In an interview on 5/16/25 at 4:40 PM, the Ombudsman stated she had an open case for Resident #1 regarding the resident being sexually inappropriate with a student who was visiting the facility. The Ombudsman stated Resident #1's RP called her because the facility was trying to discharge the resident to a group home which was inappropriate for his level of care. The Ombudsman stated the RP informed that Resident #1 was unaware of his actions and the consequences of it due to his dementia and did not feel it was right for him to be punished. The Ombudsman stated she never received a discharge notice Resident #1. She stated she visited the facility to investigate and felt the facility should have reported the incident to the state agency. The Ombudsman stated she reviewed Resident #1's clinical notes from the previous facility and found that it was recommended the resident be placed on a male secured unit. The Ombudsman stated Resident #1 should not have been admitted to the current nursing facility if they could not accommodate his care needs as they did not have a male secured unit. The Ombudsman expressed deep concerns that the incident was not reported, and the facility had considered discharging the resident to a group home. <BR/>In an interview on 5/20/25 at 1:25 PM, CNA C stated she worked with Resident #1 and he was always sexually inappropriate with staff. She stated Resident #1 would grab at her breast and thighs while she was showering him, and it made her very uncomfortable. CNA C stated she reported this to the DON, and she placed the resident on 2-person assist with care but there was not always an extra staff to help when needed. CNA C stated she was aware of the incident that happened on 4/23/25 when Resident #1 touched a student inappropriately. CNA C stated later that evening, a man who said he was the student's father came to the facility and asked to speak to someone about the incident. CNA C stated that made the staff concerned for the safety of everyone in the facility. CNA C stated it was reported to the Administrator and DON . <BR/>2.<BR/>Record review of Resident 2's face sheet, dated 5/16/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: COPD (lung disease), multiple sclerosis (nerve disorder), bipolar disorder (mood disorder), and legal blindness. <BR/>Record review of Resident #2's Quarterly Minimum Data Set (MDS) assessment, dated 5/02/25, reflected he had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #2 required partial to moderate assistance with most ADLs. The MDS Assessment under Section N-Medications, reflected Resident #2 was prescribed medication under the high-risk drug class that included an antidepressant, diuretic, and anticonvulsant. <BR/>Record review of Resident #2's care plan, dated 2/20/25, did not reflect a care plan for the resident's behavior related to substance abuse.<BR/>Record review of Resident #2's progress notes, dated 2/06/25 at 10:01 AM by the SSD reflected the following:<BR/>[Social Worker] reached out to [Resident #2's] Parole Officer to inform her that he is bringing drugs into the building to sell to other residents.<BR/>Record review of Resident #2's progress notes, dated 2/11/25 at 2:36 PM by the SSD reflected the following:<BR/>[Resident #2] 30 day discharge notice was issued and signed due to lack of facility compliance.<BR/>Record review of Resident #2's progress notes, dated 2/13/25 at 3:01 PM by the SSD reflected the following:<BR/>[SSD] spoke with [Resident #2's] [PO]. [PO] shared she would be help to his discharge process and help<BR/>him look for housing.<BR/>Record review of Resident #2's progress notes, dated 2/15/25 at 8:00 AM by LVN A reflected the following:<BR/>[LVN A] was notified by staff that [Resident #2] is not acting like himself. This nurse assessed [Resident #2] and observed resident with the following symptoms: Weakness abnormal from baseline with moments of limpness noted to both sides of body, pinpoint pupils, Confusion, difficulty talking and supporting self on the side of the bed. [Resident #2] asked by staff if he's taken any new medications or anything not prescribed by current MD, resident shook his head no. MD notified new order to send resident out to ER for further evaluation. This nurse attempted to contact RP and LVM [sic]. [Resident #2] transferred to [local hospital] MD aware.<BR/>Record review of Resident #2's hospital records, dated 2/15/25, reflected in part the following:<BR/>Today's Visit (continued) <BR/>Reason for Visit: Drug / Alcohol Assessment <BR/>Diagnosis: Bladder infection<BR/> .<BR/>Labs:<BR/>Marijuana (Cannabinoid)- Positive<BR/> .<BR/>Record review of Resident #2's progress notes, dated 2/17/25 at 9:57 AM by the SSD reflected the following:<BR/>[SSD] reached out to [Resident #2's] [PO] to inform her of his resent drug overdose hospital visit.<BR/>Record review of Resident #2's consolidated physician orders, dated 5/20/25, reflected in part the following:<BR/>-Gabapentin Capsule 300 mg-give 3 capsule by mouth three times a day for nerve pain give (3) 300 mg caps to equal 90 mg. Start date: 5/16/25.<BR/>-Hydrocodone-Acetaminophen Tablet 7.5-325 mg-give 1 tablet by mouth three times a day for pain. Start date: 5/15/25.<BR/>-Tylenol Oral Tablet 325 mg (Acetaminophen)-give 2 tablets by mouth three times a day for pain.<BR/>Further review of this document reflected Resident #2 did not have an order for medical marijuana. <BR/>Interview on 5/16/25 at 11:45 AM, Resident #10 stated he was the Resident Council President at the facility. He stated there was a lot of talk going around the facility about residents bringing in drugs to use and give to other residents. Resident #10 stated it was never said which resident was bringing drugs into the facility. Resident #10 stated he often smelled marijuana in the facility. He stated the Administrator and DON were aware of this problem.<BR/>In an interview on 5/16/25 at 12:35 PM with the Administrator and DON, they both stated being aware of concerns the residents were using drugs in the facility. The Administrator stated during a smoke break about a week ago there was a smell of marijuana, and he gave staff permission to stop the smoke break that day, and there had been other reports of marijuana being smelled . The Administrator stated he had never seen marijuana in the facility and the smell could be coming from anywhere in the area. The DON stated there was a day a package arrived at the facility for Resident #3 that had to be signed for, and Resident #3 admitted there was THC in the package, but it was for her family. The DON stated the package was not accepted at the facility and it was not opened to confirm if it was THC. The Administrator stated Resident #3 used a vape that she was very protective of and would become verbally aggressive towards staff when questioned about it. The Administrator stated he did not know what was in the vape and could not violate Resident #3's rights by searching her belongings . The Administrator and DON both stated they were not aware of any concerns for staff using or bringing illegal drugs into the facility. The Administrator stated all staff were drug tested upon hire. They stated if there were drugs in the facility, they were unsure how it was getting in. The Administrator stated they had several residents who went out into the community. The DON stated if residents showed any obvious s/sx of drug use they would be sent out to the hospital for a drug screening. The Administrator stated he did not initiate an investigation or report to the state agency when marijuana was smelled during the smoke break or when Resident #3 admitted to having THC delivered to the facility. He could not state why he did not investigate or report these incidents.<BR/>In an interview on 5/16/25 at 1:35 PM, Resident #3 stated she had concerns about residents using drugs in the facility that was being brought in by staff and other residents. She stated the Administrator and DON were aware and were not doing anything about it. Resident #3 stated she had a meeting with the Administrator, DON, and SSD on 5/12/25 where she expressed all her concerns, which included the drugs in the facility, and nothing had been done yet. She stated she had a package delivered to the facility that contained THC that she ordered from a local smoke shop, but it was not for her. Resident #3 stated she was going to visit family and was going to give it to them, but the facility did not allow her to get the package. She stated she knew it was wrong to have the package delivered to the facility, but they allowed everything else. She stated she would not order THC to the facility again. <BR/>In an interview on 5/16/25 at 2:15 PM, Resident #11 stated there was always the smell of marijuana in the facility and residents would do other drugs like methamphetamines. Resident #11 stated she could tell by the smell what type of drug was being used. Resident #11 stated it mostly happened during smoke breaks and sometimes in resident rooms, and she just tried to stay away from it. Resident #11 stated she reported her concerns to the DON; however, it was still going on. She stated the residents were supposed to be drug tested if they were suspected of using, but they would refuse, and the nurses would not force them to do it and would just let it go. <BR/>Further interview on 5/19/25 at 3:00 PM with the Administrator and DON, the DON stated she was aware of Resident #2 being sent out to the local hospital after showing signs of drug use and failing his drug screening. The DON stated the MD discontinued all of Resident #2's pain medication and put in a standing order to drug screen any resident who exhibited s/sx of drug use. The DON stated she did not drug test any residents the day it smelled like marijuana during the smoke break and could not state why. She also stated staff were not in-serviced on recognizing s/sx of drug use and reporting it after the incidents. The Administrator stated the facility was waiting on Resident #2's PO to find placement for him. He stated the PO informed he was either going to find another facility or Resident #2 would go back to jail. The Administrator stated the facility was waiting on the PO to find something since the incident happened on 2/15/25. The Administrator stated not addressing the concerns for drug use at the facility or implementing effective interventions could place residents at risk of being able to obtain and use drugs at the facility that could cause serious harm .<BR/>Record review of the facility's policy titled Abuse Prevention Program, revised January 2011, reflected in part the following:<BR/>Policy Statement:<BR/>Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. <BR/> .15. Investigate and report any allegations of abuse within timeframes as required by federal requirements <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan 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 for one of 5 residents (Resident #2) reviewed for comprehensive resident centered care plans. <BR/>The facility failed to ensure the comprehensive resident centered care plan for Resident #2 was implemented by not putting a fall mat in Resident #2's room. <BR/>This failure could place residents, that are at risk for falls, to be injured by not putting interventions listed in resident's care plan. <BR/>Findings include:<BR/>Record review of Resident's #2s Face Sheet dated 3-5-2024 indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had a primary diagnosis of Hemiplegia (paralysis) and Hemiparesis (loss of strength in limbs) following a cerebrovascular disease (condition affecting blood flow to the brain) affecting the right dominant side, unspecified visual loss, seizures, and dysarthria (difficult or unclear articulation of speech) following cerebral infarction (stroke). <BR/>Record Review of Resident #2's medical record, in Resident #2's MDS, dated [DATE], indicated a Brief Interview Mental Status (BIMS) Score of 10, indicating moderate mental impairment. <BR/>Record Review of Resident #2s Care Plan, dated 2-26-2024, revealed Resident #2 was at risk for falls and at risk for injury due to having a seizure disorder. The care plan stated Resident #2 had a fall on 2-26-2024. Resident #2s care plan revealed that Resident #2 have a fall mat, in his room, while in bed. Record Review of Nursing notes for Resident #2, dated 2-24-2024 thru 3-5-2024, indicated Resident#2 was not offered a fall mat before 3-5-2024. <BR/>In an observation/interview, on 3-5-2024 at 2:20 PM, Resident #2 was observed to be lying on his bed. Resident #2 was observed to be a right leg amputee above the knee. Resident #2 stated he had poor vison and had never been offered a fall mat nor has he ever had a fall mat in his room. <BR/>In an interview on 3-9-2024, with LVN-A, at 1:00 PM, who was the charge nurse for Resident#2s hall, revealed she did not know why Resident #2 did not have a fall mat.<BR/>In an interview with the DON on 3-9-2024, at 3:4 PM, revealed her expectation was for Resident #2 to have what his care plan called for. The DON stated if Resident #2's care plan indicated he should have a fall mat, while in bed, then she expected Resident #2 to have had it in place. The DON did not know why Resident #2 did not have a fall mat in his room. <BR/>In an interview with the Administrator, on 3-9-2024, at 4:10 PM, revealed that he had high expectations that care plans be followed by staff and that the DON is ultimately responsible that care plans are implemented. <BR/>Record Review of the facility's care plan policy dated 12-2016, revealed:<BR/>A comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .#8 the comprehensive, person-centered care plan will (b) describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident received adequate supervision and interventions for 3 of 6 residents (Resident #1, Resident #3, and Resident #5) reviewed for supervision and interventions.<BR/>1.The facility failed to use a Hoyer sling that was in good condition for Resident #1.<BR/>2. The facility failed to ensure Resident #3's wheelchair was in good condition.<BR/>3. The facility failed to safely supervise and transport Resident #5 to the facility at admission.<BR/>These failures could place residents at risk for accidents and injury.<BR/>Findings included:<BR/>1. Record review of Resident #1's admission record, dated 01/12/2024, revealed a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included cerebral infarction (stroke), vascular dementia, mixed receptive-expressive language disorder (difficulty understanding and using language) and hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) affecting right dominant side.<BR/>Record review of Resident #1's annual MDS, dated [DATE], revealed BIMS was not conducted and Resident #1 had moderate impaired cognitive skills for daily decision making. <BR/>Record review of Resident #1's care plan, dated 08/16/2016 and revised on 11/02/2021, revealed Resident #1 required extensive/total assist with ADL's, r/t hx of CVA, right flaccid with intervention of transfers with support x2 (Hoyer lift).<BR/>Observation on 01/11/2024 at 1:17 p.m., revealed Resident #1 sitting in his wheelchair, with a Hoyer sling underneath him. The green middle loops on both upper straps were broken and the purple and blue loops appeared undamaged. <BR/>Interview on 01/11/2024 at 1:17 p.m., LVN D stated he assisted the aides to get Resident #1 up and they used the purple or blue loops on the sling. He stated the green loops were broken and the straps looked worn. LVN D stated the sling should be inspected before each use for safety. He said residents could fall or worse. He stated the DON just ordered 12 new slings so each resident that required a Hoyer lift will have a personal sling. He said on his side 6 or 7 residents needed to use the Hoyer lift and about 12-13 residents for the whole building. <BR/>Interview on 01/12/2024 at 1:45 pm, the DON stated they just ordered slings earlier in the week. She stated she did not know the loops were broken on Resident #1's sling. She said the staff did not use the green loop but should not have used that sling at all because they had other slings. The DON stated the plan was for each resident to have their own sling [that required one], and two extra slings at the nurse's station. She said the night shift will wash and distribute them. The DON stated the slings must be inspected before use, and if frayed or broken, they would not be used. She stated the CNA should look at the sling to see if it was broken. She said she did not expect laundry to inspect the slings, but if the sling was falling apart, they would let them know because they have done that before. She said if slings were not inspected the resident could be injured. <BR/>Record review of census list dated 01/12/2024, provided by the facility revealed 13 residents required the use of Hoyer lift for transfers.<BR/>Record review of invoice dated 01/10/2024 revealed a purchase order for 11 large sized lift slings and 2 bariatric sized lift slings.<BR/>Observation on 01/12/2024 at 1:16 pm, revealed 12 residents had slings that appeared to be in good condition or new.<BR/>2. Record review of Resident #3's admission record, dated 01/12/2023, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of metabolic encephalopathy (brain dysfunction).<BR/>Record review of Resident #3's admission MDS, dated [DATE], revealed a BIMS of 9, indicating moderate cognitive impairment. <BR/>Observation and interview on 01/11/2024 at 12:56 p.m., revealed the backrest upholstery of the wheelchair appeared torn on Resident #3's left side. Resident #3 said the backing of his wheelchair came off and has been that way for about a week. He stated it was going to get replaced next week. Resident #1 stated he thought it was because of a bag he used on the back of the wheelchair to carry his belongings. <BR/>Interview on 01/12/2024 at 1:45 p.m., the DON stated Resident #3's wheelchair was not safe at all. She said she thought the wheelchair was brought with him and he was very protective of his wheelchair. The DON stated she did not know the wheelchair looked like that and said Resident #3 could fall out, the chair could flip over, and he could be injured. The DON stated Resident #3 was on therapy caseload and would ensure the wheelchair was functioning.<BR/>3. Record review of Resident #5's admission record, dated 01/12/2024, revealed an [AGE] year-old male who admitted on [DATE] with a diagnosis of dementia.<BR/>Record review of Resident #5's Nurse's Note, dated 11/2/2023 at 2:00 p.m., revealed Resident received in room [number], MD notified of new admission, medications verified, and placed on EMAR.<BR/>Record review of Resident #5's Discharge summary, dated [DATE] at 11:20 p.m., revealed Family wanted to take [him] home as they said that they did not approve for the resident to be in this facility.<BR/>Interview on 01/12/2024 at 9:31 a.m., with the Marketer revealed he and the Housekeeping Supervisor brought Resident #5 over because he was just across the street and the other facility's van was busy. He stated Resident #5 was in a wheelchair and had just one bag. <BR/>Interview on 01/12/2024 at 12:13 p.m., the Administrator stated the SW had just briefed him about Resident #5. He stated [facility name] was their next-door neighbor and he was not here at that time, or aware of how Resident #5 was transported. He stated the previous Administrator only came in on the weekends and that was a time when they did not have a daily administrator. He said that the Housekeeping Supervisor was not normally involved in the admission process that way. He stated the facility did not have its own facility van. He said Resident #5 should have been transported by facility van or transport should have been set up with outside companies the facility has a contract with. <BR/>Interview on 01/12/2024 at 1:45 p.m., the DON stated before a resident admits and they come from the hospital, the Marketer gives them the list of contracted transportation companies. If a resident came from another facility, he would give them the name of the company they contract with and tell that facility to contact them to schedule transportation. The DON stated she did not know why the staff members went over to get Resident #5 and expected that transportation be arranged or have the proper personnel from the transferring facility bring the resident. She stated it could have been potential harm, anything could have happened to Resident #5. <BR/>Record review of the facility's policy titled Assistive Devices and Equipment revised July 2017, reflected, in part: Our facility provides, maintains, trains and supervises the use of assistive devices and equipment for residents .1. Devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include but are not limited to: a. Wheelchairs (manual and powered); b. Walkers; and c. Canes .5. The following factors will be addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment .c. Device condition - devices and equipment will be maintained on schedule and according to manufacturer's instructions. Defective or worn devices will be discarded or repaired.<BR/>Record review of the facility's policy titled Admissions Policies, revised 2006, reflected, in part: 1. The primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility. The policy did not reflect guidelines for resident transportation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to be from abuse for 1 of 4 residents (Residents #1) reviewed for abuse. <BR/>The facility failed to protect Residents #1 from a physical and verbal altercation on 01/22/25 with the Administrator. The Administrator pushed Resident#1, causing Resident#1 to fall. The incident was not reported or documented until after surveyor intervention on 01/23/25.The Administrator was not suspended until 01/23/25 at approximately 11:30 AM. <BR/>An IJ was identified on 01/23/25. The IJ template was provided to the facility on [DATE] at 5:15 PM. While the IJ was removed on 01/25/25, the facility remained out of compliance at a scope of Isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems .<BR/>This failure placed residents at risk of subsequent abuse, mental anguish, and emotional distress. <BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 01/23/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizophrenia (Serious mental health condition that affects how people think, feel and behave), Type 2 Diabetes Mellitus with Diabetic, Unspecified Psychosis not due to substance or known major depressive disorder.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 10/28/24, reflected Resident #1 had a BIMS of 12, which indicated cognition moderate impaired. <BR/>Record review of Resident #1's care plan, revised 09/20/24, revealed the resident at risk for altered status due to a traumatic life experience while at a previous group home or [Nursing Facility]. Certain male figures in authority positions, with similar physical attributes or appearance at times trigger him. Interventions in place included: Administer medication as ordered, approach resident from the front and speak in a calm, unhurried manner .Identify cause/trigger for behavior and reduce factors that may provoke resident .Call [Family Member#1] if need to calm down or get him to comprehend the situation]<BR/> .<BR/>Record review of Record review of Psychological Services Progress Note, dated 10/08/24and completed by Psy services reflected, Resident#1 was negative for Trauma Informed Care. <BR/>Record review revealed no incident/accident report was completed about the incident on 01/22/25.<BR/>Record review of Resident#1 progress noted dated, 11/01/23 to 01/22/25 reflected: Resident#1 had other incidents with other staff but not the Administrator. <BR/>Record review of Resident#1 progress notes revealed no documentation about the incident on 01/22/25.<BR/>Record review of Resident#1 assessments revealed no documentation about incident on 01/22/25.<BR/>Record review of Resident#1 incident provided to surveyor on 01/25/25 reflected: it was initiated on 01/22/25 with no completed/ locked date on the incident report. Incident description section reflected: This [LVN K] was notified by staff after the incident that [Resident#1] slapped [MA N] and physically attacked Administrator and [Resident#1] fell to the floor. Resident description reflected: [Resident#1] stated he was approached by Administrator, in what he felt was an aggressive manner so I just swung on his . Immediate action taken section reflected: [Resident#1] assessed for injuries. None noted, denied pain or any discomfort. Physician notified, In the agencies/people notified section reflected: no notification found,<BR/>An interview on 01/23/25 at 10:20 AM Family Member#1 approached surveyor at the facility and stated the Administrator fought [Resident#1] last night. Family Member#1 stated that was wrong and he is elderly. Family Member#1 stated the Administrator was always picking on him when Resident#1 wanted to play his piano. Resident#1 did not speak to the Administrator when the Administrator would try to speak to him <BR/>An in-person interview on 01/23/25 at 10:45 AM, the Administrator and MA N entered the conference room to explain the incident on 01/22/25. The administrator stated Resident#1 assaulted a medication aide around 7pm on 01/22/25. The Administrator stated the medication aide and himself went to Resident#1s room. Resident#1 was asked why he hit the medication aide. The Administrator stated Resident#1 started punching and kicking the Administrator and made threats. The Administrator stated he put his hands up to protect himself. The Administrator stated Resident#1 tripped over his own leg and fell. The Administrator stated [CNA J], [CNA L] and [LVN P] intervened and pulled Resident#1 away. The Administrator stated he was told by Resident#1 and Family member that he reminded Resident#1 of males from his past that made fun of him and were aggressive towards him because he was gay. The Administrator stated it did not have to be reported because it was an altercation between staff and a resident.<BR/>An interview on 01/23/25 at 10:45 AM, MA N stated Resident#1 took snacks off the snack tray and hit MA N's face when she asked him what he was doing. MA N immediately reported to the Administrator who went to Resident#1 to ask what happened and Resident#1 hit the Administrator. <BR/>An interview on 01/23/25 at 11:00 AM, the DON stated she was not made aware of the incident until after 10:15 AM on 01/23/25 when Resident#1 family member came into her office. The DON immediately called her nurse consultant and informed her of the situation. <BR/>An interview and observation on 01/23/25 at 11:05 AM of the camera in the Administrator office with the PD revealed, Resident was punching and kicking the Administrator. The Administrator open hand pushed Resident#1 face area and caused Resident#1 to fall. Observed a linen cart pushed between the Administrator and Resident#1. Observation of additional staff stepped in between Resident#1 and Administrator. Staff were observed holding the Administrator back and grabbing Resident#1. PD stated an incident would be put on file but no arrest or charges because the resident started the altercation. Surveyor did not recall observing a date and time on the footage. <BR/>An interview on 01/23/25 at 11:30 AM, Ombudsmen stated she had not been notified about the physical altercation between the Administrator and Resident#1.<BR/>An over the phone interview on 01/23/25 at 1:30 PM the Corporate Operations Manager and Nurse Consultant stated they were not made aware of the abuse allegation until 1/23/25 at approximately 10:30 AM. The Administrator (Abuse coordinator) was asked to go home until the investigation was completed. Both stated it did not have to be reported to State since there was not an allegation of abuse at the time of the incident. Operations Manager stated that is the company policy for all that when an investigation of abuse had been reported the staff member would be suspended until the investigation was completed. Corporate Operations Manager and Nurse Consultant both stated the Administrator was suspended until the investigation was completed. Both stated there was no risk to residents, as soon as they found out about the incident the facility took immediate action. <BR/>An interview with Resident#1 on 01/23/25 at 2:15 PM he stated he would not feel safe in the facility if the Administrator returned. Resident#1 stated the Administrator hit him and he hit him back.<BR/>An interview on 01/23/25 at 4:11PM CNA J stated it was chaos in the hallway and he did not see how the incident started. CNA J stated he saw Resident#1 kicking and hitting the Administrator. CNA J stated he tried to intervene but did not want to get hit by Resident#1 so, he pushed a linen cart between them. CNA J stated he did not see how the resident fell. CNA J stated he grabbed Resident#1 and took him outside to smoke. <BR/>An interview on 01/23/25 at 4:20 PM LVN P stated he witnessed Resident#1 swinging both of his arms towards the Administrator LVN P stated they separated Resident#1 and the Administrator. <BR/>An interview on 01/24/25 at 4:30 PM CNA L stated Resident#1 was kicking and hitting the Administrator in the hallway. CNA L stated he did not see how Resident#1 fell but, he jumped back up and continued to attack the Administrator. CNA L stated the Administrator and Resident#1 were separated. <BR/>An interview on 01/24/25 at 4:50 PM DON stated the Administrator who is the abuse coordinator is responsible for completing and reporting investigation to corporate and State office. DON stated while the Administrator was suspended, she would be responsible. <BR/>Record review of facility policy titled; Usual Occurrence Reporting revised 12/07 reflected: H. Other occurrences that interfere with facility operations band affect welfare, safety, or health of residents, employees or vistors.2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations.<BR/>Record review of facility policy titled; Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigating revised 09/22 reflected: <BR/>All reports of resident abuse . Are reported to local state and federal agencies add (current regulations) is thoroughly investigated by facility management . findings of all investigations are documented and reported . Policy interpretation and inflammation reporting allegations to the administrator and authorities upon receiving any allegations of abuse the administrator is responsible for determining what actions (if any) are needed for protection of residents . Investigation allegations 1. all allegations are thoroughly investigated the administrative initiates investigations any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete . 9. the investigator notifies the ombudsman that in abuse investigation is being conducted the ombudsman is invited to participate in the review process B. the ombudsman is notified of the result of the investigations as well as any corrective measures taken . follow up report #1 within 5 business days of the incident the administrator will provide a follow-up investigation report direct action number one all relevant professional and licensing boards are notified when an employee is found to have committed abuse #2 if the investigation reveals that the allegations of abuse are founded the employee is terminated #3 any allegations of its view in our files in the huge employees personal records along with any statement by the employee disputing the allegation if the employee chose make one .<BR/>The Director of Nursing was notified that an Immediate Jeopardy situation was identified and record review request of ANE policy due to the above failure and provided with the Immediate Jeopardy template on 1/23/25 at 5:15 PM. A Plan of Removal was requested.<BR/>The facility's Plan of Removal was accepted on 1/24/2025 at 1:50 PM and included: <BR/>Plan of Removal:<BR/>1. <BR/>Immediate action(s) taken for the resident(s) found to have been affected include:<BR/>Resident # 1 was assessed by the Nurse on 1/22/25 . A thorough investigation was initiated by the Corporate Office and Director of Nursing Services.<BR/>The Medical Director was notified by the DON at 3:33pm and The DON called and left a message for the Ombudsman 1/23/25, at 5:30PM. The RP was notified on 1/22/25 by the Administrator. The accused Team Member was placed on Administrative Leave pending investigation. The Police Department was called and arrived at the facility. The Incident Report was completed on 1/23/25. The SIMS was initiated on 1/23/25 at 2:30pm.<BR/>In-services have been done by the DON for: Completing Incident reports, Notifications to MD/Ombudsman, Reporting Abuse/Neglect, Abuse Policy including timeline for reporting and What to do When a Team Member is accused (investigation requires for Team Member to be placed on Administrative Leave until the investigation is concluded). De-escalation of aggressive behaviors and resident to staff altercations. <BR/>The Post Test will be administered by the DON/designee after education is completed. Staff are required to pass at least 80%. Staff who do not achieve 80% passing rate will be re-educated and will retake the test.<BR/>TEXAS Abuse hotline number, [PHONE NUMBER] posted in strategic areas within the facility, staff made aware of postings.<BR/>2. <BR/>Identification of other residents having the potential to be affected was accomplished by:<BR/>The facility has determined that all residents have the potential to be affected. Supervisor Rounds have been started and will be completed by 1/24/25 to interview residents for issues related to care, respect and dignity. The rounding will be done by the Supervisors and the monitoring will be completed on the Supervisor Daily Rounds form.<BR/>3. <BR/>Actions taken/systems put into place to reduce the risk of future occurrence include:<BR/>An in-service education program was conducted by the Director of Nursing Services and the Assistant Director of Nursing with all staff addressing circumstances that require reporting including appropriate timeframes, reporting to the Corporate Office, reporting to the Ombudsman, timely completion of Incident Reports and SIMS reports and policy regarding Team Member involvement will be completed by 1/24/25. <BR/>The Corporate Nurse Team will conduct a Zoom meeting at 10 am on 1/24/25 with [Facility] Director of Nursing. The purpose of the in-service is to provide education for the following areas:<BR/>Our Abuse/Neglect Policy as it relates to Reporting Timelines to Corporate/State/Law Enforcement/Ombudsman/Medical Director<BR/>Steps to take when a Team Member is involved or is allegedly involved-Contact Corporate HR and place on Administrative Leave pending investigation of Abuse.<BR/>Conducting Education and Training with all Departments<BR/>Follow up and Monitoring that is required such as Rounding on Halls, Talking with Residents and Staff, Re-education with Staff to help Ensure There is No Breakdown in Communication<BR/>Five day follow up with the State Office<BR/>4. <BR/>How the corrective action(s) will be monitored to ensure the practice will not reoccur:<BR/>The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any incidents or injuries are identified, properly investigated and reported to the appropriate entities. <BR/>Findings of this audit will be reviewed in the Resident Council meetings.<BR/>This plan of correction will be monitored at the monthly Quality Assurance meeting until such time the IDT determines consistent substantial compliance has been met. <BR/>On 1/25/25 beginning at 3:00 PM the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of pre/posttest had been completed by1st, 2nd and 3rd shift nursing staff on ANE. <BR/>Record review of Director of Nursing in-services by the Nurse on ANE <BR/>Record review of the Administrator profile reflected, the Administrator was hired on 11/27/23 and terminated on 01/24/25.<BR/>An observation of the facility on 01/25/25 at 2:00 PM revealed 1-800 HHSC hotline number for abuse was posted at the entry of the facility, social workers door, display board in hallway and employees break room. <BR/>All staff were able to provide competency regarding in-service over ANE. All staff were able to provide policy, procedure, protocols, appropriate interventions, and when and who to report abuse to. All staff were to provide an example of ANE. <BR/>Staff interviewed on 01/24/25 between 9:00 AM to 2:00 PM CNA A, CNA B, LVN C (overnight shift) and CNA G, CNA H, LVN I (1st shift) and CNA J, CNA L LVN K, RN O, LVN P (2nd shift).<BR/>Staff interviewed on 01/25/25 3:40 AM to 3:00 PM: CNA D, CNA E, LVN F, RN N (Weekend shift) and laundry aide M.<BR/>An interview on 01/25/25 at 3:45PM the Director of Nursing stated she was in-serviced by the Corporate Nurse on 01/24/25 at 10:00 AM. The Director of Nursing stated she is currently the abuse coordinator. The Director of Nursing stated staff have been in-service and pre/posttest have been completed. <BR/>The Director of Nursing was informed the Immediate Jeopardy was removed on 01/25/25 at 3:00 PM the facility remained out of compliance at a scope of potential of minimum harm and a severity level of isolated, due to the facility's need to evaluation the effectiveness of the corrective systems. <BR/>An interview on 02/12/25 at 9:30 AM, Resident#1 stated that he was doing good and did not have any concerns and wanted to stay at the facility.<BR/>An over the phone interview on 02/12/24 at 9:52 AM Family member stated she was going by what [Resident#1] told her (Previous admin would tell him to stop playing his piano and pick on him that way.). Family member stated the previous Administrator [Current facility] favored someone from [Resident#1] past, but the sister did not know exactly who and people in general would make fun of [Resident#1] because he was gay. Family member stated he was previously, in a group home and wanted to stay there but, he could not care for himself. Since, previous admin is gone there has not been any more issues. Family Member stated he came from a group home, and he was happy there and did not want to leave. <BR/>Attempted to call PCP on 02/13/24 at 9:27 AM<BR/>Attempted to call Psy services on 02/13/24 at 9:52 AM<BR/>An observation and interview on 02/13/25 at 11:30 AM Resident#1 stated [Name] the Administrator hit him last week and he did not know why. Surveyor asked Resident#1 if he knew the previous Administrator name at the current facility that he stayed at and he said that was [Name] Resident#1 stated he felt safe and did not have any concerns.<BR/>Record review of Psy Subsequent assessment dated [DATE] and completed by Psy services reflected, <BR/>The provider asked the patient to tell him what transpired since the last few days. The patient replied nothing happened. The provider reframed the question and asked the patient if he had any altercation with anyone in the facility a few days ago. He replied someone pushed me. The provider asked the patient how the incident happened or what prompted the altercation. He replied, I do not know . <BR/>Record review of Psychological Services Progress notes dated ,01/30/25 on Resident#1 completed by Psy services reflected, Resident#1 was negative for Trauma Informed Care.<BR/>The Director of Nursing was informed the Immediate Jeopardy was removed on 01/25/25. The facility remained out of compliance at a scope of actual harm and a severity level of isolated, due to the facility's need to evaluation the effectiveness of the corrective systems.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food and nutrition services.<BR/>The facility failed to ensure food items were kept away from potential airborne contaminants (leaking sinks, dust particle and grease). <BR/>This failure could place residents at risk for food contamination and foodborne illness.<BR/>Findings included:<BR/>Observation on 04/08/25 at 8:00 AM, revealed behind the air fryer area had white and brown grease on the wall. Observation of the floor revealed brown grease behind the equipment that ran from the air fryer to the stove. <BR/>Observation on 04/08/25 at 8:30 AM, revealed one white towel that had turned brown was wrapped around a pipe. Under the towel was a hole that the piping did not fit into, and water was running to the hole. <BR/>Observation on 04/08/25 at 8:35 AM, revealed another white towel that had turned brown underneath the pots and pans sink. <BR/>Interview on 04/08/25 at 9:00 AM, CK stated the pipes had been leaking for a while and maintence worked with a plumber who put that extra pipe in for the water to flow but, the pipe was the wrong size and does not cover that hole. The towel was wrapped around the pipe to stop the water from splashing everywhere. The CK stated the pots and pans sink had a leak and <BR/>Interview on 04/08/25 at 9:30 AM, DM stated she was not exactly sure how long the pipes had been leaking. The DM stated the MD had work with a plumber and they keep saying they will be out to the facility every week and have not shown up again. The DM stated all staff are responsible for keeping the kitchen clean. The DM stated she writes down in her planner who cleaned what equipment in the kitchen. The DM said she does not think residents are at risk for cross contamination because their food are not near the sinks or air fryer.<BR/>On 04/08/25 at 9:40 AM, this Surveyor requested from the DM the cleaning schedule, and photocopy of planner on which staff completed kitchen -up. Surveyor did not receive documentation before exiting. <BR/>Interview on 04/08/25 at 9:58 AM, the MD stated he had worked with a plumber who gave an estimate of $50,000 to complete the necessary work for the kitchen. The MD stated the plumber that he is currently working with had cut the cost to more than half of the original estimate. The MD stated the plumbers' teams had to push back the work for the facility for another job. The MD stated the facility is working on getting the plumbing fixed in the kitchen. <BR/>Attempted to interview plumber on 04/09/25 at 9:00 AM, he stated to contact the MD at the facility, and he will be able to go over the details of the repair. <BR/>Record review of facility policy, undated, Sanitization reflected the food service area shall be maintained in a clean and sanitary manner. 1. All kitchen, kitchen areas and dining area shall be kept clean, free from litter and rubbish . 17. The food service manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work area during all tasks, and to clean after each task before proceeding to the next assignment. <BR/>Record review of plumber estimate sheet reflected plumber did an investigation of the kitchen on 01/20/25. Investigation reflected the sewer in kitchen floods the floor when 3 compartment sink is drained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to notify the resident's representative and ombudsman of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for 1 of 2 resident (Resident #1) reviewed for Discharge Rights.<BR/>The facility failed to notify Resident #1's resident representative in writing of the transfer/ discharge of the resident to a behavioral hospital, the reason for the transfer/discharge, and the right to appeal. <BR/>This failure could affect the residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes.<BR/>Findings included:<BR/>Resident #1's face sheet (undated) reflected she was a [AGE] year-old female readmitted to the facility on [DATE] with an initial admission on [DATE]. Resident #1 discharged to hospital for a behavioral evaluation on 02/10/2025. Resident#1 was transferred to the Behavioral hospital on [DATE] for psychological care. Resident's diagnosis is Unspecified Dementia, Unspecified Severity,<BR/>Without Behavioral Disturbance, Psychotic Disturbance (severe mental health disorder characterized by a collection of psychotic symptoms), Mood Disturbance, and Anxiety (Less mild and less aggressive with impaired concentration, apathy, anxiety, and agitation); Schizoaffective Disorder (mental health condition that combines aspects of schizophrenia and mood disorder), Bipolar Type (people with this condition experience both manic episodes and depressive episodes); Chronic Kidney Disease, Stage 3, Unspecified (kidneys do not work as well as they should to filter waste and extra fluid out of the blood). Resident #1's family member was the responsible party.<BR/>Resident #1's MDS assessment dated [DATE], noted BIMS Score to be 10/15 which reflected moderate cognitive impairment. Resident #1 had short-term and long-term memory problems, moderately impaired decision-making skills, no mood issues, physical and verbal behaviors.<BR/>Resident #1's progress notes reflected that on 02/10/2025, the social worker initiated a referral to transfer/discharge the resident to a behavioral health hospital due to the resident having an increase in her verbal, physical, and violent behaviors. <BR/>Review of Resident #1's clinical chart revealed a discharge or transfer notification was completed and given to Resident #1 before she was sent to a behavioral hospital on [DATE]. Resident did not have the mental capacity due to her dementia diagnosis to understand what the letter meant.<BR/>A telephone interview with the Ombudsman on 02/25,2025 at 4:04 p.m. revealed she did not receive a copy of the discharge notification for Resident #1 of the facility's intent to discharge until 02/14/2025. The Ombudsman stated she knew the Administrator was aware of the proper procedures for discharging a resident who is a threat to themselves and others. At the time the Ombudsman spoke with the Administrator, no notice had been provided to Resident #1 or to family member. The Ombudsman did receive a verbal notification of Resident #1's discharge from the Administrator on 02/10/2025 and the written notification on 02/14/2025. The Ombudsman requested that the resident and family member must receive written notice and at the time of the conversation, had not received notice at the time of the conversation on 02/10/2025.<BR/>An attempted interview with Resident #1's resident representative was made via telephone on 03/02/2025 at 03:59 PM with Surveyor contact information left on voice mail.<BR/> In an interview with the Administrator and DON on 02/25/2025 at 4:50 p.m. it was revealed the Administrator consulted with the DON and together they decided the facility could no longer meet Resident #1's needs. This would be the third incident involving Resident #1 r/t her behaviors. Resident #1 was a threat to herself and to the staff and residents. She would refuse to take her medications and would constantly try to elope from the facility. The Administrator issued the notice to the resident that she had to discharge to the hospital. The Administrator stated he notified the Ombudsman of the discharge and did send her a copy of the discharge. The Administrator and Social Worker have been unable to successfully get in touch with Resident #1's family member. The Social Worker was in the process of locating a place for Resident #1 to move to. The plans are for Resident #1 to return to a group home she once lived at.<BR/>Review of the facility's Admission, Transfer, and Discharge Register Policy dated June 2008, reflected, Our facility maintains an Admission, Transfer, and Discharge Register. (h) The date the resident was transferred or discharged . (i) The reason for the transfer/discharge. (j) The place to which the resident was transferred/discharged (i.e., hospital, home, room, etc.) The policy did not include the requirement to provide written notification of the transfer/discharge to the resident and/or their legally authorized representative.<BR/>Review of the facility's Unmanageable Residents Policy dated April 2010, reflected, Each resident will be provided with a safe place or residence. (5) Unmanageable resident may not be retained by the facility. Discharge proceedings will be implemented as instructed by the Attending Physician or Medical director in accordance with current laws and regulations governing such discharges. The policy did not include the requirement to provide written notification of the transfer/discharge to the resident and/or their legally authorized representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to be from abuse for 1 of 4 residents (Residents #1) reviewed for abuse. <BR/>The facility failed to protect Residents #1 from a physical and verbal altercation on 01/22/25 with the Administrator. The Administrator pushed Resident#1, causing Resident#1 to fall. The incident was not reported or documented until after surveyor intervention on 01/23/25.The Administrator was not suspended until 01/23/25 at approximately 11:30 AM. <BR/>An IJ was identified on 01/23/25. The IJ template was provided to the facility on [DATE] at 5:15 PM. While the IJ was removed on 01/25/25, the facility remained out of compliance at a scope of Isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems .<BR/>This failure placed residents at risk of subsequent abuse, mental anguish, and emotional distress. <BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 01/23/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizophrenia (Serious mental health condition that affects how people think, feel and behave), Type 2 Diabetes Mellitus with Diabetic, Unspecified Psychosis not due to substance or known major depressive disorder.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 10/28/24, reflected Resident #1 had a BIMS of 12, which indicated cognition moderate impaired. <BR/>Record review of Resident #1's care plan, revised 09/20/24, revealed the resident at risk for altered status due to a traumatic life experience while at a previous group home or [Nursing Facility]. Certain male figures in authority positions, with similar physical attributes or appearance at times trigger him. Interventions in place included: Administer medication as ordered, approach resident from the front and speak in a calm, unhurried manner .Identify cause/trigger for behavior and reduce factors that may provoke resident .Call [Family Member#1] if need to calm down or get him to comprehend the situation]<BR/> .<BR/>Record review of Record review of Psychological Services Progress Note, dated 10/08/24and completed by Psy services reflected, Resident#1 was negative for Trauma Informed Care. <BR/>Record review revealed no incident/accident report was completed about the incident on 01/22/25.<BR/>Record review of Resident#1 progress noted dated, 11/01/23 to 01/22/25 reflected: Resident#1 had other incidents with other staff but not the Administrator. <BR/>Record review of Resident#1 progress notes revealed no documentation about the incident on 01/22/25.<BR/>Record review of Resident#1 assessments revealed no documentation about incident on 01/22/25.<BR/>Record review of Resident#1 incident provided to surveyor on 01/25/25 reflected: it was initiated on 01/22/25 with no completed/ locked date on the incident report. Incident description section reflected: This [LVN K] was notified by staff after the incident that [Resident#1] slapped [MA N] and physically attacked Administrator and [Resident#1] fell to the floor. Resident description reflected: [Resident#1] stated he was approached by Administrator, in what he felt was an aggressive manner so I just swung on his . Immediate action taken section reflected: [Resident#1] assessed for injuries. None noted, denied pain or any discomfort. Physician notified, In the agencies/people notified section reflected: no notification found,<BR/>An interview on 01/23/25 at 10:20 AM Family Member#1 approached surveyor at the facility and stated the Administrator fought [Resident#1] last night. Family Member#1 stated that was wrong and he is elderly. Family Member#1 stated the Administrator was always picking on him when Resident#1 wanted to play his piano. Resident#1 did not speak to the Administrator when the Administrator would try to speak to him <BR/>An in-person interview on 01/23/25 at 10:45 AM, the Administrator and MA N entered the conference room to explain the incident on 01/22/25. The administrator stated Resident#1 assaulted a medication aide around 7pm on 01/22/25. The Administrator stated the medication aide and himself went to Resident#1s room. Resident#1 was asked why he hit the medication aide. The Administrator stated Resident#1 started punching and kicking the Administrator and made threats. The Administrator stated he put his hands up to protect himself. The Administrator stated Resident#1 tripped over his own leg and fell. The Administrator stated [CNA J], [CNA L] and [LVN P] intervened and pulled Resident#1 away. The Administrator stated he was told by Resident#1 and Family member that he reminded Resident#1 of males from his past that made fun of him and were aggressive towards him because he was gay. The Administrator stated it did not have to be reported because it was an altercation between staff and a resident.<BR/>An interview on 01/23/25 at 10:45 AM, MA N stated Resident#1 took snacks off the snack tray and hit MA N's face when she asked him what he was doing. MA N immediately reported to the Administrator who went to Resident#1 to ask what happened and Resident#1 hit the Administrator. <BR/>An interview on 01/23/25 at 11:00 AM, the DON stated she was not made aware of the incident until after 10:15 AM on 01/23/25 when Resident#1 family member came into her office. The DON immediately called her nurse consultant and informed her of the situation. <BR/>An interview and observation on 01/23/25 at 11:05 AM of the camera in the Administrator office with the PD revealed, Resident was punching and kicking the Administrator. The Administrator open hand pushed Resident#1 face area and caused Resident#1 to fall. Observed a linen cart pushed between the Administrator and Resident#1. Observation of additional staff stepped in between Resident#1 and Administrator. Staff were observed holding the Administrator back and grabbing Resident#1. PD stated an incident would be put on file but no arrest or charges because the resident started the altercation. Surveyor did not recall observing a date and time on the footage. <BR/>An interview on 01/23/25 at 11:30 AM, Ombudsmen stated she had not been notified about the physical altercation between the Administrator and Resident#1.<BR/>An over the phone interview on 01/23/25 at 1:30 PM the Corporate Operations Manager and Nurse Consultant stated they were not made aware of the abuse allegation until 1/23/25 at approximately 10:30 AM. The Administrator (Abuse coordinator) was asked to go home until the investigation was completed. Both stated it did not have to be reported to State since there was not an allegation of abuse at the time of the incident. Operations Manager stated that is the company policy for all that when an investigation of abuse had been reported the staff member would be suspended until the investigation was completed. Corporate Operations Manager and Nurse Consultant both stated the Administrator was suspended until the investigation was completed. Both stated there was no risk to residents, as soon as they found out about the incident the facility took immediate action. <BR/>An interview with Resident#1 on 01/23/25 at 2:15 PM he stated he would not feel safe in the facility if the Administrator returned. Resident#1 stated the Administrator hit him and he hit him back.<BR/>An interview on 01/23/25 at 4:11PM CNA J stated it was chaos in the hallway and he did not see how the incident started. CNA J stated he saw Resident#1 kicking and hitting the Administrator. CNA J stated he tried to intervene but did not want to get hit by Resident#1 so, he pushed a linen cart between them. CNA J stated he did not see how the resident fell. CNA J stated he grabbed Resident#1 and took him outside to smoke. <BR/>An interview on 01/23/25 at 4:20 PM LVN P stated he witnessed Resident#1 swinging both of his arms towards the Administrator LVN P stated they separated Resident#1 and the Administrator. <BR/>An interview on 01/24/25 at 4:30 PM CNA L stated Resident#1 was kicking and hitting the Administrator in the hallway. CNA L stated he did not see how Resident#1 fell but, he jumped back up and continued to attack the Administrator. CNA L stated the Administrator and Resident#1 were separated. <BR/>An interview on 01/24/25 at 4:50 PM DON stated the Administrator who is the abuse coordinator is responsible for completing and reporting investigation to corporate and State office. DON stated while the Administrator was suspended, she would be responsible. <BR/>Record review of facility policy titled; Usual Occurrence Reporting revised 12/07 reflected: H. Other occurrences that interfere with facility operations band affect welfare, safety, or health of residents, employees or vistors.2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations.<BR/>Record review of facility policy titled; Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigating revised 09/22 reflected: <BR/>All reports of resident abuse . Are reported to local state and federal agencies add (current regulations) is thoroughly investigated by facility management . findings of all investigations are documented and reported . Policy interpretation and inflammation reporting allegations to the administrator and authorities upon receiving any allegations of abuse the administrator is responsible for determining what actions (if any) are needed for protection of residents . Investigation allegations 1. all allegations are thoroughly investigated the administrative initiates investigations any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete . 9. the investigator notifies the ombudsman that in abuse investigation is being conducted the ombudsman is invited to participate in the review process B. the ombudsman is notified of the result of the investigations as well as any corrective measures taken . follow up report #1 within 5 business days of the incident the administrator will provide a follow-up investigation report direct action number one all relevant professional and licensing boards are notified when an employee is found to have committed abuse #2 if the investigation reveals that the allegations of abuse are founded the employee is terminated #3 any allegations of its view in our files in the huge employees personal records along with any statement by the employee disputing the allegation if the employee chose make one .<BR/>The Director of Nursing was notified that an Immediate Jeopardy situation was identified and record review request of ANE policy due to the above failure and provided with the Immediate Jeopardy template on 1/23/25 at 5:15 PM. A Plan of Removal was requested.<BR/>The facility's Plan of Removal was accepted on 1/24/2025 at 1:50 PM and included: <BR/>Plan of Removal:<BR/>1. <BR/>Immediate action(s) taken for the resident(s) found to have been affected include:<BR/>Resident # 1 was assessed by the Nurse on 1/22/25 . A thorough investigation was initiated by the Corporate Office and Director of Nursing Services.<BR/>The Medical Director was notified by the DON at 3:33pm and The DON called and left a message for the Ombudsman 1/23/25, at 5:30PM. The RP was notified on 1/22/25 by the Administrator. The accused Team Member was placed on Administrative Leave pending investigation. The Police Department was called and arrived at the facility. The Incident Report was completed on 1/23/25. The SIMS was initiated on 1/23/25 at 2:30pm.<BR/>In-services have been done by the DON for: Completing Incident reports, Notifications to MD/Ombudsman, Reporting Abuse/Neglect, Abuse Policy including timeline for reporting and What to do When a Team Member is accused (investigation requires for Team Member to be placed on Administrative Leave until the investigation is concluded). De-escalation of aggressive behaviors and resident to staff altercations. <BR/>The Post Test will be administered by the DON/designee after education is completed. Staff are required to pass at least 80%. Staff who do not achieve 80% passing rate will be re-educated and will retake the test.<BR/>TEXAS Abuse hotline number, [PHONE NUMBER] posted in strategic areas within the facility, staff made aware of postings.<BR/>2. <BR/>Identification of other residents having the potential to be affected was accomplished by:<BR/>The facility has determined that all residents have the potential to be affected. Supervisor Rounds have been started and will be completed by 1/24/25 to interview residents for issues related to care, respect and dignity. The rounding will be done by the Supervisors and the monitoring will be completed on the Supervisor Daily Rounds form.<BR/>3. <BR/>Actions taken/systems put into place to reduce the risk of future occurrence include:<BR/>An in-service education program was conducted by the Director of Nursing Services and the Assistant Director of Nursing with all staff addressing circumstances that require reporting including appropriate timeframes, reporting to the Corporate Office, reporting to the Ombudsman, timely completion of Incident Reports and SIMS reports and policy regarding Team Member involvement will be completed by 1/24/25. <BR/>The Corporate Nurse Team will conduct a Zoom meeting at 10 am on 1/24/25 with [Facility] Director of Nursing. The purpose of the in-service is to provide education for the following areas:<BR/>Our Abuse/Neglect Policy as it relates to Reporting Timelines to Corporate/State/Law Enforcement/Ombudsman/Medical Director<BR/>Steps to take when a Team Member is involved or is allegedly involved-Contact Corporate HR and place on Administrative Leave pending investigation of Abuse.<BR/>Conducting Education and Training with all Departments<BR/>Follow up and Monitoring that is required such as Rounding on Halls, Talking with Residents and Staff, Re-education with Staff to help Ensure There is No Breakdown in Communication<BR/>Five day follow up with the State Office<BR/>4. <BR/>How the corrective action(s) will be monitored to ensure the practice will not reoccur:<BR/>The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any incidents or injuries are identified, properly investigated and reported to the appropriate entities. <BR/>Findings of this audit will be reviewed in the Resident Council meetings.<BR/>This plan of correction will be monitored at the monthly Quality Assurance meeting until such time the IDT determines consistent substantial compliance has been met. <BR/>On 1/25/25 beginning at 3:00 PM the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of pre/posttest had been completed by1st, 2nd and 3rd shift nursing staff on ANE. <BR/>Record review of Director of Nursing in-services by the Nurse on ANE <BR/>Record review of the Administrator profile reflected, the Administrator was hired on 11/27/23 and terminated on 01/24/25.<BR/>An observation of the facility on 01/25/25 at 2:00 PM revealed 1-800 HHSC hotline number for abuse was posted at the entry of the facility, social workers door, display board in hallway and employees break room. <BR/>All staff were able to provide competency regarding in-service over ANE. All staff were able to provide policy, procedure, protocols, appropriate interventions, and when and who to report abuse to. All staff were to provide an example of ANE. <BR/>Staff interviewed on 01/24/25 between 9:00 AM to 2:00 PM CNA A, CNA B, LVN C (overnight shift) and CNA G, CNA H, LVN I (1st shift) and CNA J, CNA L LVN K, RN O, LVN P (2nd shift).<BR/>Staff interviewed on 01/25/25 3:40 AM to 3:00 PM: CNA D, CNA E, LVN F, RN N (Weekend shift) and laundry aide M.<BR/>An interview on 01/25/25 at 3:45PM the Director of Nursing stated she was in-serviced by the Corporate Nurse on 01/24/25 at 10:00 AM. The Director of Nursing stated she is currently the abuse coordinator. The Director of Nursing stated staff have been in-service and pre/posttest have been completed. <BR/>The Director of Nursing was informed the Immediate Jeopardy was removed on 01/25/25 at 3:00 PM the facility remained out of compliance at a scope of potential of minimum harm and a severity level of isolated, due to the facility's need to evaluation the effectiveness of the corrective systems. <BR/>An interview on 02/12/25 at 9:30 AM, Resident#1 stated that he was doing good and did not have any concerns and wanted to stay at the facility.<BR/>An over the phone interview on 02/12/24 at 9:52 AM Family member stated she was going by what [Resident#1] told her (Previous admin would tell him to stop playing his piano and pick on him that way.). Family member stated the previous Administrator [Current facility] favored someone from [Resident#1] past, but the sister did not know exactly who and people in general would make fun of [Resident#1] because he was gay. Family member stated he was previously, in a group home and wanted to stay there but, he could not care for himself. Since, previous admin is gone there has not been any more issues. Family Member stated he came from a group home, and he was happy there and did not want to leave. <BR/>Attempted to call PCP on 02/13/24 at 9:27 AM<BR/>Attempted to call Psy services on 02/13/24 at 9:52 AM<BR/>An observation and interview on 02/13/25 at 11:30 AM Resident#1 stated [Name] the Administrator hit him last week and he did not know why. Surveyor asked Resident#1 if he knew the previous Administrator name at the current facility that he stayed at and he said that was [Name] Resident#1 stated he felt safe and did not have any concerns.<BR/>Record review of Psy Subsequent assessment dated [DATE] and completed by Psy services reflected, <BR/>The provider asked the patient to tell him what transpired since the last few days. The patient replied nothing happened. The provider reframed the question and asked the patient if he had any altercation with anyone in the facility a few days ago. He replied someone pushed me. The provider asked the patient how the incident happened or what prompted the altercation. He replied, I do not know . <BR/>Record review of Psychological Services Progress notes dated ,01/30/25 on Resident#1 completed by Psy services reflected, Resident#1 was negative for Trauma Informed Care.<BR/>The Director of Nursing was informed the Immediate Jeopardy was removed on 01/25/25. The facility remained out of compliance at a scope of actual harm and a severity level of isolated, due to the facility's need to evaluation the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to immediately report failed to report abuse, neglect, exploitation, or critical incidents for 1 of 4 resident (Resident #1) reviewed for reporting.<BR/>The facility failed to report an incident of resident to staff physical aggression/assault to HHSC.<BR/>This failure could place residents at risk for abuse, neglect and incidents.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 01/23/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizophrenia (serious mental condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) Type 2 Diabetes Mellitus with Diabetic, Unspecified Psychosis not due to substance or known major depressive disorder.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 10/28/24, reflected Resident #1 had a BIMS of 12, which indicated cognition moderate impaired. <BR/>Record review of Resident #1's care plan, revised 09/20/24, revealed the resident at risk for altered status due to a traumatic life experience while at a previous group home or [Nursing Facility]. Certain male figures in authority positions, with similar physical attributes or appearance at times trigger him. Interventions in place included: Administer medication as ordered, approach resident from the front and speak in a calm, unhurried manner .Identify cause/trigger for behavior and reduce factors that may provoke resident .Call [Family Member#1] if need to calm down or get him to comprehend the situation]<BR/> .<BR/>Record review revealed no incident/accident report was completed about Resident#1 incident on 01/22/25.<BR/>Record review of Resident#1 progress notes revealed no documentation about the incident on 01/22/25.<BR/>Record review of Texas Unified Licensing Information Portal on 01/23/25 at 12:00 PM reflected, the verbal and physical altercation between Resident#1 and Administrator was not uploaded.<BR/>Record review of Resident#1 incident provided to surveyor on 01/25/25 reflected: it was initiated on 01/22/25 with no completed/ locked date on the incident report. Incident description section reflected: This [LVN K] was notified by staff after the incident that [Resident#1] slapped [MA N] and physically attacked Administrator and [Resident#1] fell to the floor. Resident description reflected: [Resident#1] stated he was approached by Administrator, in what he felt was an aggressive manner so I just swung on his . Immediate action taken section reflected: [Resident#1] assessed for injuries. None noted, denied pain or any discomfort. Physician notified, In the agencies/people notified section reflected: no notification found,<BR/>In an interview on at DON stated she did not find out about the incident until Resident#1 family member came into her office on 01/23/25 at 10:00 AM and stated the Administrator hit Resident#1. DON stated she called the Nurse Consultant to be advised on what to do. <BR/>An interview over the phone on 01/23/25 at 1:30 PM, Nurse Consultant and Operation Manager stated they were not made aware of the incident between Resident#1 and the Administrator until 10:30 AM by the DON. <BR/>An interview on 01/23/25 at 1:15 PM DON stated that she does not do the incident and reports, upload the information in Tulip or contact HHSC. DON stated the Administrator was responsible for doing the incident and accident reports. DON stated no incident or accident report for the incident on 01/22/25 between Resident#1 and the Administrator had been completed. DON stated by this information not do not know what interventions need to be put in place to prevent further abuse. <BR/>An over the phone interview on 01/23/35 at 1:30 PM Nurse Consultant E and Operation Manager stated the Administrator had been suspended pending the investigation. Nurse Consultant stated she will work and trained the DON on how to do the incident reports. <BR/>An observation on 01/23/25 at 7am revealed the Administrator was in the building at 7AM and did not leave the building until 12:00 PM. <BR/>Record review of Administrator profile reflected: Administrator was hired on 11/27/23 and terminated on 01/24/25. <BR/>Record review of the facility policy titled Unusual Occurrence Reports revised 12/07, reflected: Other occurrences that interfere with facility operations and affects the welfare, safety, or health of residents, employees .2. Unusual occurrences shall reported via telephone to appropriate agencies as required by current law and/ or regulations within twenty-four (24) hours of such incidents or as otherwise required by federal and state regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident received adequate supervision and interventions for 3 of 6 residents (Resident #1, Resident #3, and Resident #5) reviewed for supervision and interventions.<BR/>1.The facility failed to use a Hoyer sling that was in good condition for Resident #1.<BR/>2. The facility failed to ensure Resident #3's wheelchair was in good condition.<BR/>3. The facility failed to safely supervise and transport Resident #5 to the facility at admission.<BR/>These failures could place residents at risk for accidents and injury.<BR/>Findings included:<BR/>1. Record review of Resident #1's admission record, dated 01/12/2024, revealed a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included cerebral infarction (stroke), vascular dementia, mixed receptive-expressive language disorder (difficulty understanding and using language) and hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) affecting right dominant side.<BR/>Record review of Resident #1's annual MDS, dated [DATE], revealed BIMS was not conducted and Resident #1 had moderate impaired cognitive skills for daily decision making. <BR/>Record review of Resident #1's care plan, dated 08/16/2016 and revised on 11/02/2021, revealed Resident #1 required extensive/total assist with ADL's, r/t hx of CVA, right flaccid with intervention of transfers with support x2 (Hoyer lift).<BR/>Observation on 01/11/2024 at 1:17 p.m., revealed Resident #1 sitting in his wheelchair, with a Hoyer sling underneath him. The green middle loops on both upper straps were broken and the purple and blue loops appeared undamaged. <BR/>Interview on 01/11/2024 at 1:17 p.m., LVN D stated he assisted the aides to get Resident #1 up and they used the purple or blue loops on the sling. He stated the green loops were broken and the straps looked worn. LVN D stated the sling should be inspected before each use for safety. He said residents could fall or worse. He stated the DON just ordered 12 new slings so each resident that required a Hoyer lift will have a personal sling. He said on his side 6 or 7 residents needed to use the Hoyer lift and about 12-13 residents for the whole building. <BR/>Interview on 01/12/2024 at 1:45 pm, the DON stated they just ordered slings earlier in the week. She stated she did not know the loops were broken on Resident #1's sling. She said the staff did not use the green loop but should not have used that sling at all because they had other slings. The DON stated the plan was for each resident to have their own sling [that required one], and two extra slings at the nurse's station. She said the night shift will wash and distribute them. The DON stated the slings must be inspected before use, and if frayed or broken, they would not be used. She stated the CNA should look at the sling to see if it was broken. She said she did not expect laundry to inspect the slings, but if the sling was falling apart, they would let them know because they have done that before. She said if slings were not inspected the resident could be injured. <BR/>Record review of census list dated 01/12/2024, provided by the facility revealed 13 residents required the use of Hoyer lift for transfers.<BR/>Record review of invoice dated 01/10/2024 revealed a purchase order for 11 large sized lift slings and 2 bariatric sized lift slings.<BR/>Observation on 01/12/2024 at 1:16 pm, revealed 12 residents had slings that appeared to be in good condition or new.<BR/>2. Record review of Resident #3's admission record, dated 01/12/2023, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of metabolic encephalopathy (brain dysfunction).<BR/>Record review of Resident #3's admission MDS, dated [DATE], revealed a BIMS of 9, indicating moderate cognitive impairment. <BR/>Observation and interview on 01/11/2024 at 12:56 p.m., revealed the backrest upholstery of the wheelchair appeared torn on Resident #3's left side. Resident #3 said the backing of his wheelchair came off and has been that way for about a week. He stated it was going to get replaced next week. Resident #1 stated he thought it was because of a bag he used on the back of the wheelchair to carry his belongings. <BR/>Interview on 01/12/2024 at 1:45 p.m., the DON stated Resident #3's wheelchair was not safe at all. She said she thought the wheelchair was brought with him and he was very protective of his wheelchair. The DON stated she did not know the wheelchair looked like that and said Resident #3 could fall out, the chair could flip over, and he could be injured. The DON stated Resident #3 was on therapy caseload and would ensure the wheelchair was functioning.<BR/>3. Record review of Resident #5's admission record, dated 01/12/2024, revealed an [AGE] year-old male who admitted on [DATE] with a diagnosis of dementia.<BR/>Record review of Resident #5's Nurse's Note, dated 11/2/2023 at 2:00 p.m., revealed Resident received in room [number], MD notified of new admission, medications verified, and placed on EMAR.<BR/>Record review of Resident #5's Discharge summary, dated [DATE] at 11:20 p.m., revealed Family wanted to take [him] home as they said that they did not approve for the resident to be in this facility.<BR/>Interview on 01/12/2024 at 9:31 a.m., with the Marketer revealed he and the Housekeeping Supervisor brought Resident #5 over because he was just across the street and the other facility's van was busy. He stated Resident #5 was in a wheelchair and had just one bag. <BR/>Interview on 01/12/2024 at 12:13 p.m., the Administrator stated the SW had just briefed him about Resident #5. He stated [facility name] was their next-door neighbor and he was not here at that time, or aware of how Resident #5 was transported. He stated the previous Administrator only came in on the weekends and that was a time when they did not have a daily administrator. He said that the Housekeeping Supervisor was not normally involved in the admission process that way. He stated the facility did not have its own facility van. He said Resident #5 should have been transported by facility van or transport should have been set up with outside companies the facility has a contract with. <BR/>Interview on 01/12/2024 at 1:45 p.m., the DON stated before a resident admits and they come from the hospital, the Marketer gives them the list of contracted transportation companies. If a resident came from another facility, he would give them the name of the company they contract with and tell that facility to contact them to schedule transportation. The DON stated she did not know why the staff members went over to get Resident #5 and expected that transportation be arranged or have the proper personnel from the transferring facility bring the resident. She stated it could have been potential harm, anything could have happened to Resident #5. <BR/>Record review of the facility's policy titled Assistive Devices and Equipment revised July 2017, reflected, in part: Our facility provides, maintains, trains and supervises the use of assistive devices and equipment for residents .1. Devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include but are not limited to: a. Wheelchairs (manual and powered); b. Walkers; and c. Canes .5. The following factors will be addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment .c. Device condition - devices and equipment will be maintained on schedule and according to manufacturer's instructions. Defective or worn devices will be discarded or repaired.<BR/>Record review of the facility's policy titled Admissions Policies, revised 2006, reflected, in part: 1. The primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility. The policy did not reflect guidelines for resident transportation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure complete and accurate incident/accident report for 1 (Resident#1) of 4 residents reviewed for incident reports.<BR/>The facility failed to ensure Resident#1's incident report was completed on 01/22/25, which involved a verbal and physical altercation between Resident#1 and Administrator by LVN C.<BR/>This failure could place residents at risk of inaccurate or incomplete information, resulting in the risk of abuse or neglect by staff. <BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 01/23/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizophrenia (serious mental condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) Type 2 Diabetes Mellitus with Diabetic, Unspecified Psychosis not due to substance or known major depressive disorder.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 10/28/24, reflected Resident #1 had a BIMS of 12, which indicated cognition moderate impaired. <BR/>Record review of Resident #1's care plan, revised 09/20/24, revealed the resident at risk for altered status due to a traumatic life experience while at a previous group home or [Nursing Facility]. Certain male figures in authority positions, with similar physical attributes or appearance at times trigger him. Interventions in place included: Administer medication as ordered, approach resident from the front and speak in a calm, unhurried manner .Identify cause/trigger for behavior and reduce factors that may provoke resident .Call [Family Member#1] if need to calm down or get him to comprehend the situation]<BR/> .<BR/>Record review revealed no incident/accident report was completed about Resident#1 incident on 01/22/25.<BR/>Record review of Resident#1 progress notes revealed no documentation about the incident on 01/22/25.<BR/>Record review of Resident#1 assessments revealed no documentation of completed assessment on 01/22/25.<BR/>Record review of Resident#1 incident provided to surveyor on 01/25/25 reflected: it was initiated on 01/22/25 with no completed/ locked date on the incident report. Incident description section reflected: This [LVN K] was notified by staff after the incident that [Resident#1] slapped [MA N] and physically attacked Administrator and [Resident#1] fell to the floor. Resident description reflected: [Resident#1] stated he was approached by Administrator, in what he felt was an aggressive manner so I just swung on his . In the agencies/people notified section no notification found,<BR/>An interview on 12/23/24 at 2:30 PM, LVN K stated she did not witness the incident between the Administrator and the Resident#1 that happened on 01/22/25 at 7:00 PM. LVN K stated she was told about the incident after it happened. LVN K stated she did the incident report on 01/23/25 after the DON D told her to complete it. LVN K stated the incident and accident report should have been completed in the EHR under the resident's name the same day of the incident before she left for the day. <BR/>An interview on 12/23/24 at 3:30 PM, the DON stated the nurse who is over the resident was responsible for doing the incident/accident report. The DON stated the incident and accident report should be completed immediately after the incident or before staff leaves for the day. DON stated Resident could have delay treatment if there were injuries and/or abuse. DON stated no specific policy on documentation of incident reports in residents 'medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to be from abuse for 1 of 4 residents (Residents #1) reviewed for abuse. <BR/>The facility failed to protect Residents #1 from a physical and verbal altercation on 01/22/25 with the Administrator. The Administrator pushed Resident#1, causing Resident#1 to fall. The incident was not reported or documented until after surveyor intervention on 01/23/25.The Administrator was not suspended until 01/23/25 at approximately 11:30 AM. <BR/>An IJ was identified on 01/23/25. The IJ template was provided to the facility on [DATE] at 5:15 PM. While the IJ was removed on 01/25/25, the facility remained out of compliance at a scope of Isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems .<BR/>This failure placed residents at risk of subsequent abuse, mental anguish, and emotional distress. <BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 01/23/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizophrenia (Serious mental health condition that affects how people think, feel and behave), Type 2 Diabetes Mellitus with Diabetic, Unspecified Psychosis not due to substance or known major depressive disorder.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 10/28/24, reflected Resident #1 had a BIMS of 12, which indicated cognition moderate impaired. <BR/>Record review of Resident #1's care plan, revised 09/20/24, revealed the resident at risk for altered status due to a traumatic life experience while at a previous group home or [Nursing Facility]. Certain male figures in authority positions, with similar physical attributes or appearance at times trigger him. Interventions in place included: Administer medication as ordered, approach resident from the front and speak in a calm, unhurried manner .Identify cause/trigger for behavior and reduce factors that may provoke resident .Call [Family Member#1] if need to calm down or get him to comprehend the situation]<BR/> .<BR/>Record review of Record review of Psychological Services Progress Note, dated 10/08/24and completed by Psy services reflected, Resident#1 was negative for Trauma Informed Care. <BR/>Record review revealed no incident/accident report was completed about the incident on 01/22/25.<BR/>Record review of Resident#1 progress noted dated, 11/01/23 to 01/22/25 reflected: Resident#1 had other incidents with other staff but not the Administrator. <BR/>Record review of Resident#1 progress notes revealed no documentation about the incident on 01/22/25.<BR/>Record review of Resident#1 assessments revealed no documentation about incident on 01/22/25.<BR/>Record review of Resident#1 incident provided to surveyor on 01/25/25 reflected: it was initiated on 01/22/25 with no completed/ locked date on the incident report. Incident description section reflected: This [LVN K] was notified by staff after the incident that [Resident#1] slapped [MA N] and physically attacked Administrator and [Resident#1] fell to the floor. Resident description reflected: [Resident#1] stated he was approached by Administrator, in what he felt was an aggressive manner so I just swung on his . Immediate action taken section reflected: [Resident#1] assessed for injuries. None noted, denied pain or any discomfort. Physician notified, In the agencies/people notified section reflected: no notification found,<BR/>An interview on 01/23/25 at 10:20 AM Family Member#1 approached surveyor at the facility and stated the Administrator fought [Resident#1] last night. Family Member#1 stated that was wrong and he is elderly. Family Member#1 stated the Administrator was always picking on him when Resident#1 wanted to play his piano. Resident#1 did not speak to the Administrator when the Administrator would try to speak to him <BR/>An in-person interview on 01/23/25 at 10:45 AM, the Administrator and MA N entered the conference room to explain the incident on 01/22/25. The administrator stated Resident#1 assaulted a medication aide around 7pm on 01/22/25. The Administrator stated the medication aide and himself went to Resident#1s room. Resident#1 was asked why he hit the medication aide. The Administrator stated Resident#1 started punching and kicking the Administrator and made threats. The Administrator stated he put his hands up to protect himself. The Administrator stated Resident#1 tripped over his own leg and fell. The Administrator stated [CNA J], [CNA L] and [LVN P] intervened and pulled Resident#1 away. The Administrator stated he was told by Resident#1 and Family member that he reminded Resident#1 of males from his past that made fun of him and were aggressive towards him because he was gay. The Administrator stated it did not have to be reported because it was an altercation between staff and a resident.<BR/>An interview on 01/23/25 at 10:45 AM, MA N stated Resident#1 took snacks off the snack tray and hit MA N's face when she asked him what he was doing. MA N immediately reported to the Administrator who went to Resident#1 to ask what happened and Resident#1 hit the Administrator. <BR/>An interview on 01/23/25 at 11:00 AM, the DON stated she was not made aware of the incident until after 10:15 AM on 01/23/25 when Resident#1 family member came into her office. The DON immediately called her nurse consultant and informed her of the situation. <BR/>An interview and observation on 01/23/25 at 11:05 AM of the camera in the Administrator office with the PD revealed, Resident was punching and kicking the Administrator. The Administrator open hand pushed Resident#1 face area and caused Resident#1 to fall. Observed a linen cart pushed between the Administrator and Resident#1. Observation of additional staff stepped in between Resident#1 and Administrator. Staff were observed holding the Administrator back and grabbing Resident#1. PD stated an incident would be put on file but no arrest or charges because the resident started the altercation. Surveyor did not recall observing a date and time on the footage. <BR/>An interview on 01/23/25 at 11:30 AM, Ombudsmen stated she had not been notified about the physical altercation between the Administrator and Resident#1.<BR/>An over the phone interview on 01/23/25 at 1:30 PM the Corporate Operations Manager and Nurse Consultant stated they were not made aware of the abuse allegation until 1/23/25 at approximately 10:30 AM. The Administrator (Abuse coordinator) was asked to go home until the investigation was completed. Both stated it did not have to be reported to State since there was not an allegation of abuse at the time of the incident. Operations Manager stated that is the company policy for all that when an investigation of abuse had been reported the staff member would be suspended until the investigation was completed. Corporate Operations Manager and Nurse Consultant both stated the Administrator was suspended until the investigation was completed. Both stated there was no risk to residents, as soon as they found out about the incident the facility took immediate action. <BR/>An interview with Resident#1 on 01/23/25 at 2:15 PM he stated he would not feel safe in the facility if the Administrator returned. Resident#1 stated the Administrator hit him and he hit him back.<BR/>An interview on 01/23/25 at 4:11PM CNA J stated it was chaos in the hallway and he did not see how the incident started. CNA J stated he saw Resident#1 kicking and hitting the Administrator. CNA J stated he tried to intervene but did not want to get hit by Resident#1 so, he pushed a linen cart between them. CNA J stated he did not see how the resident fell. CNA J stated he grabbed Resident#1 and took him outside to smoke. <BR/>An interview on 01/23/25 at 4:20 PM LVN P stated he witnessed Resident#1 swinging both of his arms towards the Administrator LVN P stated they separated Resident#1 and the Administrator. <BR/>An interview on 01/24/25 at 4:30 PM CNA L stated Resident#1 was kicking and hitting the Administrator in the hallway. CNA L stated he did not see how Resident#1 fell but, he jumped back up and continued to attack the Administrator. CNA L stated the Administrator and Resident#1 were separated. <BR/>An interview on 01/24/25 at 4:50 PM DON stated the Administrator who is the abuse coordinator is responsible for completing and reporting investigation to corporate and State office. DON stated while the Administrator was suspended, she would be responsible. <BR/>Record review of facility policy titled; Usual Occurrence Reporting revised 12/07 reflected: H. Other occurrences that interfere with facility operations band affect welfare, safety, or health of residents, employees or vistors.2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations.<BR/>Record review of facility policy titled; Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigating revised 09/22 reflected: <BR/>All reports of resident abuse . Are reported to local state and federal agencies add (current regulations) is thoroughly investigated by facility management . findings of all investigations are documented and reported . Policy interpretation and inflammation reporting allegations to the administrator and authorities upon receiving any allegations of abuse the administrator is responsible for determining what actions (if any) are needed for protection of residents . Investigation allegations 1. all allegations are thoroughly investigated the administrative initiates investigations any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete . 9. the investigator notifies the ombudsman that in abuse investigation is being conducted the ombudsman is invited to participate in the review process B. the ombudsman is notified of the result of the investigations as well as any corrective measures taken . follow up report #1 within 5 business days of the incident the administrator will provide a follow-up investigation report direct action number one all relevant professional and licensing boards are notified when an employee is found to have committed abuse #2 if the investigation reveals that the allegations of abuse are founded the employee is terminated #3 any allegations of its view in our files in the huge employees personal records along with any statement by the employee disputing the allegation if the employee chose make one .<BR/>The Director of Nursing was notified that an Immediate Jeopardy situation was identified and record review request of ANE policy due to the above failure and provided with the Immediate Jeopardy template on 1/23/25 at 5:15 PM. A Plan of Removal was requested.<BR/>The facility's Plan of Removal was accepted on 1/24/2025 at 1:50 PM and included: <BR/>Plan of Removal:<BR/>1. <BR/>Immediate action(s) taken for the resident(s) found to have been affected include:<BR/>Resident # 1 was assessed by the Nurse on 1/22/25 . A thorough investigation was initiated by the Corporate Office and Director of Nursing Services.<BR/>The Medical Director was notified by the DON at 3:33pm and The DON called and left a message for the Ombudsman 1/23/25, at 5:30PM. The RP was notified on 1/22/25 by the Administrator. The accused Team Member was placed on Administrative Leave pending investigation. The Police Department was called and arrived at the facility. The Incident Report was completed on 1/23/25. The SIMS was initiated on 1/23/25 at 2:30pm.<BR/>In-services have been done by the DON for: Completing Incident reports, Notifications to MD/Ombudsman, Reporting Abuse/Neglect, Abuse Policy including timeline for reporting and What to do When a Team Member is accused (investigation requires for Team Member to be placed on Administrative Leave until the investigation is concluded). De-escalation of aggressive behaviors and resident to staff altercations. <BR/>The Post Test will be administered by the DON/designee after education is completed. Staff are required to pass at least 80%. Staff who do not achieve 80% passing rate will be re-educated and will retake the test.<BR/>TEXAS Abuse hotline number, [PHONE NUMBER] posted in strategic areas within the facility, staff made aware of postings.<BR/>2. <BR/>Identification of other residents having the potential to be affected was accomplished by:<BR/>The facility has determined that all residents have the potential to be affected. Supervisor Rounds have been started and will be completed by 1/24/25 to interview residents for issues related to care, respect and dignity. The rounding will be done by the Supervisors and the monitoring will be completed on the Supervisor Daily Rounds form.<BR/>3. <BR/>Actions taken/systems put into place to reduce the risk of future occurrence include:<BR/>An in-service education program was conducted by the Director of Nursing Services and the Assistant Director of Nursing with all staff addressing circumstances that require reporting including appropriate timeframes, reporting to the Corporate Office, reporting to the Ombudsman, timely completion of Incident Reports and SIMS reports and policy regarding Team Member involvement will be completed by 1/24/25. <BR/>The Corporate Nurse Team will conduct a Zoom meeting at 10 am on 1/24/25 with [Facility] Director of Nursing. The purpose of the in-service is to provide education for the following areas:<BR/>Our Abuse/Neglect Policy as it relates to Reporting Timelines to Corporate/State/Law Enforcement/Ombudsman/Medical Director<BR/>Steps to take when a Team Member is involved or is allegedly involved-Contact Corporate HR and place on Administrative Leave pending investigation of Abuse.<BR/>Conducting Education and Training with all Departments<BR/>Follow up and Monitoring that is required such as Rounding on Halls, Talking with Residents and Staff, Re-education with Staff to help Ensure There is No Breakdown in Communication<BR/>Five day follow up with the State Office<BR/>4. <BR/>How the corrective action(s) will be monitored to ensure the practice will not reoccur:<BR/>The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any incidents or injuries are identified, properly investigated and reported to the appropriate entities. <BR/>Findings of this audit will be reviewed in the Resident Council meetings.<BR/>This plan of correction will be monitored at the monthly Quality Assurance meeting until such time the IDT determines consistent substantial compliance has been met. <BR/>On 1/25/25 beginning at 3:00 PM the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of pre/posttest had been completed by1st, 2nd and 3rd shift nursing staff on ANE. <BR/>Record review of Director of Nursing in-services by the Nurse on ANE <BR/>Record review of the Administrator profile reflected, the Administrator was hired on 11/27/23 and terminated on 01/24/25.<BR/>An observation of the facility on 01/25/25 at 2:00 PM revealed 1-800 HHSC hotline number for abuse was posted at the entry of the facility, social workers door, display board in hallway and employees break room. <BR/>All staff were able to provide competency regarding in-service over ANE. All staff were able to provide policy, procedure, protocols, appropriate interventions, and when and who to report abuse to. All staff were to provide an example of ANE. <BR/>Staff interviewed on 01/24/25 between 9:00 AM to 2:00 PM CNA A, CNA B, LVN C (overnight shift) and CNA G, CNA H, LVN I (1st shift) and CNA J, CNA L LVN K, RN O, LVN P (2nd shift).<BR/>Staff interviewed on 01/25/25 3:40 AM to 3:00 PM: CNA D, CNA E, LVN F, RN N (Weekend shift) and laundry aide M.<BR/>An interview on 01/25/25 at 3:45PM the Director of Nursing stated she was in-serviced by the Corporate Nurse on 01/24/25 at 10:00 AM. The Director of Nursing stated she is currently the abuse coordinator. The Director of Nursing stated staff have been in-service and pre/posttest have been completed. <BR/>The Director of Nursing was informed the Immediate Jeopardy was removed on 01/25/25 at 3:00 PM the facility remained out of compliance at a scope of potential of minimum harm and a severity level of isolated, due to the facility's need to evaluation the effectiveness of the corrective systems. <BR/>An interview on 02/12/25 at 9:30 AM, Resident#1 stated that he was doing good and did not have any concerns and wanted to stay at the facility.<BR/>An over the phone interview on 02/12/24 at 9:52 AM Family member stated she was going by what [Resident#1] told her (Previous admin would tell him to stop playing his piano and pick on him that way.). Family member stated the previous Administrator [Current facility] favored someone from [Resident#1] past, but the sister did not know exactly who and people in general would make fun of [Resident#1] because he was gay. Family member stated he was previously, in a group home and wanted to stay there but, he could not care for himself. Since, previous admin is gone there has not been any more issues. Family Member stated he came from a group home, and he was happy there and did not want to leave. <BR/>Attempted to call PCP on 02/13/24 at 9:27 AM<BR/>Attempted to call Psy services on 02/13/24 at 9:52 AM<BR/>An observation and interview on 02/13/25 at 11:30 AM Resident#1 stated [Name] the Administrator hit him last week and he did not know why. Surveyor asked Resident#1 if he knew the previous Administrator name at the current facility that he stayed at and he said that was [Name] Resident#1 stated he felt safe and did not have any concerns.<BR/>Record review of Psy Subsequent assessment dated [DATE] and completed by Psy services reflected, <BR/>The provider asked the patient to tell him what transpired since the last few days. The patient replied nothing happened. The provider reframed the question and asked the patient if he had any altercation with anyone in the facility a few days ago. He replied someone pushed me. The provider asked the patient how the incident happened or what prompted the altercation. He replied, I do not know . <BR/>Record review of Psychological Services Progress notes dated ,01/30/25 on Resident#1 completed by Psy services reflected, Resident#1 was negative for Trauma Informed Care.<BR/>The Director of Nursing was informed the Immediate Jeopardy was removed on 01/25/25. The facility remained out of compliance at a scope of actual harm and a severity level of isolated, due to the facility's need to evaluation the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to immediately report failed to report abuse, neglect, exploitation, or critical incidents for 1 of 4 resident (Resident #1) reviewed for reporting.<BR/>The facility failed to report an incident of resident to staff physical aggression/assault to HHSC.<BR/>This failure could place residents at risk for abuse, neglect and incidents.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 01/23/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizophrenia (serious mental condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) Type 2 Diabetes Mellitus with Diabetic, Unspecified Psychosis not due to substance or known major depressive disorder.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 10/28/24, reflected Resident #1 had a BIMS of 12, which indicated cognition moderate impaired. <BR/>Record review of Resident #1's care plan, revised 09/20/24, revealed the resident at risk for altered status due to a traumatic life experience while at a previous group home or [Nursing Facility]. Certain male figures in authority positions, with similar physical attributes or appearance at times trigger him. Interventions in place included: Administer medication as ordered, approach resident from the front and speak in a calm, unhurried manner .Identify cause/trigger for behavior and reduce factors that may provoke resident .Call [Family Member#1] if need to calm down or get him to comprehend the situation]<BR/> .<BR/>Record review revealed no incident/accident report was completed about Resident#1 incident on 01/22/25.<BR/>Record review of Resident#1 progress notes revealed no documentation about the incident on 01/22/25.<BR/>Record review of Texas Unified Licensing Information Portal on 01/23/25 at 12:00 PM reflected, the verbal and physical altercation between Resident#1 and Administrator was not uploaded.<BR/>Record review of Resident#1 incident provided to surveyor on 01/25/25 reflected: it was initiated on 01/22/25 with no completed/ locked date on the incident report. Incident description section reflected: This [LVN K] was notified by staff after the incident that [Resident#1] slapped [MA N] and physically attacked Administrator and [Resident#1] fell to the floor. Resident description reflected: [Resident#1] stated he was approached by Administrator, in what he felt was an aggressive manner so I just swung on his . Immediate action taken section reflected: [Resident#1] assessed for injuries. None noted, denied pain or any discomfort. Physician notified, In the agencies/people notified section reflected: no notification found,<BR/>In an interview on at DON stated she did not find out about the incident until Resident#1 family member came into her office on 01/23/25 at 10:00 AM and stated the Administrator hit Resident#1. DON stated she called the Nurse Consultant to be advised on what to do. <BR/>An interview over the phone on 01/23/25 at 1:30 PM, Nurse Consultant and Operation Manager stated they were not made aware of the incident between Resident#1 and the Administrator until 10:30 AM by the DON. <BR/>An interview on 01/23/25 at 1:15 PM DON stated that she does not do the incident and reports, upload the information in Tulip or contact HHSC. DON stated the Administrator was responsible for doing the incident and accident reports. DON stated no incident or accident report for the incident on 01/22/25 between Resident#1 and the Administrator had been completed. DON stated by this information not do not know what interventions need to be put in place to prevent further abuse. <BR/>An over the phone interview on 01/23/35 at 1:30 PM Nurse Consultant E and Operation Manager stated the Administrator had been suspended pending the investigation. Nurse Consultant stated she will work and trained the DON on how to do the incident reports. <BR/>An observation on 01/23/25 at 7am revealed the Administrator was in the building at 7AM and did not leave the building until 12:00 PM. <BR/>Record review of Administrator profile reflected: Administrator was hired on 11/27/23 and terminated on 01/24/25. <BR/>Record review of the facility policy titled Unusual Occurrence Reports revised 12/07, reflected: Other occurrences that interfere with facility operations and affects the welfare, safety, or health of residents, employees .2. Unusual occurrences shall reported via telephone to appropriate agencies as required by current law and/ or regulations within twenty-four (24) hours of such incidents or as otherwise required by federal and state regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan 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 for one of 5 residents (Resident #2) reviewed for comprehensive resident centered care plans. <BR/>The facility failed to ensure the comprehensive resident centered care plan for Resident #2 was implemented by not putting a fall mat in Resident #2's room. <BR/>This failure could place residents, that are at risk for falls, to be injured by not putting interventions listed in resident's care plan. <BR/>Findings include:<BR/>Record review of Resident's #2s Face Sheet dated 3-5-2024 indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had a primary diagnosis of Hemiplegia (paralysis) and Hemiparesis (loss of strength in limbs) following a cerebrovascular disease (condition affecting blood flow to the brain) affecting the right dominant side, unspecified visual loss, seizures, and dysarthria (difficult or unclear articulation of speech) following cerebral infarction (stroke). <BR/>Record Review of Resident #2's medical record, in Resident #2's MDS, dated [DATE], indicated a Brief Interview Mental Status (BIMS) Score of 10, indicating moderate mental impairment. <BR/>Record Review of Resident #2s Care Plan, dated 2-26-2024, revealed Resident #2 was at risk for falls and at risk for injury due to having a seizure disorder. The care plan stated Resident #2 had a fall on 2-26-2024. Resident #2s care plan revealed that Resident #2 have a fall mat, in his room, while in bed. Record Review of Nursing notes for Resident #2, dated 2-24-2024 thru 3-5-2024, indicated Resident#2 was not offered a fall mat before 3-5-2024. <BR/>In an observation/interview, on 3-5-2024 at 2:20 PM, Resident #2 was observed to be lying on his bed. Resident #2 was observed to be a right leg amputee above the knee. Resident #2 stated he had poor vison and had never been offered a fall mat nor has he ever had a fall mat in his room. <BR/>In an interview on 3-9-2024, with LVN-A, at 1:00 PM, who was the charge nurse for Resident#2s hall, revealed she did not know why Resident #2 did not have a fall mat.<BR/>In an interview with the DON on 3-9-2024, at 3:4 PM, revealed her expectation was for Resident #2 to have what his care plan called for. The DON stated if Resident #2's care plan indicated he should have a fall mat, while in bed, then she expected Resident #2 to have had it in place. The DON did not know why Resident #2 did not have a fall mat in his room. <BR/>In an interview with the Administrator, on 3-9-2024, at 4:10 PM, revealed that he had high expectations that care plans be followed by staff and that the DON is ultimately responsible that care plans are implemented. <BR/>Record Review of the facility's care plan policy dated 12-2016, revealed:<BR/>A comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .#8 the comprehensive, person-centered care plan will (b) describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to develop, prepare, and periodically update menu items to meet residents needs and preferences. The facility failed to utilize and follow dietitian approved recipes for pureed food items.The facility failed to prepare an alternate menu in advance. The facility failed to ensure alternate menus were reviewed and approved to ensure it met the residents nutritional needs by the facility's dietitian.The facility failed to make reasonable efforts to develop a menu based on resident complaints about the lack of variety in food options. These failures could result in an adverse effect to resident's physical and psychosocial well-being.Findings included: During an observation on 07/29/2025 at 9:30AM, this surveyor asked the dietary assistant for a regular and alternate menu for the next 3 days. The dietary assistant was able to provide a regular menu of the meal being served that day, but not an alternate menu. She explained the alternate menu item was chosen the day of and there was not an official alternate menu. An interview on 07/29/25 at 11:58 AM with Resident #41 revealed he thought the food sucked. He said they had chicken 4-5 times a week, and it was overkill on the chicken. He said he had things listed on his slip that he could not eat, and they continually brought them to him. He said sandwiches were always their go-to alternative; if you were allergic, or did not like the main meal, you were stuck with a sandwich. He said the sandwiches were not good, either. He said their grilled cheese sandwich was so dry it was hard. He said when the residents made suggestions, the dietary staff would tell them there were set guidelines about what they could serve and they could not change it. He said they served terrible chicken patties often, and one time they had a different kind that was really good, and they never saw it again after the single time they served it. An observation on 07/30/2025 at 12:27PM revealed [NAME] F preparing pureed shrimp. [NAME] F added bread slices as thickener. [NAME] F asked the dietary assistant to get hot water to add into the pureed shrimp. At that time, this surveyor intervened before hot water was added in as the liquid ingredient. [NAME] F revealed that she was told to use bread slices as thickener and water for the liquid consistency. She stated she had seen broth and food thickener used in other kitchens outside of the facility, but that she had been doing what she was told to, and that the facility did not have food thickener or broth. When asked what the recipe instructs, the cook discussed that she used her knowledge when determining pureed food consistency. [NAME] F proceeded to pour the pureed shrimp onto pre-divided plates. When asked why she didn't use a scoop, she stated doesn't use a scoop to fill a portion of the plate. She said she was told to fill a portion of the plate with the pureed food. At that time, the dietary assistant asked if milk was acceptable to use in place of the water. This surveyor responded by asking what the recipe for pureed shrimp instructed, the dietary assistant looked for the pureed shrimp recipe in the kitchen's recipe book and was not able to provide one. The dietary assistant and [NAME] F decided to use the liquid the cooked shrimp were in. An interview on 07/29/25 at 12:57 PM with Resident #11 revealed he was unhappy with the food in the facility. He said he had not eaten pork since he was very small (young), but the facility kept serving him pork. He said some days the lunch meal, and the dinner meal would be pork, and if the alternate was also something he did not eat, they would give him a sandwich. He said he had lost weight in the facility because the food was so bad. He said pork was listed on his meal ticket as a dislike and they were not supposed to bring it to him, but they had it on the menu all the time, and they brought it to him a lot. He said he knew of a few other residents who did not eat pork in the facility, and they also continued to be served pork. He said they also just made-up names for things that did not describe what the food was. He said they served something they called turkey tetrazzini, but it was just a pasta dish with hot dogs cut up in it, and it was disgusting. An interview on 07/31/2025 at 12:42PM with Resident #80 revealed that she had resided at the facility for a few years and had issues with meal variety. Resident #80 stated that she sometimes received food items that she does not want. She explained that CNAs inform her of the alternative menu item of the day about an hour before the meal being served, and residents could only choose the regular or alternative menu item for each meal. She stated she wished she knew of the alternative options sooner than an hour before the meal was served. She further discussed sometimes they (the kitchen) don't have enough of what residents want, the menus need more variety, and the menus were too repetitive. When asked what alternative options were, she stated it may be a sandwich and chips or soup, it maybe last nights dinner as next day alternative meal item. As an example, the resident stated Salisbury steak will be given for lunch as the regular menu item and then as the alternate menu option the same day. Resident #80 said there was a lot of repetition of same old food items. She explained the turkey tetrazzini was on the regular menu item and had been used over the previous years and it was an item she did not enjoy. Resident #80 stated she had expressed these issues with the food service manager, but had been told someone else makes the menu, not the dietary staff. She stated the food service manager does not follow up with the resident regarding her concerns. During an interview on 8/01/2025 at 9:19AM with facility's registered dietitian, she explained that cycle menus (menu changes every day but eventually repeats itself in the same order) were utilized at the facility and she signs off on recipes and menus that come from a food vendor. If there was an issue, a substitution would be made to the menu, and she would approve of it. She further discussed the alternate menu option was chosen the day of, and that had always been done the day of. She stated that an official alternate menu would be beneficial for the dietary staff. The registered dietitian stated she did not sign off on the alternate menu items. She stated anything on the regular menu was okay, the alternates typically a balanced meal. When asked if a deli sandwich with chips was a balanced alternate meal, she stated residents should get a salad or vegetable and would offer fruit with it. When asked if the regular menu item for lunch was acceptable for the dinner's alternate menu item, she stated that the dietary staff try to do different meats for regular and alternate menus. The registered dietitian explained the dietary staff had pureed recipes from the vendor. She further discussed bread was being used as thickener and milk was typically used as the liquid for the pureed foods, to add calories. She expected staff to not pour pureed foods onto plates and use scoops to have correct portion size. During an interview with the food service manager on 08/01/2025 at 10:55AM, she stated that alternate menus were not planned ahead of time. Dietary staff plan the alternate menu the day of, and sandwiches or leftovers were the alternate most of the time. She further explained leftovers would be the alternate for the next day or next evening depending on what the kitchen had in stock. The food service manager stated she normally did not serve the same meats for the regular and alternate menu items, if pork was on the regular menu, she would try to serve beef or chicken as the alternate option. She said she had told her staff to do that during in-services. The food service manager stated residents occasionally complained of meals being repetitive and if residents continue to complain about a specific meal, they dietary staff try to address the complaints by doing an alternate for that meal. The food service manager stated the alternate menu was something she needed to work on. She explained that in the past, she had hot dogs and burgers as an alternate all the time, but the residents were wanting the alternate instead of the regular menu item. The food service manager did not find it to be a concern that the residents preferred the hot dogs and hamburgers over the regular menu items. The food service manager said she expected staff to use scoops when serving food items and did not know why a scoop was not used for pureed food items. She expected staff to utilize recipes that had been signed off by the dietitian and can be found in the recipe book in the kitchen. She stated there were recipes for pureed foods. The food service manager stated she would put milk in pureed food instead of hot water, and broth could be an option. She stated that using recipes make the cooking process easier. Record review of the facility's regular menu Sysco Acadiana 2025 Spring Summer Menus revealed the menus were approved by the facility's registered dietitian. The menus were shown to have a start date of April 6 and end date of October 25 (29 weeks), and to be cycled every 4 weeks. Week 1's menu was shown to be repetitively used for 8 weeks, Week 2's, 3's, and 4's menu were shown to be repetitively used for 7 weeks each. The breakfast menu item for every day of every week reflected: Egg Choice, Juice, Cereal of Choice, Breakfast Meat of Choice, Breakfast Bread, Coffee, Milk/Water. Record review of the facility's Menus policy revised October 2017 reflected: Policy - Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy.Policy and Interpretation and Implementation1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences).2. Menus for regular and therapeutic diets are written at least two (2) weeks in advance and are dated and posted in the kitchen at least one (1) week in advance.3. Menu items and available snacks reflect the religious, cultural and ethnic preferences of the residents, whenever reasonable.4. The Dietitian reviews and approves all menus.5. Input from the resident is considered in menu planning.8. Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal.9. If a food group is missing from a resident's daily diet (e.g., dairy products), the resident is provided an alternate means of meeting his or her nutritional needs (e.g., calcium supplementation or fortified non-dairy alternatives). 10. Menus are updated periodically.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food and nutrition services.<BR/>The facility failed to ensure food items were kept away from potential airborne contaminants (leaking sinks, dust particle and grease). <BR/>This failure could place residents at risk for food contamination and foodborne illness.<BR/>Findings included:<BR/>Observation on 04/08/25 at 8:00 AM, revealed behind the air fryer area had white and brown grease on the wall. Observation of the floor revealed brown grease behind the equipment that ran from the air fryer to the stove. <BR/>Observation on 04/08/25 at 8:30 AM, revealed one white towel that had turned brown was wrapped around a pipe. Under the towel was a hole that the piping did not fit into, and water was running to the hole. <BR/>Observation on 04/08/25 at 8:35 AM, revealed another white towel that had turned brown underneath the pots and pans sink. <BR/>Interview on 04/08/25 at 9:00 AM, CK stated the pipes had been leaking for a while and maintence worked with a plumber who put that extra pipe in for the water to flow but, the pipe was the wrong size and does not cover that hole. The towel was wrapped around the pipe to stop the water from splashing everywhere. The CK stated the pots and pans sink had a leak and <BR/>Interview on 04/08/25 at 9:30 AM, DM stated she was not exactly sure how long the pipes had been leaking. The DM stated the MD had work with a plumber and they keep saying they will be out to the facility every week and have not shown up again. The DM stated all staff are responsible for keeping the kitchen clean. The DM stated she writes down in her planner who cleaned what equipment in the kitchen. The DM said she does not think residents are at risk for cross contamination because their food are not near the sinks or air fryer.<BR/>On 04/08/25 at 9:40 AM, this Surveyor requested from the DM the cleaning schedule, and photocopy of planner on which staff completed kitchen -up. Surveyor did not receive documentation before exiting. <BR/>Interview on 04/08/25 at 9:58 AM, the MD stated he had worked with a plumber who gave an estimate of $50,000 to complete the necessary work for the kitchen. The MD stated the plumber that he is currently working with had cut the cost to more than half of the original estimate. The MD stated the plumbers' teams had to push back the work for the facility for another job. The MD stated the facility is working on getting the plumbing fixed in the kitchen. <BR/>Attempted to interview plumber on 04/09/25 at 9:00 AM, he stated to contact the MD at the facility, and he will be able to go over the details of the repair. <BR/>Record review of facility policy, undated, Sanitization reflected the food service area shall be maintained in a clean and sanitary manner. 1. All kitchen, kitchen areas and dining area shall be kept clean, free from litter and rubbish . 17. The food service manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work area during all tasks, and to clean after each task before proceeding to the next assignment. <BR/>Record review of plumber estimate sheet reflected plumber did an investigation of the kitchen on 01/20/25. Investigation reflected the sewer in kitchen floods the floor when 3 compartment sink is drained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview 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 one of ten residents (Residents #19) reviewed for infection control.<BR/>1. The facility failed to ensure MA A performed hand hygiene and wore gloves when administering eye medication to Resident #19.<BR/>2. The facility failed to ensure MA A did not use his bare finger to remove Coreg 6.25 MG tablet out of Resident #19's. <BR/>medication cup before administering her medications.<BR/>These failures could place residents at risk of infectious diseases and cross contamination.<BR/>Findings include:<BR/>1. Record review of Resident #19's face sheet, dated 06/25/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included generalized anxiety disorder a condition of severe, ongoing anxiety that interferes with daily activities, breast cancer, depression, low vision in right eye, high blood pressure, high cholesterol, and a fracture of the lower legs. Resident #19 was her own responsible party.<BR/>Record review of Resident #19's quarterly MDS, dated [DATE], reflected Resident #19 had a BIMS of 15 out of 15, which indicated she was cognitively intact. Resident #19 could understand others and others could understand her. <BR/>Record review of Resident #19's order summary, dated 06/24/24, reflected:<BR/>1.Coreg Oral Tablet 6.25 MG (Carvedilol). Give 1 tablet by mouth two times a day related to essential (primary) hypertension.<BR/>2. Artificial Tears Ophthalmic Solution (Artificial Tear Solution) Instill 2 drop in both eyes two times a day for dry eyes.<BR/>During medication observation and interview with MA A on 06/24/24 at 08:19 AM, revealed MA A performed hand hygiene with hand sanitizer, he dispensed six medications in a medication cup for Resident #19. Then he stated he needed to check Resident #19 BP and he took the medication cup and locked it in the med cart. He took the BP cuff and went into Resident #19's room to check her BP. The reading was 105/72 with a pulse rate of 69 BPM. He returned to med cart, placed the soiled BP cuff on top of med cart. He got the keys out of his pocket and unlocked the med cart. No hand hygiene was performed after checking the BP. He picked up the medication cup and retrieved the Artificial Tears Ophthalmic Solution medication box for Resident #19. He placed both items on top of med cart. With no hand hygiene performed and no gloves on his right hand, MA A reached into Resident #19's medication cup, and he took the Coreg 6.25 MG tablet out of the medication cup with his pointer finger. He placed the pill in the sharps, and he stated he would notify the nurse for holding the BP medication due to the vital sign reading. No hand hygiene was performed after touching the pill with his bare hand. MA A picked up the eye drops, medication cup and a soft tissue paper and went into Resident #19's room. He handed Resident #19 her pills and she took them. He then put two eye drops in each eye and wiped the excess with the soft tissue then he handed Resident #19 the soft paper tissue to wipe herself. He went back to the med cart, took keys out of his pocket, and unlocked the med cart and placed the eye drops back inside the med cart. MA A performed hand hygiene and he pushed the med cart to the next room. MA A stated he performed hand hygiene, and it was missed by the observer. He stated he was not aware he could not touch the pill with his bare finger. He stated he forgot to wear gloves when administering the eye drops to Resident #19. He stated the risk to the resident was to spread infection. <BR/>In an interview with the DON on 06/25/24 at 04:58 PM, she stated MA A should have used a spoon or gloved hand to remove the pill from Resident #19's cup. She stated she expected all staff to perform hand hygiene before and after medication administration. She stated she expected staff to wear gloves when administering eye drops to residents. <BR/>In an interview with the ADM on 06/25/24 at 06:05 PM, he stated he expected all staff to follow the facility policies of hand hygiene when administering medication and before and after resident care.<BR/>Record review of the facility's Administering Medications, revision date April 2019, read in part, .24. Staff should follow established facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precautions, etc.) for administration of medication as applicable. <BR/>Record review of the facility's policy titled Standard Precautions, revision date October 2028, read in part .the facility's infection control policies and practices are intended to facilitate maintaining a safe, a sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections . Policy Interpretation and Implementation . 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities

Based on observation, interview, and record review, the facility failed to maintain safe and functional essential kitchen equipment in the facility's only kitchen. The facility failed to ensure the gas stove top oven had all turn knobs, did not leak grease, and was safe to touch when operating.The facility failed to assure the wall plug sockets were free of food and grease particles, and in safe operating condition. The facility failed to ensure the toaster oven was in safe operating condition. These failures could place residents at a risk for facility essential equipment not being maintained in working order. Findings included: An observation on 07/29/2025 at 8:52AM of the gas stove top oven revealed a small pile of white cloth towels with grease on them under the left front corner of the oven.An observation on 07/30/2025 beginning at 11:50AM of the facility's kitchen revealed:- A toaster over with electrical tape around its power cord- 2 wall sockets with black burn-like appearance- 2 wall sockets covered with food particles and grease- Food particles and grease build up on the wall behind the 3-compartment sink - Power strip on the counter next to the 3-compartment sink, covered with food particles and grease- [NAME] grease like stains lining the top of the left oven door on the gas stove top oven.- 2 turn knobs missing from the stove topAt that time, an interview with [NAME] F revealed the toaster oven had electrical tape on the power cord since she began working at the facility 3 months ago. [NAME] F further discussed issues with the kitchen's stove top oven. She stated the oven had a problem with dripping grease and it had been like this since she began working at the facility. [NAME] F said the kitchen staff drain the grease from the grease tray after using the grill top on the stove, but it continued to leak. The towels were placed under the oven to catch the grease drips. She stated the turn knobs were hot to the touch and turn knob to turn on the oven does not have labeling to indicate the temperature the ovens turned onto. This surveyor touched the oven's turn knobs and was able to confirm the cook's concern of the hot turn knobs on the oven. During an interview on 07/30/2025 at 1:53PM with the dietary assistant she stated the kitchen staff had tried to have maintenance work on the oven due to the leaking grease and hot turn knobs. An interview on 07/31/2025 at 1:20PM with the maintenance director revealed that he had been planning to paint and repair imperfections in the kitchen. He further discussed that the gas stove top oven must be worked on by the vendor, and that it had been recalibrated earlier in the year. During an interview on 8/01/2025 at 9:19AM with facility's registered dietitian, she stated kitchen equipment like the steam tray table had to be fixed. The registered dietitian stated condition of the kitchen equipment matters because its good practice to have not well used equipment that's going to be serviceable. She further discussed that when the food service manager was at the facility, the kitchens operating, but it had been a challenge since the food service manager had been out. She explained the kitchen was old and the problems were ongoing. During an interview on 08/01/2025 at 10:55AM with the food service manager, she stated after discussing the oven issues with the maintenance manager, the vendor came and recalibrated the oven. She further discussed that she needed to order new turn knob, but she did not know why grease leaked from the oven. The food service manager stated she was not sure why electrical tape was on the toaster oven power cord because the toaster oven was purchased about a year ago. Record review of the U.S. FDA Food Code 2022 reflected: 4-1 Materials for Construction and Repair.4-101.11 Characteristics. Materials that are used in the construction of UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be: (A) Safe; (B) Durable, CORROSION-RESISTANT, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated WAREWASHING; (D) Finished to have a SMOOTH, EASILY CLEANABLE surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.4-2 Design and Construction 4-201 Durability and Strength 4-201.11 Equipment and Utensils. EQUIPMENT and UTENSILS shall be designed and constructed to be durable and to retain their characteristic qualities under normal use conditions. 4-201.12 Food Temperature Measuring Devices. FOOD TEMPERATURE MEASURING DEVICES may not have sensors or stems constructed of glass, except that thermometers with glass sensors or stems that are encased in a shatterproof coating such as candy thermometers may be used.4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation or mistreatment have evidence that all alleged violations were thoroughly investigated and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for two of eleven residents (Resident #1 and Resident #2) reviewed for abuse, neglect and exploitation. <BR/>1. <BR/>The facility failed to investigate an alleged violation when Resident #1 exhibited sexually inappropriate behaviors to prevent further abuse or neglect towards Resident #1 and others. <BR/>2. <BR/>The facility failed to investigate when Resident #2 obtained and used nonprescription drugs at the facility, was found exhibiting signs of an overdose, and was transported to the local hospital where he tested positive for marijuana .<BR/>This failure could place all residents at an increased risk for abuse and neglect.<BR/>Findings included: <BR/>1.<BR/>Record review of Resident #1's face sheet, dated 5/20/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: dementia (brain disorder that affects memory, thinking, and behavior), metabolic encephalopathy (brain disorder that causes confusion) COPD (lung disease), type II diabetes (inability to regulate blood sugar levels), chronic respiratory failure (lack of oxygen), end-stage renal failure (kidney disease), and hypertension (high blood pressure). <BR/>Record review of Resident #1's admission MDS assessment, dated 4/08/25, reflected his BIMS score was 10, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required partial to moderate assistance with most ADLs, used a walker, and was independent with most mobility tasks. The MDS Assessment under Section E-Behaviors, reflected Resident #1 did not have any physical or verbal behaviors. <BR/>Record review of Resident #1's care plan, revised 4/23/25, reflected the resident had a history of socially inappropriate behaviors: sexually inappropriate behavior. Interventions included: administering medication as ordered, eliciting family input for best approaches, praising the resident for demonstrating desired behavior, providing all care with another staff member, and removing the resident from public area when behavior was disruptive and/or unacceptable. Further review of this document reflected Resident #1 was not care planned for sexually inappropriate behaviors upon admission.<BR/>Record review of Resident #1's clinical notes, dated 3/21/25 and signed by the MD, from previous nursing facility reflected in part the following:<BR/>HPI: <BR/>LTC on therapy <BR/>Today: <BR/> . [Resident #1] has had multiple complaints and issues regarding inappropriate sexual behavior with staff and residents, He currently has a sitter, Psychiatry also following, Vitals stable. I believe patient is no longer safe to remain at the facility given sexual aggression towards other residents. I believe patient would be more appropriate to reside in a male only locked unit given behaviors.<BR/> .<BR/>Record review of Resident #1's progress note, dated 4/23/25 at 9:34 AM by the SSD, reflected the following:<BR/>[SSD] contacted [RP] to make her aware of [Resident #1's] behavior and what all took place during the activity with the high school students. [RP] shared that [Resident #1] had already told her he spanked a high [NAME] on the butt.<BR/>Record review of Resident #1's progress note, dated 4/23/25 at 9:53 AM by the DON, reflected the following:<BR/>[DON] was notified by [Activity Director] that [Resident #1] has inappropriately touched a student that was in facility for a activity. [Activity Director] stated that another student told him but didn't say who the student was. [DON] asked if police was made aware, was told that they have already gone, [DON] told director to notify abuse coordinator. Nursing placed [Resident #1] on Q15 min monitoring, until alternate placement can be made, immediate discharge to be given, MD made aware.<BR/>Record review of Resident #1's progress note, dated 4/23/25 at 10:12 AM by the SSD, reflected the following:<BR/>[Resident #1's] [RP] reached out and shared that she won't be able to properly care for [Resident #1]so she is not able to pick him up. [SSD] informed [RP] that she will be sending over clinical information to several nursing homes and facilities.<BR/>Record review of documents provided by the DON titled Resident 15 Minute Checks, dated 4/23/25-5/04/25, reflected Resident #1 remained on Q15 monitoring during this time. <BR/>Record review of documents provided by the DON titled [Nursing Facility] Resident Safe Survey Questionnaire for Staff, dated 4/23/25, reflected 30 residents were surveyed regarding abuse and neglected from staff with no concerns. Further review of this document reflected there were no questions directly regarding concerns for sexual abuse by staff or other residents. <BR/>Record review of Resident #1's active consolidated physician orders, dated 5/20/25, reflected in part the following:<BR/>-Estradiol Oral Tablet 2 mg; give 1 tablet by mouth one time a day for hypersexuality. Start Date: 5/15/25. <BR/>Further review of this document reflected Resident #1 did not have an order for psychological/psychiatric services.<BR/>Attempted interview on 5/16/25 at 10:30 AM with Resident #1 was unsuccessful due to the resident being away from the facility at the dialysis clinic. <BR/>In an interview on 5/16/25 at 12:35 PM with the DON and Administrator, the DON denied knowing Resident #1 had a history of exhibiting sexually inappropriate behaviors. The Administrator stated the facility did not have a policy that required the facility to check a resident's background or the sex offender registry prior to admission. The DON stated per regional managers, the facility did not discriminate against residents regarding criminal background. The Administrator and DON failed to mention Resident #1 was involved in an incident on 4/23/25 where he exhibited sexually inappropriate behavior by touching a student visitor during this interview. <BR/>In an interview on 5/16/25 at 1:35 PM, Resident #3 stated she felt uncomfortable around Resident #1, who she called a sex offender, because he always stared at her while making sexual gestures. Resident #3 stated a lot of female residents were uncomfortable around Resident #1 and it was reported to the Administrator and the DON, and they never did anything about it. Resident #3 stated students from the local high school used to visit and paint the female residents' fingernails; however, they stopped after Resident #1 touched one of the students inappropriately last month. She denied ever being touched by Resident #1. <BR/>In an interview on 5/16/25 at 2:15 PM, Resident #11 stated Resident #1 was creepy because he would come up to her room door and stick his tongue out, wink, and blow kisses at her. Resident #11 stated Resident #1 did that to a lot of other female residents, and they were all uncomfortable around him. Resident #11 stated she reported this to her nurse ; however, Resident #1's behavior did not stop. Resident #11 denied ever being touched by Resident #1 but stated he touched a student while they were visiting the facility to participate in activities with the residents. Resident #11 stated after the incident Resident #1 had 1 to 1 supervision and that stopped the behaviors, but he was not on it long. <BR/>In an interview on 5/16/25 at 4:20 PM with the Administrator and DON, the DON stated she was aware of Resident #1 touching a student visitor inappropriately. The DON stated she did not know the state surveyor was referring to that incident during the earlier interview. The DON stated the Activity Director reported to her the students were in the dining room areas doing an activity with the residents when one of the students ran out upset and another student reported she was touched inappropriately by Resident #1. The DON stated Resident #1 was placed on Q 15-minute supervision and issued an immediate discharge notice; however, they were unable to find placement and Resident #1's RP stated she could not care for the resident. The DON stated she was responsible for reviewing clinical notes before admitting a resident; however, she did not remember seeing in Resident #1's clinical notes that he had a history of exhibiting sexually inappropriate behaviors or that it was recommended he be placed on an all-male secured unit. The DON stated if she saw the recommendation, she probably would not have admitted Resident #1, or she would have put appropriate interventions in place. The DON stated the MD recently placed Resident #1 on medication for his hypersexual behaviors and he was care planned to have 2 staff when care was being provided. The Administrator stated he was aware of the incident and after reviewing the camera footage he was unable to determine exactly what happened due to a pole blocking the view. He stated he only saw the student jump back then get up and run from the area. The Administrator stated since he could not determine what happened from the footage, he did not proceed with a full investigation or report it to the state agency. The Administrator stated it was the facility's policy to investigate and report abuse and neglect; however, he did not think he needed to investigate or report the incident based on the information he had. He stated the risk of not investigating and reporting incidents of alleged abuse or neglect could place the residents at risk of being harmed. <BR/>In an interview on 5/16/25 at 4:40 PM, the Ombudsman stated she had an open case for Resident #1 regarding the resident being sexually inappropriate with a student who was visiting the facility. The Ombudsman stated Resident #1's RP called her because the facility was trying to discharge the resident to a group home which was inappropriate for his level of care. The Ombudsman stated the RP informed that Resident #1 was unaware of his actions and the consequences of it due to his dementia and did not feel it was right for him to be punished. The Ombudsman stated she never received a discharge notice Resident #1. She stated she visited the facility to investigate and felt the facility should have reported the incident to the state agency. The Ombudsman stated she reviewed Resident #1's clinical notes from the previous facility and found that it was recommended the resident be placed on a male secured unit. The Ombudsman stated Resident #1 should not have been admitted to the current nursing facility if they could not accommodate his care needs as they did not have a male secured unit. The Ombudsman expressed deep concerns that the incident was not reported, and the facility had considered discharging the resident to a group home. <BR/>In an interview on 5/20/25 at 1:25 PM, CNA C stated she worked with Resident #1 and he was always sexually inappropriate with staff. She stated Resident #1 would grab at her breast and thighs while she was showering him, and it made her very uncomfortable. CNA C stated she reported this to the DON, and she placed the resident on 2-person assist with care but there was not always an extra staff to help when needed. CNA C stated she was aware of the incident that happened on 4/23/25 when Resident #1 touched a student inappropriately. CNA C stated later that evening, a man who said he was the student's father came to the facility and asked to speak to someone about the incident. CNA C stated that made the staff concerned for the safety of everyone in the facility. CNA C stated it was reported to the Administrator and DON . <BR/>2.<BR/>Record review of Resident 2's face sheet, dated 5/16/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: COPD (lung disease), multiple sclerosis (nerve disorder), bipolar disorder (mood disorder), and legal blindness. <BR/>Record review of Resident #2's Quarterly Minimum Data Set (MDS) assessment, dated 5/02/25, reflected he had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #2 required partial to moderate assistance with most ADLs. The MDS Assessment under Section N-Medications, reflected Resident #2 was prescribed medication under the high-risk drug class that included an antidepressant, diuretic, and anticonvulsant. <BR/>Record review of Resident #2's care plan, dated 2/20/25, did not reflect a care plan for the resident's behavior related to substance abuse.<BR/>Record review of Resident #2's progress notes, dated 2/06/25 at 10:01 AM by the SSD reflected the following:<BR/>[Social Worker] reached out to [Resident #2's] Parole Officer to inform her that he is bringing drugs into the building to sell to other residents.<BR/>Record review of Resident #2's progress notes, dated 2/11/25 at 2:36 PM by the SSD reflected the following:<BR/>[Resident #2] 30 day discharge notice was issued and signed due to lack of facility compliance.<BR/>Record review of Resident #2's progress notes, dated 2/13/25 at 3:01 PM by the SSD reflected the following:<BR/>[SSD] spoke with [Resident #2's] [PO]. [PO] shared she would be help to his discharge process and help<BR/>him look for housing.<BR/>Record review of Resident #2's progress notes, dated 2/15/25 at 8:00 AM by LVN A reflected the following:<BR/>[LVN A] was notified by staff that [Resident #2] is not acting like himself. This nurse assessed [Resident #2] and observed resident with the following symptoms: Weakness abnormal from baseline with moments of limpness noted to both sides of body, pinpoint pupils, Confusion, difficulty talking and supporting self on the side of the bed. [Resident #2] asked by staff if he's taken any new medications or anything not prescribed by current MD, resident shook his head no. MD notified new order to send resident out to ER for further evaluation. This nurse attempted to contact RP and LVM [sic]. [Resident #2] transferred to [local hospital] MD aware.<BR/>Record review of Resident #2's hospital records, dated 2/15/25, reflected in part the following:<BR/>Today's Visit (continued) <BR/>Reason for Visit: Drug / Alcohol Assessment <BR/>Diagnosis: Bladder infection<BR/> .<BR/>Labs:<BR/>Marijuana (Cannabinoid)- Positive<BR/> .<BR/>Record review of Resident #2's progress notes, dated 2/17/25 at 9:57 AM by the SSD reflected the following:<BR/>[SSD] reached out to [Resident #2's] [PO] to inform her of his resent drug overdose hospital visit.<BR/>Record review of Resident #2's consolidated physician orders, dated 5/20/25, reflected in part the following:<BR/>-Gabapentin Capsule 300 mg-give 3 capsule by mouth three times a day for nerve pain give (3) 300 mg caps to equal 90 mg. Start date: 5/16/25.<BR/>-Hydrocodone-Acetaminophen Tablet 7.5-325 mg-give 1 tablet by mouth three times a day for pain. Start date: 5/15/25.<BR/>-Tylenol Oral Tablet 325 mg (Acetaminophen)-give 2 tablets by mouth three times a day for pain.<BR/>Further review of this document reflected Resident #2 did not have an order for medical marijuana. <BR/>Interview on 5/16/25 at 11:45 AM, Resident #10 stated he was the Resident Council President at the facility. He stated there was a lot of talk going around the facility about residents bringing in drugs to use and give to other residents. Resident #10 stated it was never said which resident was bringing drugs into the facility. Resident #10 stated he often smelled marijuana in the facility. He stated the Administrator and DON were aware of this problem.<BR/>In an interview on 5/16/25 at 12:35 PM with the Administrator and DON, they both stated being aware of concerns the residents were using drugs in the facility. The Administrator stated during a smoke break about a week ago there was a smell of marijuana, and he gave staff permission to stop the smoke break that day, and there had been other reports of marijuana being smelled . The Administrator stated he had never seen marijuana in the facility and the smell could be coming from anywhere in the area. The DON stated there was a day a package arrived at the facility for Resident #3 that had to be signed for, and Resident #3 admitted there was THC in the package, but it was for her family. The DON stated the package was not accepted at the facility and it was not opened to confirm if it was THC. The Administrator stated Resident #3 used a vape that she was very protective of and would become verbally aggressive towards staff when questioned about it. The Administrator stated he did not know what was in the vape and could not violate Resident #3's rights by searching her belongings . The Administrator and DON both stated they were not aware of any concerns for staff using or bringing illegal drugs into the facility. The Administrator stated all staff were drug tested upon hire. They stated if there were drugs in the facility, they were unsure how it was getting in. The Administrator stated they had several residents who went out into the community. The DON stated if residents showed any obvious s/sx of drug use they would be sent out to the hospital for a drug screening. The Administrator stated he did not initiate an investigation or report to the state agency when marijuana was smelled during the smoke break or when Resident #3 admitted to having THC delivered to the facility. He could not state why he did not investigate or report these incidents.<BR/>In an interview on 5/16/25 at 1:35 PM, Resident #3 stated she had concerns about residents using drugs in the facility that was being brought in by staff and other residents. She stated the Administrator and DON were aware and were not doing anything about it. Resident #3 stated she had a meeting with the Administrator, DON, and SSD on 5/12/25 where she expressed all her concerns, which included the drugs in the facility, and nothing had been done yet. She stated she had a package delivered to the facility that contained THC that she ordered from a local smoke shop, but it was not for her. Resident #3 stated she was going to visit family and was going to give it to them, but the facility did not allow her to get the package. She stated she knew it was wrong to have the package delivered to the facility, but they allowed everything else. She stated she would not order THC to the facility again. <BR/>In an interview on 5/16/25 at 2:15 PM, Resident #11 stated there was always the smell of marijuana in the facility and residents would do other drugs like methamphetamines. Resident #11 stated she could tell by the smell what type of drug was being used. Resident #11 stated it mostly happened during smoke breaks and sometimes in resident rooms, and she just tried to stay away from it. Resident #11 stated she reported her concerns to the DON; however, it was still going on. She stated the residents were supposed to be drug tested if they were suspected of using, but they would refuse, and the nurses would not force them to do it and would just let it go. <BR/>Further interview on 5/19/25 at 3:00 PM with the Administrator and DON, the DON stated she was aware of Resident #2 being sent out to the local hospital after showing signs of drug use and failing his drug screening. The DON stated the MD discontinued all of Resident #2's pain medication and put in a standing order to drug screen any resident who exhibited s/sx of drug use. The DON stated she did not drug test any residents the day it smelled like marijuana during the smoke break and could not state why. She also stated staff were not in-serviced on recognizing s/sx of drug use and reporting it after the incidents. The Administrator stated the facility was waiting on Resident #2's PO to find placement for him. He stated the PO informed he was either going to find another facility or Resident #2 would go back to jail. The Administrator stated the facility was waiting on the PO to find something since the incident happened on 2/15/25. The Administrator stated not addressing the concerns for drug use at the facility or implementing effective interventions could place residents at risk of being able to obtain and use drugs at the facility that could cause serious harm .<BR/>Record review of the facility's policy titled Abuse Prevention Program, revised January 2011, reflected in part the following:<BR/>Policy Statement:<BR/>Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. <BR/> .15. Investigate and report any allegations of abuse within timeframes as required by federal requirements <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status for 2 of 7 residents (Resident #1 and Resident #5) reviewed for Accuracy of Assessments.<BR/>1. <BR/>Resident #1's discharge MDS assessment dated [DATE] did not accurately reflect his current and MD order for Hemodialysis treatment in Section O.<BR/>2. <BR/>Resident #5's quarterly MDS assessment dated [DATE] did not accurately reflect his current MD order for continuous oxygen treatment in Section O.<BR/>These failures could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. <BR/>Findings included:<BR/>Resident #1<BR/>Record review of Resident #1's face sheet dated 10/28/24 reflected he was a [AGE] year-old-male, admitted on [DATE] and readmission on [DATE]. Resident #1's DX included: Chronic Kidney Disease Stage 3 convulsions dependent on dialysis (kidney failure). <BR/>Record review of Resident #1's MD orders, dated 01/26/24 reflected an order for Dialysis on (Tuesday, Thursday, and Saturday) at 6:00 AM.<BR/>Record review of Resident # 1's October 2024 TAR and progress notes reflected that Resident was transported and received Dialysis treatment on Tuesday,10/01/24; Thursday, 10/03/24; Sunday, 10/06/24; Tuesday, 10/08/24; Thursday, 10/10/24; Saturday, 10/12/24; Tuesday, 10/15/24; Thursday, 10/17/24; Saturday, 10/19/24; and Tuesday 10/22/24.<BR/>Record review of Resident #1's discharge MDS dated [DATE] reflected he had a BIMS score of 11 indicating he was moderately impaired cognitively. Resident #1's treatment of dialysis after discharge to a new facility was not addressed in his MDS.<BR/>Record review of Resident #1's Care Plans dated 07/29/24 revealed Resident #1 a Focus area Resident has the potential for complications related to ESRD (End Stage Renal Disease, kidney failure) Dialysis on Tuesday, Thursday, and Saturday chair time .<BR/>Communicate with Dialysis as needed re: medication, diet, lab results.<BR/>Enhanced barrier precautions, monitor dialysis site q (every) shift for s/s infections, bleeding, swelling & other <BR/>abnormalities, notify physician if noted &/or as needed .Free Transportation.<BR/>Resident will remain free from discomfort or further complications related to ESRD through next review in 90 days. <BR/>Administer related medication as ordered observing for effectiveness &/or side effects. Notify physician as needed.<BR/>Check dialysis fistula (surgical connection between artery and vein for dialysis) to (right chest) for thrill & bruit q shift. <BR/>Notify dialysis & physician if not thrill/bruit (a vibration/ sound in the skin caused by irregular blood flow) noted.<BR/>Communicate with dialysis as needed re: medication, diet, lab results.<BR/>In an interview with Resident #1 on 10/22/24 at 12:45 PM revealed he was transported to dialysis every Tuesday, Thursday, and Saturday morning for treatment by his insurance transporter. He denied missing any appointments or that his MD orders had been discontinued.<BR/>Resident #5<BR/>Record review of Resident #5's face sheet dated 10/28/24 reflected he was a [AGE] year-old male, admitted on [DATE] with DX: COPD (Continuous obstructive pulmonary disease lung disease), Asthma (a disease affecting the flow of air to the lungs, CHF (Congestive Heart Failure.) <BR/>Record review of Resident #5's quarterly MDS dated [DATE] reflected a BIMS score of 11 indicating he was moderately impaired cognitively. The MDS reflected active diagnosis: Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease (e.g., chronic bronchitis and restrictive lung diseases). The MDS did not address Resident #5's MD orders for continuous use of oxygen treatments. <BR/>Record review of Resident#5's care plan dated 09/05/24 reflected Resident requires oxygen therapy r/t COPD . please document refusals every evening and night shift .Resident will have no signs and symptoms of poor oxygen absorption during this quarter. Assure call light always within reach so if assistance needed when having respiratory distress .Give medications as ordered, monitor/document side effects and effectiveness .Monitor for signs and symptoms of respiratory distress such as respirations, pulse oximetry device that monitors blood oxygen, increased heart rate, restlessness confusion, skin color Obtain O2 saturation (oxygen in the blood) q shift. Potential for respiratory difficulty/complications related to CHF .Related medication will be effective as evidenced by no s/s exacerbation of CHF. Review in 90 days . Lung sounds prn. Notify physician abnormalities noted &/or as needed. Monitor for changes in/development of s/s of breathing difficulty re: SOB, productive or non-productive cough, fever, chills, difficulty speaking, bluish skin color, changes in cognitive. Notify physician if noted .Monitor for edema & SOB q shift. Notify physician as needed abnormalities noted monitor for edema (fluid retention) q shift every shift for edema weekly weights .Give medications as ordered. Monitor/document side effects and effectiveness Monitor for s/sx of impending asthma attack: coughing spells, decreased energy, rapid breathing, complaint of chest tightness or hurting, wheezing (whistle sound in the lungs), shortness of breath, tightness of neck or chest muscles, fatigue .Monitor vital signs as ordered, skin color, pulse oximetry, airway functioning and degree of restlessness which may indicate hypoxia (area deprived from oxygen).<BR/> O2 sats Q shift. Oxygen at 3L continuous shortness of breath<BR/>Record review of Resident #5's MD orders dated 04/19/24 reflected Check O2 sat every shift every shift .Oxygen at 3L continuous. every shift. <BR/>Resident review of Resident #5's August 2024 TAR reflected he was administered oxygen treatment continuously per MD orders 08/01/24 to 08/31/24.<BR/>Resident review of Resident #5's September 2024 TAR reflected continuous oxygen treatment he was administered oxygen treatment continuously per MD orders from 09/01/24 to 09/30/24. <BR/>Resident review of Resident #5's October TAR reflected he was administered oxygen treatment continuously per MD orders from 10/01/24 to 10/28/24.<BR/>In an observation on 10/22/24 at 11:10 AM of Resident #5 revealed the resident with his nasal cannula in his nose and the oxygen concentrator powered on and in use. <BR/>In an interview on 10/22/24 at 11:13 AM with Resident #5 he stated that he received oxygen treatment daily. Resident #5 stated that he had not missed any oxygen treatments while residing at the facility. <BR/>In an interview on 10/28/24 at 1:14 PM with the MDS/LVN he stated he had worked at the facility for 6 years. He stated that he completed the MDS assessments for Resident #1 on 10/23/24 and Resident #5 on 08/29/24. The MDS/LVN stated that he missed documenting Resident #1's dialysis on his discharge MDS assessment. The MDS/LVN said that he missed documenting Resident #5's oxygen use on his quarterly MDS. The MDS/LVN said there was not a risk to the residents for MDSs being incorrect. The MDS LVN said he reviews the MDS, and the assessment was for state agency's audits and resident billing. The MDS/LVN said it was important for the MDS to be comprehensive of the resident's treatment and accurate for all residents at the facility. <BR/>In an interview on 10/28/24 at 1:44 PM with the DON revealed that Resident #1 had an active order for dialysis treatment and Resident #5 has an MD order for continuous oxygen use to addressed related diagnosis. She stated that the MDS should reflect all treatments ordered by the MD for accuracy of care and consistent records to prevent the residents from missing care and treatments. <BR/>In an interview on 10/28/24 at 1:49 PM with the ADM revealed that he was not sure if there was a risk to the residents when the comprehensive MDSs was not accurate and reflected needed treatments ordered by the MD. He provided no additional information when asked.<BR/>Record review of the CMS's RAI Version 3.0 Manual dated 10/01/24 reflected The RAI-related processes help staff identify key information about residents as a basis for identifying resident-specific issues and objectives. In accordance with 42 CFR 483.21(b) the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The Minimum Data Set (MDS) is a standardized instrument used to assess nursing home residents. It is a collection of basic physical (e.g., medical conditions, mood, and vision), functional (e.g., activities of daily living, behavior), and psychosocial (e.g., preferences, goals, and interests) information about residents. The information in the MDS constitutes the core of the required CMS-specified Resident Assessment Instrument (RAI). Based on assessing the resident, the MDS identifies actual or potential areas of concern. The remainder of the RAI process supports the efforts of nursing home staff, health professionals, and practitioners to further assess these triggered areas of concern in order to identify, to the extent possible, whether the findings represent a problem or risk requiring further intervention, as well as the causes and risk factors related to the triggered care area under assessment. These conclusions then provide the basis for developing an individualized care plan for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide residents who were unable to carry out ADLs the necessary services to maintain good personal hygiene for 1 of 25 residents (Resident #1) reviewed for showers. <BR/>The facility failed to ensure Resent #1 received showers/baths on scheduled shower/bath days. <BR/>This failure affected residents by putting them at risk for a diminished quality of life, hygiene, and self-esteem. <BR/>Findings include:<BR/>Record review of Resident's #1 Face Sheet dated 3-5-2024, indicated a [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of type 2 diabetes mellitus, morbid obesity due to excess calories, cerebral infarction (stroke), and osteoarthritis. <BR/>Record review of Resident's #1 care plan dated 6-21-2023, revealed he required extensive/total assist with ADL's due to morbid obesity and late effect CVA (an interruption in the flow of blood to cells in the brain) with hemiplegia (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscle). CNAs were to provide incontinence care in PAIRS, d/t resident's sexually inappropriate behaviors. Resident #1 had impaired cognitive function needing staff to sometimes use yes/no questions to determine Resident #1's needs. Resident #1 had impaired comprehension which required staff to speak distinctly and slowly while communicating. Resident #1 required checks every two hours for total care with toileting with disposable briefs. Resident #1 required cleansing of the right buttock shear with normal saline/wound cleanser and pat dry. Apply triad to the area daily and as needed for soiling. <BR/>In an observation of Resident #1, on 3-5-2024 at 11:25 AM, in his bedroom, revealed a strong smell of feces coming from Resident #1s bed. <BR/>In an interview with Resident #1, on 3/5/2024, at 12:20 PM, Resident #1 stated his problem was getting a bed-bath on a regular basis. Resident #1 stated he cannot get showers. Resident #1 stated he is supposed to get a bath on Mondays, Wednesdays, and Fridays. Resident #1 said sometimes he goes a week at a time without getting a bed-bath by staff. Resident #1 stated that sometimes CNAs will walk in the doorway of his room and tell him you're not getting a bath today. Resident #1 stated he does not always get bathed on scheduled days since he was admitted to the facility, and he has never refused a bed-bath. Resident #1 stated he uses a bed pan to have bowel movement in bed as he cannot get to the bathroom to use it. Resident #1 stated he is totally dependent on staff to clean/wipe him when he has a bowel movement or urinates. Resident #1 stated female staff have made fun of him before because of his obese size. This made him feel disrespected. <BR/>In an interview with CNA-D, on 3-5-2024 at 1:20 PM, CNA-D stated working with Resident #1 has been difficult as he would be disrespectful, curse staff, and yell at them - if he does not get help instantly. CNA-D stated her work hours were 6:00 AM - 2:00 PM. CNA-D said, when she came to work on Sunday (3-3-2024), there was a shift meeting indicating a call light had been left on, for a long time, with no response on Saturday. CNA-D stated, for the facility to be fully staffed, there should be 4 CNAs and 1 shower aide. CNA-D stated that today, 3-5-2024, there was only 3 CNAs working and no shower aide. CNA-D stated Resident #1 used a bed pan for restroom use and today (3-5-2024) he received a bed-bath. <BR/>In an interview with LVN-A on 3-9-2024 at 1:00 PM, LVN-A stated she has only worked at the facility for a month and worked in Hall B where Resident #1 was residing. LVN-A stated that the facility had a shower aide that gives the showers for the facility. The showers were documented in the shower logbook and not documented in the Point Care Click Electronic Medical Record System. LVN-A stated, as for as she knew, the shower aide, gives the showers to all the residents in Hall B. LVN-A stated she has not witnessed aides being rude to Resident #1. LVN-A stated that the nurse signs off on the shower log ensuring showers are given but the shower aide is responsible for giving the showers. <BR/>In an interview with CNA-F, on 3-9-2024, at 2:35 PM, it was revealed CNA has worked at facility for 25 years. CNA-F stated that when a resident received a shower, it is documented in the shower logbook for each hall. Resident #1 is in Hall-B. Resident #1s shower sheets are in Hall-B's shower logbook. CNA-F stated the PCC may not be used when staffing is short. CNA-F stated that if a resident refused a shower/bath, it would have been documented in the shower logbook. CNA-F stated, because of Resident #1's sexual inuendoes, new CNAs might not have wanted to bath Resident #1. <BR/>Record Review of the shower log, on 3-5-2024, for the B-Hall area, for Resident #1 revealed the last time Resident #1 took a shower was 2-28-2024. This shower log indicated it had been 6 days since Resident #1 had received a bed-bath or shower. The shower log for Hall B indicated that even number of resident's rooms were bathed or showered on Monday, Wednesday, and Friday. Resident #1s room was room [ROOM NUMBER]. There was no indication where Resident #1 ever refused a shower/bed-bath. <BR/>In an interview with the DON on 3-9-2024, at 3:49 PM, it was disclosed that the DON is responsible for ensuring showers/baths are completed for residents. The DON stated that the CNAs gave the showers and sometimes they could have a shower aide who gave their showers. The shower sheets were where the shower/baths were documented when showers were given or refused. The DON revealed in Hall-B, showers were given in the evening time. The DON stated the CNAs were responsible for ensuring residents who needed ADL assistance get bathed/showered. <BR/>In an interview with the Administrator on 3-9-2024, at 4:10 PM, it was disclosed that showers and baths were an issue at every nursing home. The Administrator stated the worst thing was for a resident to say the facility was not up to date on his/her showers. The Administrator stated residents should be offered a shower every other day and residents could tell him if they were not getting a shower. The Administrator stated he had zero tolerance for a resident not getting his/her shower or bath. The Administrator stated it is every staff member's responsibility to ensure residents get showers. <BR/>Record Review of the facility's shower policy, not dated, on the shower log, indicated A-bed residents shower on 6 AM to 2 PM shift and B-bed residents will receive showers on the 2 PM to 10 PM Shift. The policy further revealed even numbered rooms will shower/bath Monday, Wednesday, Fridays, and odd number rooms will shower on Tuesday, Thursday, and Friday. The policy revealed every resident is offered a shower 3 times a week and are encouraged to take their shower on their scheduled day and time. Bed baths are an acceptable option, but the best practice is a full warm shower, so all areas of skin are cleaned .bed baths are good, but not as good or beneficial as a nice invigorating shower. <BR/>Record Review of the facility's call light policy dated 3-2018, shows the purpose and guidelines are:<BR/> .to ensure timely responses to the resident's request and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to immediately consult with the resident's physician and notify the resident representative when there was a significant change in the resident's condition or need to alter treatment significantly for one (Resident #1) of five residents reviewed for change of condition.<BR/>-The facility failed to notify Resident #1's physician and responsible party when the resident had a fall on 3/27/24 and when the resident showed signs of increased lethargy and altered mental status as the week progressed.<BR/>An Immediate Jeopardy (IJ) was identified on 04/22/24. An IJ Template was provided to the facility on [DATE] at 1:28 PM. While the Immediate Jeopardy was removed on 04/23/24 at 02:02 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.<BR/>This failure could place all residents at risk of not receiving immediate medical attention when there is a change in their condition. <BR/>Findings included : <BR/>Record review of Resident #1's face sheet, dated, 04/02/24, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: encephalopathy (change in brain function), sickle cell (blood disorder), type II diabetes, cerebral infarction (stroke), and cirrhosis of liver (chronic liver damage). <BR/>Record review of Resident #1's EHR revealed she did not have a completed admission MDS assessment. Further review revealed Resident #1 had a BIMs of 11 which indicated moderate cognitive impairment. <BR/>Record review of Resident #1's baseline care plan, dated, 03/27/24, revealed the resident's level of consciousness was lethargic and she was cognitively impaired.<BR/>Record review of Resident #1's consolidated admitting orders, dated 3/25/24, reflected an order to make the family/resident/responsible party aware of the resident's conditions. Further review reflected a lack of documentation of an order to make the MD aware of Resident #1's conditions, besides new onset symptoms of COVID-19. <BR/>Record review of Resident #1's discharge hospital records (prior to admitting to [nursing facility]), dated 3/11/24-3/25/24, reflected the following:<BR/>Progress note at 3/14/24 1:30 PM:<BR/> .<BR/>Assessment/Plan:<BR/> .<BR/>-Place NGT if [Resident #1] is lethargic and is unable to take PO.<BR/> .<BR/>Discharge Summary at 03/25/24 7:06 PM: <BR/>Principle Final Diagnosis: Acute hepatic encephalopathy<BR/> .<BR/>Test results pending at discharge: none.<BR/>Follow-up appointments: none<BR/>Summary of hospital course:<BR/>Hepatic encephalopathy<BR/>Known history of cirrhosis secondary to alcohol abuse<BR/> .<BR/>Physical therapy and occupational therapy consulted, recommending SNF.<BR/>[Resident #1] was improving but 03/19/24 worsening in mental status; oriented to person only.<BR/>Repeat ammonia on 03/20/24 up to 178.<BR/> .<BR/>Mental status has now returned to [Resident #1] baseline. <BR/> .<BR/>Therapeutic diet, encourage PO intake. <BR/> .<BR/>Further review of discharge hospital records reflected no documentation that ammonia levels were rechecked on 03/20/24 or prior to discharge.<BR/>Record review of Resident #1's hospital records, dated 3/31/24, reflected the following:<BR/> [Resident #1 is a [AGE] year-old female with history of CKD, cirrhosis (liver damage), encephalopathy (change in brain function), CVA (stroke), diabetes, hypertension (high blood pressure), who presents via EMS from nursing home due to altered mental status and facial droop. Per EMS, [Resident #1] is GCS (scale that assesses consciousness) 15 (mild brain injury) at baseline and able to speak and follow commands. Last known normal was 2 days ago per EMS until noticing change in neurological status today. [Resident #1] was recently admitted on [DATE] for hepatic encephalopathy (loss of brain function due to liver damage).<BR/> .<BR/>Laboratory Results:<BR/> .<BR/>Ammonia, plasma-205 umol/L (severely elevated) <BR/> .<BR/>Imaging results (CT head):<BR/>1. No acute intracranial abnormality. Chronic atrophic and chronic ischemic changes (brain damage), similar to the prior.<BR/>In an interview on 04/02/24 at 9:48 AM, Resident #1's family member stated Resident #1 admitted to the facility after being in the hospital for about two weeks where she was being treated for complications related to her diabetes to her knowledge. The family member stated Resident #1 was visited at the facility on 03/30/24 by another family member and they were upset because Resident #1 did not look good, and staff reported she had been sleeping a lot more. The family member stated she had not been informed of a change in Resident #1's condition by the facility. The family member stated Resident #1 had a fall on 03/27/24 and they were informed of that by the roommate.<BR/>In an interview on 04/02/24 at 10:48 AM, RN A, who worked at the local hospital, stated Resident #1 was previously admitted to the hospital from [DATE]-[DATE] for altered mental status and hyperglycemia (high blood sugar), and returned to the hospital on [DATE] with similar symptoms. RN A stated Resident #1 returned with altered mental status, encephalopathy (change in brain function), and critically high levels of ammonia from liver failure. RN A stated Resident #1 has been sleeping and nonverbal since admitting and had to get a nasogastric tube placed to receive nutrition and medication. RN A stated Resident #1's CT scans only showed evidence of past stroke with no new changes. <BR/>In an interview on 04/02/24 at 10:48 AM, LVN B stated she worked at the facility since 02/2024. She stated she worked weekdays, 6am-2pm, and worked with Resident #1. LVN B stated she worked with Resident #1 on the day she was admitted , and Resident #1 was alert x 2 (only aware of person and place) and could respond to her name and answer yes/no questions. LVN B stated Resident #1 was confused and required assistance with eating as she would not initiate eating or drinking on her own. LVN B stated Resident #1 always seemed to have low energy and did not speak most of the time, but one morning during rounds she heard Resident #1 saying she was hungry and wanted a hotdog. LVN B stated she was the nurse who received report from the hospital before Resident #1 admitted to the facility, and they reported that Resident #1 had an altered mental status, hyperglycemia, and encephalopathy (change in brain function). LVN B stated she last worked with Resident #1 on the morning of 03/29/24 and the resident seemed to be less responsive than she had been and now required touch for response; however, before she would respond to her name. LVN B denied that Resident #1 showed signs of a stroke. LVN B stated she was responsible for checking Resident #1's blood sugar every morning and she was a little more responsive during previous mornings. LVN B stated a resident being less responsive was something that would be reported to the MD. LVN B stated she did not notify the MD of the change because she thought Resident #1 could have been sleepy due to it being early in the morning.<BR/>In an interview on 04/02/24 at 10:48 AM, CNA C stated she worked at the facility for 3 years. CNA C stated she worked 6am-2pm on different halls, but she worked with Resident #1 on 03/28/24 and 03/31/24. CNA C stated on 03/28/24, Resident #1 was alert and eating but was not talking. CNA C stated she worked with Resident #1 again on 03/31/24 and there was a significant change. CNA C stated Resident #1 would not eat and required total assistance with care. CNA C stated before, Resident #1 could help move herself slightly during incontinent care. CNA C stated Resident #1 was weaker and less responsive. She stated she reported it to LVN F on 3/31/24.<BR/>In an interview on 04/02/24 at 10:48 AM, CNA D stated she worked at the facility for 4 weeks. She stated she worked 6am-2pm on weekdays and worked with Resident #1 on 03/26/24, 03/27/24, and 03/28/24. CNA D stated earlier in the week, Resident #1 was talkative and very feisty. CNA D stated as the week went on, Resident #1 started talking less and was sleeping more. CNA D stated on the last day she worked with Resident #1 she was still sleeping more and had to be woken up for meals. She stated she was able to get Resident #1 to eat some of her food, but she was eating less. CNA D stated this was reported to the nurse; however, staff were still learning Resident #1's baseline and she was not sure what to think about the change. <BR/>In an interview on 04/02/24 at 01:19 PM, the DON stated she was not at the facility when Resident #1 admitted ; however, she was there the next day and poked her head in to speak to Resident #1 and she responded. The DON stated there were no reports of a significant change in Resident #1 until 03/26/24 when LVN E reported the resident being nonresponsive with a blood glucose level of 50. The DON stated the MD was notified on 03/26/24 regarding the resident's low blood glucose, and after giving Resident #1 emergency Glucagon (medication to regulate blood glucose) and juice, her blood glucose stabilized. The DON stated EMS had already been called out to the facility, but the DON and MD decided not to transport Resident #1 to the hospital since her vitals were stable. The DON stated she did not receive any other report of a significant change in Resident #1 until 03/31/24 when it was reported that the resident was not waking up, eating, or responding. The DON stated staff reported Resident #1 had not eaten a lot in a day or so. The DON stated she went to assess Resident #1 and she was sleeping. The DON stated she pinched Resident #1's skin and she appeared to be dehydrated. The DON stated she told LVN G to call the MD and he gave an order to send Resident #1 to the hospital. The DON stated Resident #1 admitted to the hospital with hyperglycemia and was always lethargic with little response from the beginning. The DON stated the staff were still getting familiar with Resident #1's baseline as she had only been at the facility for a week; however, if there was any change from the day she admitted , the expectation was for the staff to report it to the DON and MD. <BR/>In an interview on 04/02/24 at 02:05 PM, LVN E stated she admitted Resident #1 to the facility on [DATE]. LVN E stated Resident #1 was unarousable and would not speak or open her eyes when she admitted . LVN E stated Resident #1's baseline remained the same throughout the week and she never saw the resident feisty or very alert. LVN E stated on 03/26/24 she had to call the MD after Resident #1's blood glucose dropped, and she received an order to give the resident Glucagon (medication to regulate blood glucose). LVN E stated Resident #1 then had a fall on 03/27/24 with no injuries and she did not notify the MD although it was protocol. LVN E stated she would normally notify the MD of falls; however, she just forgot to do so for this incident. <BR/>In an interview on 04/02/24 at 02:53 PM, the MD stated he visited the facility every Wednesday; however, he did not see Resident #1 when he visited on 03/27/24. The MD stated he had been notified of Resident #1's low blood sugar the day prior (3/26/24), but no one reported any other significant change or brought it to his attention that Resident #1 needed to be seen that day. The MD stated he was also not notified that Resident #1 had a fall on 03/27/24. The MD stated it was the expectation for staff to notify him of falls, but if it was late at night with no injury or change of condition, they could report it the following morning. The MD stated with Resident #1 being a new resident and due to her condition, he would have expected staff to notify him of her fall and any other changes. <BR/>In an interview on 04/02/24 at 03:30 PM, LVN F stated she worked at the facility for 2 weeks. She stated she worked with Resident #1 on 03/30/24 and 03/31/24. LVN F stated Resident #1 was sleeping most of the time and not eating much during both shifts. LVN F stated on 03/31/24 the aide reported Resident #1 did not look like she was going to make it. LVN F stated she went to assess Resident #1 and she was very weak and lethargic, but the resident would open her eyes when spoken to, respond to sternum rub, and her vitals were normal. LVN F stated Resident #1's face was not drooping, and she did not have any other signs of a stroke. LVN F stated she notified the MD on 3/31/24 that Resident #1 had been sleeping more the past two days, was unarousable, and eating less, and the MD ordered Resident #1 to be sent out to the hospital. <BR/>In an interview on 04/02/24 at 04:00PM, Resident #2 stated Resident #1 was her roommate for about a week. Resident #2 stated Resident #1 would sleep most of the time and only wake up for medication and to eat. Resident #2 stated Resident #1 was not able to converse with her but would sometimes pick up words from the television and repeat them over and over. <BR/>In an interview on 04/02/24 at 05:05 PM with the DON and the Administrator, the DON stated she expected staff to notify her and the MD of any significant change in a resident's condition. The DON stated the MD wanted to make it clear to Investigator that the facility received a resident who was not stable enough to leave the hospital. The Administrator stated reporting a change of condition was easier said than done, especially with a new resident when staff were not familiar with their baseline. In an attempt to further interview about expectations and risks to the resident, the Administrator stated, no comment. <BR/>In an interview on 04/23/24 at 10:08 AM with the Regional Nurse revealed she understood the facility failed to notify the physician of significant changes in Resident #1 after multiple opportunities presented, including a fall and other changes in mental and physical status that indicated a decline in health. The Regional Nurse stated her expectation and the facility's policy for any significant incidents and change in condition to be reported immediately. The Regional Nurse stated the risk of not notifying the MD of significant incidents and change of condition could result in a resident having serious harm or death. <BR/>Review of the facility's policy titled Notification of Change, undated, revealed in part the following:<BR/>Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.<BR/> .<BR/>Compliance Guidelines:<BR/>The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. <BR/>Circumstances requiring notification include:<BR/> .<BR/>2. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health mental. Or psychosocial status [sic]. This may include:<BR/> a. Life-threatening conditions, or<BR/> b. Clinical complications<BR/>An Immediate Jeopardy (IJ) was identified on 04/22/24 at 11:45 AM.<BR/>On 04/22/24 at 12:35 PM, the Administrator and the DON were notified of the IJ. The IJ template was provided to the Administrator and a plan of removal (POR) was requested at that time.<BR/>The POR was accepted on 04/23/24 at 10:11 AM. The POR reflected the following: <BR/>Issue Cited: <BR/>Failure to Notify the Physician of a Significant Change of Condition<BR/>Preparation and/or execution of this plan do not constitute admission or agreement by the provider that immediate jeopardy exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and immediate jeopardy removal plan. This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur or recur.<BR/>1. <BR/>Identification of Residents Affected or Likely to be Affected:<BR/>The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 4/22/24)<BR/>o <BR/>The DON or designee notified the facility Medical Director of the incident.<BR/>o <BR/>Nursing supervisors/designees completed physical assessments on all residents to identify any changes in condition and notification was made to the physician of any noted changes. Concerns were/were not identified. (Provide details if concerns were identified from the physical assessments).<BR/>2. <BR/>Actions to Prevent Occurrence/Recurrence:<BR/>The facility took, the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 4/23/24)<BR/>o <BR/>All licensed nurses will be educated by the DON/designee on change of condition and physician notification regulations, as well as facility policy and procedure.<BR/>o <BR/>Nurse aides will be educated by the DON/designee on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurses.<BR/>o <BR/>Staff members are not permitted to work a shift until education was completed.<BR/>o <BR/>New hires (licensed nurses and nurse aides) will be educated on change of condition and physician notification regulations, as well as facility policy and procedure, accordingly in orientation by human resources/designee.<BR/>o <BR/>The DON implemented a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) with a focus on physician notification of significant changes.<BR/>o <BR/>The PIP resulted in implementation of daily DON/designee audits of the 24-hour report to monitor for change in resident condition.<BR/>o <BR/>The DON/designee will also complete chart audits/health document assessment as follows:<BR/>o <BR/>Three residents weekly for four weeks then;<BR/>o <BR/>Two residents weekly for two weeks then;<BR/>o <BR/>Two residents a month for two months.<BR/>o <BR/>The regional/corporate/consultant nurse will visit the facility monthly to provide general oversight and monitoring of the PIP.<BR/>Monitoring 04/23/24 (10:15 AM-1:45 PM): <BR/>Record review of Residents #2, #3, #4, #5, #6, #7, #8, #9 and #10's, who were all at risk of having a physical, mental, or psychosocial change in condition based on diagnoses, electronic health records reflected no documented incidents or change of condition. <BR/>Record review of in-service on 04/22/24, conducted by the Regional Nurse, reflected the DON and ADON were trained on their responsibility to monitor resident charting for any changes in resident status and follow up accordingly. <BR/>Record review of in-services on 04/22/24-04/23/24, conducted by the DON, reflected all staff were trained during or prior to their shift on guidelines for notifying the physician of clinical problems, incidents, and change of condition.<BR/>Record review of a document provided by the DON reflected a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented for the DON and/or designees to audit 24-hour reports to monitor for change of condition of residents and audit resident charts. <BR/>Record review of a document provided by the DON reflected a fax form for non-emergent notification to ensure the physician is aware of all incidents and residents' conditions. <BR/>Interview on 4/22/24 at 3:00 PM with the Administrator and the DON revealed the MD was notified of the facility's failure to report a resident's change of condition.<BR/>Interviews on 4/22/24-4/23/24 (various times) with Residents #2, #3, #4, #5, #6, #7, #8, #9 and #10's, who were all at risk of having a physical, mental, or psychosocial change in condition, revealed they had not experienced any signs or symptoms of a change in their condition. <BR/>Interviews on 04/23/24 (10:08 AM-1:43 PM) were conducted with DON, ADON, LVN B (1st shift), LVN E (2nd shift), LVN G (1st shift), LVN H (1st shift), CNA I (1st shift), MA J (1st shift), CNA K (1st shift), CNA L (2nd shift), LVN M (2nd shift), CNA N (3rd shift), LVN O (3rd shift), LVN P (double weekends). All interviewed aides were able to provide competency regarding in-services over monitoring for and reporting change of condition to the charge nurse. The aides stated they knew to monitor residents for any changes to skin, behavior, mental/physical status while performing care and to immediately report it to the charge nurse and/or DON. All interviewed licensed staff were able to provide competency regarding monitoring for and acknowledging reports of change of condition and reporting to the physician. The licensed staff stated they were responsible for monitoring resident for any signs of change in condition, assessing a resident after receiving reports of change in condition from the aides, and immediately reporting any concerns to the DON/MD/family. <BR/>An Immediate Jeopardy (IJ) was identified on 04/22/24. An IJ Template was provided to the facility on [DATE] at 1:28 PM. While the Immediate Jeopardy was removed on 04/23/24 at 02:02 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide services to residents with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents by not providing a call light system within reach for 1 of 25 (Resident #2) observed for call lights. <BR/>The facility failed to ensure Resident #2 had a call light within reach so Resident #2 could communicate to staff he needed assistance. <BR/>This failure affected residents by placing them at risk for not getting their needs met and diminishing their quality of life. <BR/>Findings include:<BR/>Record review of Resident's #2s Face Sheet dated 3-5-2024 indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had a primary diagnosis of Hemiplegia (paralysis) and Hemiparesis (loss of strength in limbs) following a cerebrovascular disease (condition affecting blood flow to the brain) affecting the right dominant side, unspecified visual loss, seizures, and dysarthria (difficult or unclear articulation of speech) following cerebral infarction (stroke). <BR/>Record Review of Resident #2s medical record dated 3-1-2024, indicated a Brief Interview Mental Status (BIMS) Score of 10, indicating moderate mental impairment. <BR/>Record Review of Resident #2s Care Plan, dated 2-26-2024, revealed Resident #2 was at risk for falls. Resident #2s Care Plan stated interventions were to assure call light is within reach and encourage Resident #2 to call for assistance as needed. <BR/>In an observation/interview, on 3-5-2024 at 2:20 PM, Resident #2 was observed to be lying on his bed. Resident #2 was observed to be a right leg amputee. Resident #2 was observed to not have a call light within reach. Resident #2s call light was observed to be underneath his bed, on the floor, and out of the reach of the resident. Resident #2 stated he used his call light and could not see well. Resident #2 stated he did not know where his call light was, and the call light was not within his reach. Resident #2 stated that the aides were not very attentive to resident's needs at the facility. <BR/>In an observation on 3-5-2024, at 4:15 PM, Resident #2 was observed to still not have his call light within reach and it was on the floor underneath his bed. <BR/>On 3-5-2024, at 4:17 PM, CNA-E was informed of Resident #2 not having a call light within reach. CNA-E got on the floor, found the call light, put the call light within reach, and attached it to Resident #2s bed. <BR/>In an interview with LVN-A, on 3-9-2024, at 1:00 PM, it was revealed if a resident does not have a call light within reach, it is considered neglect. LVN-A stated she did not know Resident #2's call light was not within reach. LVN-A stated, in her opinion, staff answer call lights timely. The concern, if a resident cannot reach his call light, is the resident may need help and staff will not know it. <BR/>In an interview with the DON, on 3-9-2024 at 3:49 PM, it was revealed that CNAs are responsible for ensuring resident's call light are within reach, especially those with needs of ADL assistance. CNAs should make rounds every 2 hours to ensure this expectation is met. CNAs should also check when they first come onto their shifts and when they are leaving their shifts, to ensure residents have their call lights within reach. <BR/>In an interview with the Administrator, on 3-9-2024, at 4:10 PM, revealed that his expectations for residents who need ADL assistance, were for call lights to be placed within reach and keep them close to the nurse's station as possible. The Administrator stated he has high expectations that care plans be followed by staff. The Administrator stated that the DON is responsible to ensure call lights remain within reach to ADL dependent residents and to ensure care plans are followed. <BR/>Review of the facility's call light policy, dated 9-2022, revealed under general guidelines:<BR/>#5) Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide residents who were unable to carry out ADLs the necessary services to maintain good personal hygiene for 1 of 25 residents (Resident #1) reviewed for showers. <BR/>The facility failed to ensure Resent #1 received showers/baths on scheduled shower/bath days. <BR/>This failure affected residents by putting them at risk for a diminished quality of life, hygiene, and self-esteem. <BR/>Findings include:<BR/>Record review of Resident's #1 Face Sheet dated 3-5-2024, indicated a [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of type 2 diabetes mellitus, morbid obesity due to excess calories, cerebral infarction (stroke), and osteoarthritis. <BR/>Record review of Resident's #1 care plan dated 6-21-2023, revealed he required extensive/total assist with ADL's due to morbid obesity and late effect CVA (an interruption in the flow of blood to cells in the brain) with hemiplegia (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscle). CNAs were to provide incontinence care in PAIRS, d/t resident's sexually inappropriate behaviors. Resident #1 had impaired cognitive function needing staff to sometimes use yes/no questions to determine Resident #1's needs. Resident #1 had impaired comprehension which required staff to speak distinctly and slowly while communicating. Resident #1 required checks every two hours for total care with toileting with disposable briefs. Resident #1 required cleansing of the right buttock shear with normal saline/wound cleanser and pat dry. Apply triad to the area daily and as needed for soiling. <BR/>In an observation of Resident #1, on 3-5-2024 at 11:25 AM, in his bedroom, revealed a strong smell of feces coming from Resident #1s bed. <BR/>In an interview with Resident #1, on 3/5/2024, at 12:20 PM, Resident #1 stated his problem was getting a bed-bath on a regular basis. Resident #1 stated he cannot get showers. Resident #1 stated he is supposed to get a bath on Mondays, Wednesdays, and Fridays. Resident #1 said sometimes he goes a week at a time without getting a bed-bath by staff. Resident #1 stated that sometimes CNAs will walk in the doorway of his room and tell him you're not getting a bath today. Resident #1 stated he does not always get bathed on scheduled days since he was admitted to the facility, and he has never refused a bed-bath. Resident #1 stated he uses a bed pan to have bowel movement in bed as he cannot get to the bathroom to use it. Resident #1 stated he is totally dependent on staff to clean/wipe him when he has a bowel movement or urinates. Resident #1 stated female staff have made fun of him before because of his obese size. This made him feel disrespected. <BR/>In an interview with CNA-D, on 3-5-2024 at 1:20 PM, CNA-D stated working with Resident #1 has been difficult as he would be disrespectful, curse staff, and yell at them - if he does not get help instantly. CNA-D stated her work hours were 6:00 AM - 2:00 PM. CNA-D said, when she came to work on Sunday (3-3-2024), there was a shift meeting indicating a call light had been left on, for a long time, with no response on Saturday. CNA-D stated, for the facility to be fully staffed, there should be 4 CNAs and 1 shower aide. CNA-D stated that today, 3-5-2024, there was only 3 CNAs working and no shower aide. CNA-D stated Resident #1 used a bed pan for restroom use and today (3-5-2024) he received a bed-bath. <BR/>In an interview with LVN-A on 3-9-2024 at 1:00 PM, LVN-A stated she has only worked at the facility for a month and worked in Hall B where Resident #1 was residing. LVN-A stated that the facility had a shower aide that gives the showers for the facility. The showers were documented in the shower logbook and not documented in the Point Care Click Electronic Medical Record System. LVN-A stated, as for as she knew, the shower aide, gives the showers to all the residents in Hall B. LVN-A stated she has not witnessed aides being rude to Resident #1. LVN-A stated that the nurse signs off on the shower log ensuring showers are given but the shower aide is responsible for giving the showers. <BR/>In an interview with CNA-F, on 3-9-2024, at 2:35 PM, it was revealed CNA has worked at facility for 25 years. CNA-F stated that when a resident received a shower, it is documented in the shower logbook for each hall. Resident #1 is in Hall-B. Resident #1s shower sheets are in Hall-B's shower logbook. CNA-F stated the PCC may not be used when staffing is short. CNA-F stated that if a resident refused a shower/bath, it would have been documented in the shower logbook. CNA-F stated, because of Resident #1's sexual inuendoes, new CNAs might not have wanted to bath Resident #1. <BR/>Record Review of the shower log, on 3-5-2024, for the B-Hall area, for Resident #1 revealed the last time Resident #1 took a shower was 2-28-2024. This shower log indicated it had been 6 days since Resident #1 had received a bed-bath or shower. The shower log for Hall B indicated that even number of resident's rooms were bathed or showered on Monday, Wednesday, and Friday. Resident #1s room was room [ROOM NUMBER]. There was no indication where Resident #1 ever refused a shower/bed-bath. <BR/>In an interview with the DON on 3-9-2024, at 3:49 PM, it was disclosed that the DON is responsible for ensuring showers/baths are completed for residents. The DON stated that the CNAs gave the showers and sometimes they could have a shower aide who gave their showers. The shower sheets were where the shower/baths were documented when showers were given or refused. The DON revealed in Hall-B, showers were given in the evening time. The DON stated the CNAs were responsible for ensuring residents who needed ADL assistance get bathed/showered. <BR/>In an interview with the Administrator on 3-9-2024, at 4:10 PM, it was disclosed that showers and baths were an issue at every nursing home. The Administrator stated the worst thing was for a resident to say the facility was not up to date on his/her showers. The Administrator stated residents should be offered a shower every other day and residents could tell him if they were not getting a shower. The Administrator stated he had zero tolerance for a resident not getting his/her shower or bath. The Administrator stated it is every staff member's responsibility to ensure residents get showers. <BR/>Record Review of the facility's shower policy, not dated, on the shower log, indicated A-bed residents shower on 6 AM to 2 PM shift and B-bed residents will receive showers on the 2 PM to 10 PM Shift. The policy further revealed even numbered rooms will shower/bath Monday, Wednesday, Fridays, and odd number rooms will shower on Tuesday, Thursday, and Friday. The policy revealed every resident is offered a shower 3 times a week and are encouraged to take their shower on their scheduled day and time. Bed baths are an acceptable option, but the best practice is a full warm shower, so all areas of skin are cleaned .bed baths are good, but not as good or beneficial as a nice invigorating shower. <BR/>Record Review of the facility's call light policy dated 3-2018, shows the purpose and guidelines are:<BR/> .to ensure timely responses to the resident's request and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident received adequate supervision and interventions for 3 of 6 residents (Resident #1, Resident #3, and Resident #5) reviewed for supervision and interventions.<BR/>1.The facility failed to use a Hoyer sling that was in good condition for Resident #1.<BR/>2. The facility failed to ensure Resident #3's wheelchair was in good condition.<BR/>3. The facility failed to safely supervise and transport Resident #5 to the facility at admission.<BR/>These failures could place residents at risk for accidents and injury.<BR/>Findings included:<BR/>1. Record review of Resident #1's admission record, dated 01/12/2024, revealed a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included cerebral infarction (stroke), vascular dementia, mixed receptive-expressive language disorder (difficulty understanding and using language) and hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) affecting right dominant side.<BR/>Record review of Resident #1's annual MDS, dated [DATE], revealed BIMS was not conducted and Resident #1 had moderate impaired cognitive skills for daily decision making. <BR/>Record review of Resident #1's care plan, dated 08/16/2016 and revised on 11/02/2021, revealed Resident #1 required extensive/total assist with ADL's, r/t hx of CVA, right flaccid with intervention of transfers with support x2 (Hoyer lift).<BR/>Observation on 01/11/2024 at 1:17 p.m., revealed Resident #1 sitting in his wheelchair, with a Hoyer sling underneath him. The green middle loops on both upper straps were broken and the purple and blue loops appeared undamaged. <BR/>Interview on 01/11/2024 at 1:17 p.m., LVN D stated he assisted the aides to get Resident #1 up and they used the purple or blue loops on the sling. He stated the green loops were broken and the straps looked worn. LVN D stated the sling should be inspected before each use for safety. He said residents could fall or worse. He stated the DON just ordered 12 new slings so each resident that required a Hoyer lift will have a personal sling. He said on his side 6 or 7 residents needed to use the Hoyer lift and about 12-13 residents for the whole building. <BR/>Interview on 01/12/2024 at 1:45 pm, the DON stated they just ordered slings earlier in the week. She stated she did not know the loops were broken on Resident #1's sling. She said the staff did not use the green loop but should not have used that sling at all because they had other slings. The DON stated the plan was for each resident to have their own sling [that required one], and two extra slings at the nurse's station. She said the night shift will wash and distribute them. The DON stated the slings must be inspected before use, and if frayed or broken, they would not be used. She stated the CNA should look at the sling to see if it was broken. She said she did not expect laundry to inspect the slings, but if the sling was falling apart, they would let them know because they have done that before. She said if slings were not inspected the resident could be injured. <BR/>Record review of census list dated 01/12/2024, provided by the facility revealed 13 residents required the use of Hoyer lift for transfers.<BR/>Record review of invoice dated 01/10/2024 revealed a purchase order for 11 large sized lift slings and 2 bariatric sized lift slings.<BR/>Observation on 01/12/2024 at 1:16 pm, revealed 12 residents had slings that appeared to be in good condition or new.<BR/>2. Record review of Resident #3's admission record, dated 01/12/2023, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of metabolic encephalopathy (brain dysfunction).<BR/>Record review of Resident #3's admission MDS, dated [DATE], revealed a BIMS of 9, indicating moderate cognitive impairment. <BR/>Observation and interview on 01/11/2024 at 12:56 p.m., revealed the backrest upholstery of the wheelchair appeared torn on Resident #3's left side. Resident #3 said the backing of his wheelchair came off and has been that way for about a week. He stated it was going to get replaced next week. Resident #1 stated he thought it was because of a bag he used on the back of the wheelchair to carry his belongings. <BR/>Interview on 01/12/2024 at 1:45 p.m., the DON stated Resident #3's wheelchair was not safe at all. She said she thought the wheelchair was brought with him and he was very protective of his wheelchair. The DON stated she did not know the wheelchair looked like that and said Resident #3 could fall out, the chair could flip over, and he could be injured. The DON stated Resident #3 was on therapy caseload and would ensure the wheelchair was functioning.<BR/>3. Record review of Resident #5's admission record, dated 01/12/2024, revealed an [AGE] year-old male who admitted on [DATE] with a diagnosis of dementia.<BR/>Record review of Resident #5's Nurse's Note, dated 11/2/2023 at 2:00 p.m., revealed Resident received in room [number], MD notified of new admission, medications verified, and placed on EMAR.<BR/>Record review of Resident #5's Discharge summary, dated [DATE] at 11:20 p.m., revealed Family wanted to take [him] home as they said that they did not approve for the resident to be in this facility.<BR/>Interview on 01/12/2024 at 9:31 a.m., with the Marketer revealed he and the Housekeeping Supervisor brought Resident #5 over because he was just across the street and the other facility's van was busy. He stated Resident #5 was in a wheelchair and had just one bag. <BR/>Interview on 01/12/2024 at 12:13 p.m., the Administrator stated the SW had just briefed him about Resident #5. He stated [facility name] was their next-door neighbor and he was not here at that time, or aware of how Resident #5 was transported. He stated the previous Administrator only came in on the weekends and that was a time when they did not have a daily administrator. He said that the Housekeeping Supervisor was not normally involved in the admission process that way. He stated the facility did not have its own facility van. He said Resident #5 should have been transported by facility van or transport should have been set up with outside companies the facility has a contract with. <BR/>Interview on 01/12/2024 at 1:45 p.m., the DON stated before a resident admits and they come from the hospital, the Marketer gives them the list of contracted transportation companies. If a resident came from another facility, he would give them the name of the company they contract with and tell that facility to contact them to schedule transportation. The DON stated she did not know why the staff members went over to get Resident #5 and expected that transportation be arranged or have the proper personnel from the transferring facility bring the resident. She stated it could have been potential harm, anything could have happened to Resident #5. <BR/>Record review of the facility's policy titled Assistive Devices and Equipment revised July 2017, reflected, in part: Our facility provides, maintains, trains and supervises the use of assistive devices and equipment for residents .1. Devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include but are not limited to: a. Wheelchairs (manual and powered); b. Walkers; and c. Canes .5. The following factors will be addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment .c. Device condition - devices and equipment will be maintained on schedule and according to manufacturer's instructions. Defective or worn devices will be discarded or repaired.<BR/>Record review of the facility's policy titled Admissions Policies, revised 2006, reflected, in part: 1. The primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility. The policy did not reflect guidelines for resident transportation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observations and record review, the facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for three (Residents #1, #2, and #3) of six residents reviewed for incontinent care and catheter care, in that: <BR/>Residents #1, #2, and #3 had an indwelling urinary catheter (a catheter which is inserted into the bladder, via the urethra and remains in to drain urine) without a physician's order, regarding a valid rationale for the placement of an indwelling urinary catheter. <BR/>This deficient practice could place residents at-risk for infection due to improper care practice. <BR/>The findings included:<BR/>Record Review of resident #1's face sheet, printed on 02/29/24, indicated Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1 had diagnosis of tracheostomy status (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck), depression, anxiety disorder, adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior), mild cognitive impairment of uncertain or unknown etiology (problems with memory, language or judgment.), epileptic seizures, essential (primary) hypertension (abnormally high blood pressure ), chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems), chronic respiratory failure (a serious condition that makes it difficult to breathe), obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional). <BR/>Record review of Resident #1's quarterly MDS assessment, dated 01/24/24, reflected Resident #1 had a BIMS score of 08, which indicated Resident #1 had moderate cognitive impairment. Section GG - Functional Abilities and Goals, question GG0130. Self-Care indicated Resident #1 required maximal assistance with ADLs of oral hygiene, toileting, bathing, dressing and personal hygiene. Section H - Bladder and Bowel, question H0100. Appliances indicated Resident #1 had an indwelling catheter. <BR/>Record review of Resident #1's Care Plan, initiated on 01/16/24, reflected . indwelling catheter due to diagnosis of obstructive uropathy . Interventions - Catheter care every shift, change catheter tubing and bag as facility protocol, encourage fluid intake, keep fresh water within reach . <BR/>Record review of Resident #1's physician orders tab of his electronic health record indicated the following orders, with a start date of 01/17/24:<BR/> - foley [catheter] (soft, plastic or rubber tube that is inserted into the bladder to drain the urine)care with soap and water q shift every shift. <BR/>- foley [catheter] output q shift every shift.<BR/>The physician orders tab revealed no other order for an indwelling urinary catheter.<BR/>In an observation and interview on 02/29/24 at 11:45 a.m., Resident #1 was observed in his room sitting in a wheelchair, with a catheter bag hung below his chair. Resident #1 stated he had no issues with his catheter or care provided. <BR/>Record review of Resident #2's face sheet, printed on 02/29/24, indicated Resident #2 was an [AGE] year-old male who admitted to the facility on [DATE]. Resident #2 had diagnoses of paraplegia (paralysis that affects the legs), sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection), chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems) , chronic respiratory failure (a serious condition that makes it difficult to breathe), hypercapnia (high levels of carbon dioxide in the blood), flaccid neuropathic bladder (bladder doesn't contract enough), type 2 diabetes mellitus (insulin resistance), essential (primary) hypertension (abnormally high blood pressure ),, other speech and language deficits following cerebral infarction, low back pain, obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional), cerebral infarction (stroke). <BR/>Record review of Resident #2's quarterly MDS assessment, dated 12/18/23, reflected Resident #2 had a BIMS score of 11, which indicated he had moderate cognitive impairment. Section GG - Functional Abilities and Goals, question GG0130. Self-Care indicated Resident #2 required moderate assistance with ADLs of bathing, toileting, dressing, and required touching assistance with personal hygiene, and oral hygiene. Section H - Bladder and Bowel, question H0100. Appliances indicated Resident #2 had an indwelling catheter. <BR/>Record review of Resident #2's Care Plan, initiated on 08/26/23, reflected . indwelling catheter due to diagnosis of obstructive uropathy . Interventions - Catheter care every shift, encourage fluid intake, keep fresh water within reach.<BR/> Ongoing assessment of color, clarity and character of urine . <BR/>Record review of Resident #2's physician orders tab of his electronic health record indicated RECORD URINARY OUTPUT FROM FOLEY CATHETER Q SHIFT., with a start date of 12/06/23. The physician orders tab revealed no other order for an indwelling urinary catheter.<BR/>In an observation and interview on 02/29/24 at 9:45 a.m. at a local hospital, revealed Resident #2 was observed with a catheter, but decline to speak with the surveyor. <BR/>Record review of Resident #3's face sheet, printed on 02/29/24, reflected Resident #3 was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #3 had diagnoses of unspecified psychosis not due to a substance or known physiological condition ( collection of symptoms that affect the mind), encephalopathy (disease that affects the brain), anemia(low red blood cell count), type 2 diabetes mellitus (insulin resistance), bipolar disorder (a serious mental illness that causes unusual shifts in mood), paranoid personality disorder (a mental health condition marked by a long-term pattern of distrust and suspicion of others without adequate reason to be suspicious), obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional).<BR/>Record review of Resident #3's quarterly MDS assessment, dated 02/11/24, reflected Resident #3 had a BIMS of 05, which indicated Resident #3 had severe cognitive impairment. Section GG - Functional Abilities and Goals, question GG0130. Self-Care indicated Resident #3 required maximal assistance with ADLs of toileting, bathing, dressing, and personal hygiene. Section H - Bladder and Bowel, question H0100. Appliances indicated Resident #3 had an indwelling catheter. <BR/>Record review of Resident #3's Care Plan, initiated on 01/22/24, reflected . indwelling catheter due to diagnosis of obstructive uropathy . Interventions - Catheter care every shift, change catheter tubing and bag as facility protocol, observe for acute behavioral changes that may indicate UTI . <BR/>Record review of Resident #3's physician orders tab of his electronic health record indicated Foley catheter care every shift and PRN with soap and water, with a start date of 01/20/24. The physician orders tab revealed no other order for an indwelling urinary catheter.<BR/>In an observation on 02/29/24 at 11:50 a.m., Resident #3 was observed laying in his bed asleep, with a catheter bag hung from his bedside. <BR/>In an interview on 02/29/24 at 5:20 p.m., the ADON stated she was unaware that Residents #1, #2 and #3 did not have foley catheter physician orders. The ADON stated when a resident admits to the facility with a catheter, it is the responsibility of the admitting nurse to review the resident's admittance orders and notify the residents physician of the catheter. The ADON stated the order for the catheter, catheter care and as needed reinsertion would be written by the physician. The ADON stated residents who had catheters without orders could introduce an infection control issue. The ADON stated the facility would in-service staff on catheter orders, care and monitoring. The ADON stated an audit would be heal on all residents to ensure all orders were written and in residents electronic health record as needed. <BR/>In an interview on 02/29/24 at 5:32 p.m. with the ADMIN and CM revealed it was the facilities expectation that catheter orders be placed in the electronic health record of every resident with a catheter and catheter care would be provided per physician orders. The CM stated nurses ADON and DON were to ensure catheter orders were in residents health records as needed and not having the orders in their health records would make the resident susceptible to infection. The CM stated an in-service on catheter orders and care would be started. The CM and ADMIN stated the facility would review residents' health records to ensure orders were entered appropriately. <BR/>Record review of a facility policy titled, Catheter Care, Urinary, revised in August 2022, revealed no verbiage regarding a valid rationale for the placement of an indwelling urinary catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident received adequate supervision and interventions for 3 of 6 residents (Resident #1, Resident #3, and Resident #5) reviewed for supervision and interventions.<BR/>1.The facility failed to use a Hoyer sling that was in good condition for Resident #1.<BR/>2. The facility failed to ensure Resident #3's wheelchair was in good condition.<BR/>3. The facility failed to safely supervise and transport Resident #5 to the facility at admission.<BR/>These failures could place residents at risk for accidents and injury.<BR/>Findings included:<BR/>1. Record review of Resident #1's admission record, dated 01/12/2024, revealed a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included cerebral infarction (stroke), vascular dementia, mixed receptive-expressive language disorder (difficulty understanding and using language) and hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) affecting right dominant side.<BR/>Record review of Resident #1's annual MDS, dated [DATE], revealed BIMS was not conducted and Resident #1 had moderate impaired cognitive skills for daily decision making. <BR/>Record review of Resident #1's care plan, dated 08/16/2016 and revised on 11/02/2021, revealed Resident #1 required extensive/total assist with ADL's, r/t hx of CVA, right flaccid with intervention of transfers with support x2 (Hoyer lift).<BR/>Observation on 01/11/2024 at 1:17 p.m., revealed Resident #1 sitting in his wheelchair, with a Hoyer sling underneath him. The green middle loops on both upper straps were broken and the purple and blue loops appeared undamaged. <BR/>Interview on 01/11/2024 at 1:17 p.m., LVN D stated he assisted the aides to get Resident #1 up and they used the purple or blue loops on the sling. He stated the green loops were broken and the straps looked worn. LVN D stated the sling should be inspected before each use for safety. He said residents could fall or worse. He stated the DON just ordered 12 new slings so each resident that required a Hoyer lift will have a personal sling. He said on his side 6 or 7 residents needed to use the Hoyer lift and about 12-13 residents for the whole building. <BR/>Interview on 01/12/2024 at 1:45 pm, the DON stated they just ordered slings earlier in the week. She stated she did not know the loops were broken on Resident #1's sling. She said the staff did not use the green loop but should not have used that sling at all because they had other slings. The DON stated the plan was for each resident to have their own sling [that required one], and two extra slings at the nurse's station. She said the night shift will wash and distribute them. The DON stated the slings must be inspected before use, and if frayed or broken, they would not be used. She stated the CNA should look at the sling to see if it was broken. She said she did not expect laundry to inspect the slings, but if the sling was falling apart, they would let them know because they have done that before. She said if slings were not inspected the resident could be injured. <BR/>Record review of census list dated 01/12/2024, provided by the facility revealed 13 residents required the use of Hoyer lift for transfers.<BR/>Record review of invoice dated 01/10/2024 revealed a purchase order for 11 large sized lift slings and 2 bariatric sized lift slings.<BR/>Observation on 01/12/2024 at 1:16 pm, revealed 12 residents had slings that appeared to be in good condition or new.<BR/>2. Record review of Resident #3's admission record, dated 01/12/2023, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of metabolic encephalopathy (brain dysfunction).<BR/>Record review of Resident #3's admission MDS, dated [DATE], revealed a BIMS of 9, indicating moderate cognitive impairment. <BR/>Observation and interview on 01/11/2024 at 12:56 p.m., revealed the backrest upholstery of the wheelchair appeared torn on Resident #3's left side. Resident #3 said the backing of his wheelchair came off and has been that way for about a week. He stated it was going to get replaced next week. Resident #1 stated he thought it was because of a bag he used on the back of the wheelchair to carry his belongings. <BR/>Interview on 01/12/2024 at 1:45 p.m., the DON stated Resident #3's wheelchair was not safe at all. She said she thought the wheelchair was brought with him and he was very protective of his wheelchair. The DON stated she did not know the wheelchair looked like that and said Resident #3 could fall out, the chair could flip over, and he could be injured. The DON stated Resident #3 was on therapy caseload and would ensure the wheelchair was functioning.<BR/>3. Record review of Resident #5's admission record, dated 01/12/2024, revealed an [AGE] year-old male who admitted on [DATE] with a diagnosis of dementia.<BR/>Record review of Resident #5's Nurse's Note, dated 11/2/2023 at 2:00 p.m., revealed Resident received in room [number], MD notified of new admission, medications verified, and placed on EMAR.<BR/>Record review of Resident #5's Discharge summary, dated [DATE] at 11:20 p.m., revealed Family wanted to take [him] home as they said that they did not approve for the resident to be in this facility.<BR/>Interview on 01/12/2024 at 9:31 a.m., with the Marketer revealed he and the Housekeeping Supervisor brought Resident #5 over because he was just across the street and the other facility's van was busy. He stated Resident #5 was in a wheelchair and had just one bag. <BR/>Interview on 01/12/2024 at 12:13 p.m., the Administrator stated the SW had just briefed him about Resident #5. He stated [facility name] was their next-door neighbor and he was not here at that time, or aware of how Resident #5 was transported. He stated the previous Administrator only came in on the weekends and that was a time when they did not have a daily administrator. He said that the Housekeeping Supervisor was not normally involved in the admission process that way. He stated the facility did not have its own facility van. He said Resident #5 should have been transported by facility van or transport should have been set up with outside companies the facility has a contract with. <BR/>Interview on 01/12/2024 at 1:45 p.m., the DON stated before a resident admits and they come from the hospital, the Marketer gives them the list of contracted transportation companies. If a resident came from another facility, he would give them the name of the company they contract with and tell that facility to contact them to schedule transportation. The DON stated she did not know why the staff members went over to get Resident #5 and expected that transportation be arranged or have the proper personnel from the transferring facility bring the resident. She stated it could have been potential harm, anything could have happened to Resident #5. <BR/>Record review of the facility's policy titled Assistive Devices and Equipment revised July 2017, reflected, in part: Our facility provides, maintains, trains and supervises the use of assistive devices and equipment for residents .1. Devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include but are not limited to: a. Wheelchairs (manual and powered); b. Walkers; and c. Canes .5. The following factors will be addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment .c. Device condition - devices and equipment will be maintained on schedule and according to manufacturer's instructions. Defective or worn devices will be discarded or repaired.<BR/>Record review of the facility's policy titled Admissions Policies, revised 2006, reflected, in part: 1. The primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility. The policy did not reflect guidelines for resident transportation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident received adequate supervision and interventions for 3 of 6 residents (Resident #1, Resident #3, and Resident #5) reviewed for supervision and interventions.<BR/>1.The facility failed to use a Hoyer sling that was in good condition for Resident #1.<BR/>2. The facility failed to ensure Resident #3's wheelchair was in good condition.<BR/>3. The facility failed to safely supervise and transport Resident #5 to the facility at admission.<BR/>These failures could place residents at risk for accidents and injury.<BR/>Findings included:<BR/>1. Record review of Resident #1's admission record, dated 01/12/2024, revealed a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included cerebral infarction (stroke), vascular dementia, mixed receptive-expressive language disorder (difficulty understanding and using language) and hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) affecting right dominant side.<BR/>Record review of Resident #1's annual MDS, dated [DATE], revealed BIMS was not conducted and Resident #1 had moderate impaired cognitive skills for daily decision making. <BR/>Record review of Resident #1's care plan, dated 08/16/2016 and revised on 11/02/2021, revealed Resident #1 required extensive/total assist with ADL's, r/t hx of CVA, right flaccid with intervention of transfers with support x2 (Hoyer lift).<BR/>Observation on 01/11/2024 at 1:17 p.m., revealed Resident #1 sitting in his wheelchair, with a Hoyer sling underneath him. The green middle loops on both upper straps were broken and the purple and blue loops appeared undamaged. <BR/>Interview on 01/11/2024 at 1:17 p.m., LVN D stated he assisted the aides to get Resident #1 up and they used the purple or blue loops on the sling. He stated the green loops were broken and the straps looked worn. LVN D stated the sling should be inspected before each use for safety. He said residents could fall or worse. He stated the DON just ordered 12 new slings so each resident that required a Hoyer lift will have a personal sling. He said on his side 6 or 7 residents needed to use the Hoyer lift and about 12-13 residents for the whole building. <BR/>Interview on 01/12/2024 at 1:45 pm, the DON stated they just ordered slings earlier in the week. She stated she did not know the loops were broken on Resident #1's sling. She said the staff did not use the green loop but should not have used that sling at all because they had other slings. The DON stated the plan was for each resident to have their own sling [that required one], and two extra slings at the nurse's station. She said the night shift will wash and distribute them. The DON stated the slings must be inspected before use, and if frayed or broken, they would not be used. She stated the CNA should look at the sling to see if it was broken. She said she did not expect laundry to inspect the slings, but if the sling was falling apart, they would let them know because they have done that before. She said if slings were not inspected the resident could be injured. <BR/>Record review of census list dated 01/12/2024, provided by the facility revealed 13 residents required the use of Hoyer lift for transfers.<BR/>Record review of invoice dated 01/10/2024 revealed a purchase order for 11 large sized lift slings and 2 bariatric sized lift slings.<BR/>Observation on 01/12/2024 at 1:16 pm, revealed 12 residents had slings that appeared to be in good condition or new.<BR/>2. Record review of Resident #3's admission record, dated 01/12/2023, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of metabolic encephalopathy (brain dysfunction).<BR/>Record review of Resident #3's admission MDS, dated [DATE], revealed a BIMS of 9, indicating moderate cognitive impairment. <BR/>Observation and interview on 01/11/2024 at 12:56 p.m., revealed the backrest upholstery of the wheelchair appeared torn on Resident #3's left side. Resident #3 said the backing of his wheelchair came off and has been that way for about a week. He stated it was going to get replaced next week. Resident #1 stated he thought it was because of a bag he used on the back of the wheelchair to carry his belongings. <BR/>Interview on 01/12/2024 at 1:45 p.m., the DON stated Resident #3's wheelchair was not safe at all. She said she thought the wheelchair was brought with him and he was very protective of his wheelchair. The DON stated she did not know the wheelchair looked like that and said Resident #3 could fall out, the chair could flip over, and he could be injured. The DON stated Resident #3 was on therapy caseload and would ensure the wheelchair was functioning.<BR/>3. Record review of Resident #5's admission record, dated 01/12/2024, revealed an [AGE] year-old male who admitted on [DATE] with a diagnosis of dementia.<BR/>Record review of Resident #5's Nurse's Note, dated 11/2/2023 at 2:00 p.m., revealed Resident received in room [number], MD notified of new admission, medications verified, and placed on EMAR.<BR/>Record review of Resident #5's Discharge summary, dated [DATE] at 11:20 p.m., revealed Family wanted to take [him] home as they said that they did not approve for the resident to be in this facility.<BR/>Interview on 01/12/2024 at 9:31 a.m., with the Marketer revealed he and the Housekeeping Supervisor brought Resident #5 over because he was just across the street and the other facility's van was busy. He stated Resident #5 was in a wheelchair and had just one bag. <BR/>Interview on 01/12/2024 at 12:13 p.m., the Administrator stated the SW had just briefed him about Resident #5. He stated [facility name] was their next-door neighbor and he was not here at that time, or aware of how Resident #5 was transported. He stated the previous Administrator only came in on the weekends and that was a time when they did not have a daily administrator. He said that the Housekeeping Supervisor was not normally involved in the admission process that way. He stated the facility did not have its own facility van. He said Resident #5 should have been transported by facility van or transport should have been set up with outside companies the facility has a contract with. <BR/>Interview on 01/12/2024 at 1:45 p.m., the DON stated before a resident admits and they come from the hospital, the Marketer gives them the list of contracted transportation companies. If a resident came from another facility, he would give them the name of the company they contract with and tell that facility to contact them to schedule transportation. The DON stated she did not know why the staff members went over to get Resident #5 and expected that transportation be arranged or have the proper personnel from the transferring facility bring the resident. She stated it could have been potential harm, anything could have happened to Resident #5. <BR/>Record review of the facility's policy titled Assistive Devices and Equipment revised July 2017, reflected, in part: Our facility provides, maintains, trains and supervises the use of assistive devices and equipment for residents .1. Devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include but are not limited to: a. Wheelchairs (manual and powered); b. Walkers; and c. Canes .5. The following factors will be addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment .c. Device condition - devices and equipment will be maintained on schedule and according to manufacturer's instructions. Defective or worn devices will be discarded or repaired.<BR/>Record review of the facility's policy titled Admissions Policies, revised 2006, reflected, in part: 1. The primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility. The policy did not reflect guidelines for resident transportation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility are labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions for one (Resident #38) of five residents reviewed for storage of drugs and Biologicals.<BR/>The facility failed to ensure MA B administered Amiodarone 200 mg (a medication used to regulate and lower heat rate) without checking vital signs or heart rate for Resident # 38 even with warning reflected on the medication bubble card to hold if heart rate was less than 60 BPM. <BR/>These failure could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.<BR/>Record review of Resident #38's face sheet, dated 06/24/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy (a condition of brain confusion due to chemical imbalance in the blood), left tibia (lower leg) fracture, left hip fracture, vision loss in both eyes, muscle wasting and dying muscle (atrophy), atrial fibrillation (an irregular heartbeat), type 2 diabetes (a condition of uncontrolled blood sugar), high blood pressure (hypertension), cataract in both eyes (an eye disease that causes vision loss) and kidney failure. <BR/>Record review of Resident #38's quarterly MDS, dated [DATE], reflected a BIMS of 3 out of 15, which indicated severe cognitive impairment. <BR/>Record review of Resident #38's order summary, dated 06/24/24, reflected Amiodarone HCl Oral Tablet 200 MG (Amiodarone HCl) Give 1 tablet by mouth in the morning for heart disease. <BR/>During medication observation and interview with MA B on 06/24/24 at 09:20 AM, revealed MA B took the medication bubble pack which contained medication Amiodarone 200 mg, she popped 1 pill out and placed it in a medication cup with other medications. She then handed over the medication bubble packs to be recorded by surveyor. The medication bubble pack read Amiodarone TAB 200MG. Give 1 tablet by mouth one time a day for atrial rhythm abnormality. Hold if HR&lt;60. Expiration 04/17/25. MA B administered all medications to Resident #38 without checking her BP and Heart Rate (HR). MA B said she did not know she had to check Resident #38's heart rate before administration of the Amiodarone 200 mg. She stated the bubble pack contained parameters from an old prescription given to Resident #38 before she went to the hospital. She stated she did not know the heart rate for Resident #38 prior to administering medication. She stated administration of heart medications without checking the heart rate could cause Resident #38's heart rate to drop lower and cause adverse effects.<BR/>In an interview with LVN D on 06/24/24 at 09:54 AM, he stated MA B should have checked Resident #38's vital signs. He said he expected MA B to not just follow the MAR but also to remember when administering any blood pressure or heart medications to check vital signs. He stated MA B should have looked at the bubble pack and saw the parameters to hold medication when or if heart rate was less than 60. He stated the risk to the resident was an adverse effect of a low heart rate or even low blood pressure. He stated he checked Resident #38's vitals and notified the physician and RP. He stated the physician gave orders to hold all of Resident #38's blood pressure medications for the day. He stated he would continue to monitor Resident #38 and notify the physician.<BR/>In an interview with the DON on 06/25/24 at 04:58 PM, she stated it was the physician's preference to add parameters to blood pressure medications. She stated the physician did not add nor did not require the nursing staff to have BP parameters to administer BP medications to residents. The DON stated the pharmacists had also told her they do not need to check BP and HR before medication administration because residents did not even check their own BP at home before taking these medications. She stated had the physician added parameters to the orders, then she would expect the nursing staff to follow the physician parameters for BP and HR medication administrations. She did not state risk to resident.<BR/>In an interview with the Medical Director on 06/27/24 at 03:18 PM, he stated the facility notified him of the missing parameters for BP medications. He stated he put in place a standing blanket order with parameters for all BP medications as of Wednesday 06/26/24 [after surveyor intervention]. He stated he expected the nursing staff to add parameters when he gave them verbal orders and to ask him if the parameters were missing on orders. He stated it was best nursing practice to always check vital signs before administering medications that altered BP or HR. He stated residents who came back from the hospital with new BP medications may have missing parameters, however, he expected the nursing staff to notify him for clarification. He stated not checking vital signs before administering blood pressure or heart medication could cause adverse effects to the patient because you did not know the current vital signs whether it was too high or too low. He stated moving forward, he expected to be notified of missing parameters on orders.<BR/>In an interview with the ADM on 06/25/24 at 06:05 PM, he stated he expected all staff to follow the medication administration policy when administering medications.<BR/>Record review of the facility's Administering Medications, dated April 2019, read in part, . Medications shall be administered in a safe and timely manner, and as prescribed . Policy Interpretation and Implementation .eight. if a dosage is believed to be inappropriate or excessive for a resident or the medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences the person preparing or administering the medication will contact the prescriber, the residents attending physician or the facility's medical director to discuss the concerns .10. The individual administering the medication checks the label three times to verify the right residence, right medication, right dose, right time, right method, before giving the medication. 11. the following information is checked/verified for each resident prior to administering medication; allergies to medication and vital signs if necessary

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food and nutrition services.<BR/>The facility failed to ensure food items were kept away from potential airborne contaminants (leaking sinks, dust particle and grease). <BR/>This failure could place residents at risk for food contamination and foodborne illness.<BR/>Findings included:<BR/>Observation on 04/08/25 at 8:00 AM, revealed behind the air fryer area had white and brown grease on the wall. Observation of the floor revealed brown grease behind the equipment that ran from the air fryer to the stove. <BR/>Observation on 04/08/25 at 8:30 AM, revealed one white towel that had turned brown was wrapped around a pipe. Under the towel was a hole that the piping did not fit into, and water was running to the hole. <BR/>Observation on 04/08/25 at 8:35 AM, revealed another white towel that had turned brown underneath the pots and pans sink. <BR/>Interview on 04/08/25 at 9:00 AM, CK stated the pipes had been leaking for a while and maintence worked with a plumber who put that extra pipe in for the water to flow but, the pipe was the wrong size and does not cover that hole. The towel was wrapped around the pipe to stop the water from splashing everywhere. The CK stated the pots and pans sink had a leak and <BR/>Interview on 04/08/25 at 9:30 AM, DM stated she was not exactly sure how long the pipes had been leaking. The DM stated the MD had work with a plumber and they keep saying they will be out to the facility every week and have not shown up again. The DM stated all staff are responsible for keeping the kitchen clean. The DM stated she writes down in her planner who cleaned what equipment in the kitchen. The DM said she does not think residents are at risk for cross contamination because their food are not near the sinks or air fryer.<BR/>On 04/08/25 at 9:40 AM, this Surveyor requested from the DM the cleaning schedule, and photocopy of planner on which staff completed kitchen -up. Surveyor did not receive documentation before exiting. <BR/>Interview on 04/08/25 at 9:58 AM, the MD stated he had worked with a plumber who gave an estimate of $50,000 to complete the necessary work for the kitchen. The MD stated the plumber that he is currently working with had cut the cost to more than half of the original estimate. The MD stated the plumbers' teams had to push back the work for the facility for another job. The MD stated the facility is working on getting the plumbing fixed in the kitchen. <BR/>Attempted to interview plumber on 04/09/25 at 9:00 AM, he stated to contact the MD at the facility, and he will be able to go over the details of the repair. <BR/>Record review of facility policy, undated, Sanitization reflected the food service area shall be maintained in a clean and sanitary manner. 1. All kitchen, kitchen areas and dining area shall be kept clean, free from litter and rubbish . 17. The food service manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work area during all tasks, and to clean after each task before proceeding to the next assignment. <BR/>Record review of plumber estimate sheet reflected plumber did an investigation of the kitchen on 01/20/25. Investigation reflected the sewer in kitchen floods the floor when 3 compartment sink is drained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview 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 one of ten residents (Residents #19) reviewed for infection control.<BR/>1. The facility failed to ensure MA A performed hand hygiene and wore gloves when administering eye medication to Resident #19.<BR/>2. The facility failed to ensure MA A did not use his bare finger to remove Coreg 6.25 MG tablet out of Resident #19's. <BR/>medication cup before administering her medications.<BR/>These failures could place residents at risk of infectious diseases and cross contamination.<BR/>Findings include:<BR/>1. Record review of Resident #19's face sheet, dated 06/25/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included generalized anxiety disorder a condition of severe, ongoing anxiety that interferes with daily activities, breast cancer, depression, low vision in right eye, high blood pressure, high cholesterol, and a fracture of the lower legs. Resident #19 was her own responsible party.<BR/>Record review of Resident #19's quarterly MDS, dated [DATE], reflected Resident #19 had a BIMS of 15 out of 15, which indicated she was cognitively intact. Resident #19 could understand others and others could understand her. <BR/>Record review of Resident #19's order summary, dated 06/24/24, reflected:<BR/>1.Coreg Oral Tablet 6.25 MG (Carvedilol). Give 1 tablet by mouth two times a day related to essential (primary) hypertension.<BR/>2. Artificial Tears Ophthalmic Solution (Artificial Tear Solution) Instill 2 drop in both eyes two times a day for dry eyes.<BR/>During medication observation and interview with MA A on 06/24/24 at 08:19 AM, revealed MA A performed hand hygiene with hand sanitizer, he dispensed six medications in a medication cup for Resident #19. Then he stated he needed to check Resident #19 BP and he took the medication cup and locked it in the med cart. He took the BP cuff and went into Resident #19's room to check her BP. The reading was 105/72 with a pulse rate of 69 BPM. He returned to med cart, placed the soiled BP cuff on top of med cart. He got the keys out of his pocket and unlocked the med cart. No hand hygiene was performed after checking the BP. He picked up the medication cup and retrieved the Artificial Tears Ophthalmic Solution medication box for Resident #19. He placed both items on top of med cart. With no hand hygiene performed and no gloves on his right hand, MA A reached into Resident #19's medication cup, and he took the Coreg 6.25 MG tablet out of the medication cup with his pointer finger. He placed the pill in the sharps, and he stated he would notify the nurse for holding the BP medication due to the vital sign reading. No hand hygiene was performed after touching the pill with his bare hand. MA A picked up the eye drops, medication cup and a soft tissue paper and went into Resident #19's room. He handed Resident #19 her pills and she took them. He then put two eye drops in each eye and wiped the excess with the soft tissue then he handed Resident #19 the soft paper tissue to wipe herself. He went back to the med cart, took keys out of his pocket, and unlocked the med cart and placed the eye drops back inside the med cart. MA A performed hand hygiene and he pushed the med cart to the next room. MA A stated he performed hand hygiene, and it was missed by the observer. He stated he was not aware he could not touch the pill with his bare finger. He stated he forgot to wear gloves when administering the eye drops to Resident #19. He stated the risk to the resident was to spread infection. <BR/>In an interview with the DON on 06/25/24 at 04:58 PM, she stated MA A should have used a spoon or gloved hand to remove the pill from Resident #19's cup. She stated she expected all staff to perform hand hygiene before and after medication administration. She stated she expected staff to wear gloves when administering eye drops to residents. <BR/>In an interview with the ADM on 06/25/24 at 06:05 PM, he stated he expected all staff to follow the facility policies of hand hygiene when administering medication and before and after resident care.<BR/>Record review of the facility's Administering Medications, revision date April 2019, read in part, .24. Staff should follow established facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precautions, etc.) for administration of medication as applicable. <BR/>Record review of the facility's policy titled Standard Precautions, revision date October 2028, read in part .the facility's infection control policies and practices are intended to facilitate maintaining a safe, a sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections . Policy Interpretation and Implementation . 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident received adequate supervision and interventions for 3 of 6 residents (Resident #1, Resident #3, and Resident #5) reviewed for supervision and interventions.<BR/>1.The facility failed to use a Hoyer sling that was in good condition for Resident #1.<BR/>2. The facility failed to ensure Resident #3's wheelchair was in good condition.<BR/>3. The facility failed to safely supervise and transport Resident #5 to the facility at admission.<BR/>These failures could place residents at risk for accidents and injury.<BR/>Findings included:<BR/>1. Record review of Resident #1's admission record, dated 01/12/2024, revealed a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included cerebral infarction (stroke), vascular dementia, mixed receptive-expressive language disorder (difficulty understanding and using language) and hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) affecting right dominant side.<BR/>Record review of Resident #1's annual MDS, dated [DATE], revealed BIMS was not conducted and Resident #1 had moderate impaired cognitive skills for daily decision making. <BR/>Record review of Resident #1's care plan, dated 08/16/2016 and revised on 11/02/2021, revealed Resident #1 required extensive/total assist with ADL's, r/t hx of CVA, right flaccid with intervention of transfers with support x2 (Hoyer lift).<BR/>Observation on 01/11/2024 at 1:17 p.m., revealed Resident #1 sitting in his wheelchair, with a Hoyer sling underneath him. The green middle loops on both upper straps were broken and the purple and blue loops appeared undamaged. <BR/>Interview on 01/11/2024 at 1:17 p.m., LVN D stated he assisted the aides to get Resident #1 up and they used the purple or blue loops on the sling. He stated the green loops were broken and the straps looked worn. LVN D stated the sling should be inspected before each use for safety. He said residents could fall or worse. He stated the DON just ordered 12 new slings so each resident that required a Hoyer lift will have a personal sling. He said on his side 6 or 7 residents needed to use the Hoyer lift and about 12-13 residents for the whole building. <BR/>Interview on 01/12/2024 at 1:45 pm, the DON stated they just ordered slings earlier in the week. She stated she did not know the loops were broken on Resident #1's sling. She said the staff did not use the green loop but should not have used that sling at all because they had other slings. The DON stated the plan was for each resident to have their own sling [that required one], and two extra slings at the nurse's station. She said the night shift will wash and distribute them. The DON stated the slings must be inspected before use, and if frayed or broken, they would not be used. She stated the CNA should look at the sling to see if it was broken. She said she did not expect laundry to inspect the slings, but if the sling was falling apart, they would let them know because they have done that before. She said if slings were not inspected the resident could be injured. <BR/>Record review of census list dated 01/12/2024, provided by the facility revealed 13 residents required the use of Hoyer lift for transfers.<BR/>Record review of invoice dated 01/10/2024 revealed a purchase order for 11 large sized lift slings and 2 bariatric sized lift slings.<BR/>Observation on 01/12/2024 at 1:16 pm, revealed 12 residents had slings that appeared to be in good condition or new.<BR/>2. Record review of Resident #3's admission record, dated 01/12/2023, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of metabolic encephalopathy (brain dysfunction).<BR/>Record review of Resident #3's admission MDS, dated [DATE], revealed a BIMS of 9, indicating moderate cognitive impairment. <BR/>Observation and interview on 01/11/2024 at 12:56 p.m., revealed the backrest upholstery of the wheelchair appeared torn on Resident #3's left side. Resident #3 said the backing of his wheelchair came off and has been that way for about a week. He stated it was going to get replaced next week. Resident #1 stated he thought it was because of a bag he used on the back of the wheelchair to carry his belongings. <BR/>Interview on 01/12/2024 at 1:45 p.m., the DON stated Resident #3's wheelchair was not safe at all. She said she thought the wheelchair was brought with him and he was very protective of his wheelchair. The DON stated she did not know the wheelchair looked like that and said Resident #3 could fall out, the chair could flip over, and he could be injured. The DON stated Resident #3 was on therapy caseload and would ensure the wheelchair was functioning.<BR/>3. Record review of Resident #5's admission record, dated 01/12/2024, revealed an [AGE] year-old male who admitted on [DATE] with a diagnosis of dementia.<BR/>Record review of Resident #5's Nurse's Note, dated 11/2/2023 at 2:00 p.m., revealed Resident received in room [number], MD notified of new admission, medications verified, and placed on EMAR.<BR/>Record review of Resident #5's Discharge summary, dated [DATE] at 11:20 p.m., revealed Family wanted to take [him] home as they said that they did not approve for the resident to be in this facility.<BR/>Interview on 01/12/2024 at 9:31 a.m., with the Marketer revealed he and the Housekeeping Supervisor brought Resident #5 over because he was just across the street and the other facility's van was busy. He stated Resident #5 was in a wheelchair and had just one bag. <BR/>Interview on 01/12/2024 at 12:13 p.m., the Administrator stated the SW had just briefed him about Resident #5. He stated [facility name] was their next-door neighbor and he was not here at that time, or aware of how Resident #5 was transported. He stated the previous Administrator only came in on the weekends and that was a time when they did not have a daily administrator. He said that the Housekeeping Supervisor was not normally involved in the admission process that way. He stated the facility did not have its own facility van. He said Resident #5 should have been transported by facility van or transport should have been set up with outside companies the facility has a contract with. <BR/>Interview on 01/12/2024 at 1:45 p.m., the DON stated before a resident admits and they come from the hospital, the Marketer gives them the list of contracted transportation companies. If a resident came from another facility, he would give them the name of the company they contract with and tell that facility to contact them to schedule transportation. The DON stated she did not know why the staff members went over to get Resident #5 and expected that transportation be arranged or have the proper personnel from the transferring facility bring the resident. She stated it could have been potential harm, anything could have happened to Resident #5. <BR/>Record review of the facility's policy titled Assistive Devices and Equipment revised July 2017, reflected, in part: Our facility provides, maintains, trains and supervises the use of assistive devices and equipment for residents .1. Devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include but are not limited to: a. Wheelchairs (manual and powered); b. Walkers; and c. Canes .5. The following factors will be addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment .c. Device condition - devices and equipment will be maintained on schedule and according to manufacturer's instructions. Defective or worn devices will be discarded or repaired.<BR/>Record review of the facility's policy titled Admissions Policies, revised 2006, reflected, in part: 1. The primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility. The policy did not reflect guidelines for resident transportation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to immediately report failed to report abuse, neglect, exploitation, or critical incidents for 1 of 4 resident (Resident #1) reviewed for reporting.<BR/>The facility failed to report an incident of resident to staff physical aggression/assault to HHSC.<BR/>This failure could place residents at risk for abuse, neglect and incidents.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 01/23/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizophrenia (serious mental condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) Type 2 Diabetes Mellitus with Diabetic, Unspecified Psychosis not due to substance or known major depressive disorder.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 10/28/24, reflected Resident #1 had a BIMS of 12, which indicated cognition moderate impaired. <BR/>Record review of Resident #1's care plan, revised 09/20/24, revealed the resident at risk for altered status due to a traumatic life experience while at a previous group home or [Nursing Facility]. Certain male figures in authority positions, with similar physical attributes or appearance at times trigger him. Interventions in place included: Administer medication as ordered, approach resident from the front and speak in a calm, unhurried manner .Identify cause/trigger for behavior and reduce factors that may provoke resident .Call [Family Member#1] if need to calm down or get him to comprehend the situation]<BR/> .<BR/>Record review revealed no incident/accident report was completed about Resident#1 incident on 01/22/25.<BR/>Record review of Resident#1 progress notes revealed no documentation about the incident on 01/22/25.<BR/>Record review of Texas Unified Licensing Information Portal on 01/23/25 at 12:00 PM reflected, the verbal and physical altercation between Resident#1 and Administrator was not uploaded.<BR/>Record review of Resident#1 incident provided to surveyor on 01/25/25 reflected: it was initiated on 01/22/25 with no completed/ locked date on the incident report. Incident description section reflected: This [LVN K] was notified by staff after the incident that [Resident#1] slapped [MA N] and physically attacked Administrator and [Resident#1] fell to the floor. Resident description reflected: [Resident#1] stated he was approached by Administrator, in what he felt was an aggressive manner so I just swung on his . Immediate action taken section reflected: [Resident#1] assessed for injuries. None noted, denied pain or any discomfort. Physician notified, In the agencies/people notified section reflected: no notification found,<BR/>In an interview on at DON stated she did not find out about the incident until Resident#1 family member came into her office on 01/23/25 at 10:00 AM and stated the Administrator hit Resident#1. DON stated she called the Nurse Consultant to be advised on what to do. <BR/>An interview over the phone on 01/23/25 at 1:30 PM, Nurse Consultant and Operation Manager stated they were not made aware of the incident between Resident#1 and the Administrator until 10:30 AM by the DON. <BR/>An interview on 01/23/25 at 1:15 PM DON stated that she does not do the incident and reports, upload the information in Tulip or contact HHSC. DON stated the Administrator was responsible for doing the incident and accident reports. DON stated no incident or accident report for the incident on 01/22/25 between Resident#1 and the Administrator had been completed. DON stated by this information not do not know what interventions need to be put in place to prevent further abuse. <BR/>An over the phone interview on 01/23/35 at 1:30 PM Nurse Consultant E and Operation Manager stated the Administrator had been suspended pending the investigation. Nurse Consultant stated she will work and trained the DON on how to do the incident reports. <BR/>An observation on 01/23/25 at 7am revealed the Administrator was in the building at 7AM and did not leave the building until 12:00 PM. <BR/>Record review of Administrator profile reflected: Administrator was hired on 11/27/23 and terminated on 01/24/25. <BR/>Record review of the facility policy titled Unusual Occurrence Reports revised 12/07, reflected: Other occurrences that interfere with facility operations and affects the welfare, safety, or health of residents, employees .2. Unusual occurrences shall reported via telephone to appropriate agencies as required by current law and/ or regulations within twenty-four (24) hours of such incidents or as otherwise required by federal and state regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure complete and accurate incident/accident report for 1 (Resident#1) of 4 residents reviewed for incident reports.<BR/>The facility failed to ensure Resident#1's incident report was completed on 01/22/25, which involved a verbal and physical altercation between Resident#1 and Administrator by LVN C.<BR/>This failure could place residents at risk of inaccurate or incomplete information, resulting in the risk of abuse or neglect by staff. <BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 01/23/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizophrenia (serious mental condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) Type 2 Diabetes Mellitus with Diabetic, Unspecified Psychosis not due to substance or known major depressive disorder.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 10/28/24, reflected Resident #1 had a BIMS of 12, which indicated cognition moderate impaired. <BR/>Record review of Resident #1's care plan, revised 09/20/24, revealed the resident at risk for altered status due to a traumatic life experience while at a previous group home or [Nursing Facility]. Certain male figures in authority positions, with similar physical attributes or appearance at times trigger him. Interventions in place included: Administer medication as ordered, approach resident from the front and speak in a calm, unhurried manner .Identify cause/trigger for behavior and reduce factors that may provoke resident .Call [Family Member#1] if need to calm down or get him to comprehend the situation]<BR/> .<BR/>Record review revealed no incident/accident report was completed about Resident#1 incident on 01/22/25.<BR/>Record review of Resident#1 progress notes revealed no documentation about the incident on 01/22/25.<BR/>Record review of Resident#1 assessments revealed no documentation of completed assessment on 01/22/25.<BR/>Record review of Resident#1 incident provided to surveyor on 01/25/25 reflected: it was initiated on 01/22/25 with no completed/ locked date on the incident report. Incident description section reflected: This [LVN K] was notified by staff after the incident that [Resident#1] slapped [MA N] and physically attacked Administrator and [Resident#1] fell to the floor. Resident description reflected: [Resident#1] stated he was approached by Administrator, in what he felt was an aggressive manner so I just swung on his . In the agencies/people notified section no notification found,<BR/>An interview on 12/23/24 at 2:30 PM, LVN K stated she did not witness the incident between the Administrator and the Resident#1 that happened on 01/22/25 at 7:00 PM. LVN K stated she was told about the incident after it happened. LVN K stated she did the incident report on 01/23/25 after the DON D told her to complete it. LVN K stated the incident and accident report should have been completed in the EHR under the resident's name the same day of the incident before she left for the day. <BR/>An interview on 12/23/24 at 3:30 PM, the DON stated the nurse who is over the resident was responsible for doing the incident/accident report. The DON stated the incident and accident report should be completed immediately after the incident or before staff leaves for the day. DON stated Resident could have delay treatment if there were injuries and/or abuse. DON stated no specific policy on documentation of incident reports in residents 'medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure they did not request or require residents to waive potential facility liability for losses of personal property for 1 of 4 Residents (Resident #1) reviewed for misappropriation.<BR/>The facility had Resident #1 sign a waiver indicating the facility would not be responsible for losses of personal property.<BR/>This deficient practice could place residents at risk for signing documents that waive facility liability for personal losses.<BR/>The findings included:<BR/>Review of Resident #1's MDS admission assessment, dated 03/24/23, revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses including cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture) . The MDS assessment did not show his BIMs score. <BR/>Review of Resident #1's face sheet dated 06/22/23 reflected he was his own responsible party. <BR/>Review of Resident #1's Cash on Hand form, dated 04/04/23, reflected:<BR/>Resident #1 admitted to facility with $890. The form advised the resident to open up a trust fund account or to have the money locked up to keep it safe. The form indicated the facility was not responsible for lost or misplaced property. <BR/>The form contained the resident's signature. <BR/>An observation of a video provided by the Administrator on 06/22/23 at 11:00 AM showed Agency CNA A entered Resident #1's room and then exited from his room. When she exited, she put her hand on her pocket. The video does not show Agency CNA A taking the wallet or money. <BR/>Interviews with Resident #1 on 06/21/23 at 1:00 PM and 3:55 PM revealed he was awake, alert, and oriented. He said he had money stolen by an agency CNA ($904) a few months prior. He said the police were involved, but he had not heard from the police in months. He said the facility had not reimbursed him for his loss. He said he was broke and could not buy anything but the issue had not affected him mentally. <BR/>An interview on 06/21/23 at 12:30 PM with the Administrator revealed Resident #1's money (unknown amount) was identified as missing on 04/20/23. He said he reviewed the camera footage and saw Agency CNA A go into his room and she put something in her pocket that was long and hanging out. She left the room and came back. The Administrator said he talked to her, and she denied taking the wallet, but that on the video he could definitely see that she had something long and black in her pocket. He said he made a report with the police department and gave them the copy of the video. The Administrator said he was not going to reimburse the resident because he refused to put the money in safe keeping as requested by the facility. The Administrator said he did not know the true amount that was in the wallet, because the resident never let anyone count it. The Administrator said they did not allow Agency CNA A to return to the facility. <BR/>An interview on 6/22/23 at 1:30 PM with Agency CNA A revealed she said she did not steal anything from Resident #1. She said she helped him to bed, and he told her the wallet was stolen. She said the Administrator called her and asked if she carried a phone in her pocket and she said she actually carried a lot of things in her pockets. She said the Administrator did not say she was accused of stealing.<BR/>An interview was attempted with the police department on 06/22/23 at 11:20 AM but they did not answer the phone.<BR/>Review of facility policy, Investigating Incidents of Theft and/or Misappropriation of Resident Property, dated April 2017 reflected, <BR/>1. Residents have the right to be free from theft and/or misappropriation of property .<BR/>4. Residents are not required or requested to waive facility liability for loss or misappropriation of personal property .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, 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 1 of 6 (Resident #2) residents reviewed for quality of care, in that:<BR/>The facility failed to provide wound care services for Resident #2 on the dates of 05/04, 05/07, 05/08 and 05/09 as ordered by the resident's wound care physician.<BR/>This failure could lead to an increased and unnecessary risk of complications including worsening of existing wounds, development of new wounds, and infection. <BR/>Findings Included:<BR/>A review of Resident #2's electronic face sheet revealed a [AGE] year-old male, was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #2 was discharged from the facility on 05/21/23. Resident#2's diagnoses included Diabetes, Schizophrenia, and Chronic viral Hepatitis C. Resident #2 was his responsible party. <BR/>A review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS of 09, indicating moderate cognitive impairment. The MDS for Resident#2 revealed no rejection of care. Resident#2 had no behaviors noted on the MDS. Resident #2 required supervision with setup help only with ADLs. The MDS revealed Resident #2 had no ulcers, wounds, or skin problems noted. The MDS noted Resident#2 received skin and ulcer/injury treatment that included, the application of nonsurgical dressings and the application of ointments/medications.<BR/>A review of Resident #2's care plan dated 04/22/23 revealed Resident was at risk for skin breakdown due to incontinence and poor mobility later revised on 04/07/23. Resident #2 had an alteration in skin integrity due to a diabetic ulcer to the posterior neck last revised on 09/11/22. Resident #2 was at risk for infection to a neck wound due to refusing wound care initiated on 04/15/23. The interventions included attempting wound care as ordered, psyche services as needed, and when Resident #2 refuses wound care attempt again at a later time. <BR/>An interview and observation with Resident #2 on 05/23/23 beginning at 9:17 am while at the local hospital, revealed he had called emergency services while at the facility on 05/21/23 because he was not receiving wound care treatment at the nursing facility. He had not refused wound care at the facility. Resident #2 believed the wound had gotten worse at the nursing facility. <BR/>A review of the local hospital record dated 05/23/23 for Resident #2 revealed the resident was admitted to the facility for a wound check, his Chronic wound to his neck/upper back, reports recently got worse with a foul odor. A review of Resident #2 skin revealed an assessment of a Significant open wound to the posterior neck and upper thoracic spine concerning a possible active versus chronic cellulitis process, there is also some ulceration concerning for possible malignant process. <BR/>A review of the Treatment Administration Record (TAR) for Resident #2 for May 2023, revealed he did not receive wound care treatment on the dates of 05/04, 05/07, 05/08, and 05/09 as ordered.<BR/>A review of the physician order for Resident #2 for May 2023, revealed an order of Cleanse posterior neck, wound with NS or wound cleanser, pat dry, apply gentamicin then Santyl, then Calcium Alginate to fit wound, and then cover with dry dressing daily and prn, with the start date of 04/19/23 and discharge date [DATE]. <BR/>A review of the physician order for Resident #2 for May 2023, revealed an active order of Cleanse posterior neck, wound with NS or wound cleanser, pat dry, apply Santyl, then Calcium Alginate to fit wound, and then cover with dry dressing daily and prn, with the start date of 05/10/23. <BR/>A review of the progress notes for Resident #2 for May 2023, revealed no evidence of Resident #2 receiving wound care treatment for 05/04, 05/07, 05/08, and 05/09 as ordered.<BR/>Review of Resident #2 weekly wound evaluation completed by the wound care physician on the following dates reflected:<BR/>04/25/23-Current Treatment plan: Cleanse posterior neck, wound with NS or wound cleanser, pat dry, apply gentamicin then Santyl, then Calcium Alginate to fit wound, and then cover with dry dressing daily and prn.<BR/>Wound progress: continue current tx as ordered <BR/>05/04/23- Current Treatment plan: gentamicin, Santyl, calcium alginate, cover with a dry dressing<BR/>Wound progress: Unchanged Continue with gentamicin, Santyl, and calcium alginate, and cover with a dry dressing.<BR/>05/09/23- Current Treatment plan: Cleanse posterior neck, wound with NS or wound cleanser, pat dry, apply Santyl, then Calcium Alginate to fit wound, and then cover with dry dressing daily and prn.<BR/>Wound progress: Unchanged, DC gentamicin, Continue with Santyl, and calcium alginate, and cover with dry dressing.<BR/>05/16/23- Current Treatment plan: Santyl, calcium, alginate, and dry dressing daily and prn.<BR/>Wound progress: worsening, continue with current tx as ordered. <BR/>An interview with the wound care physician on 05/23/23 at 10:05 am revealed he completed wound care treatment rounds weekly on Resident #2. The most recent evaluation on 05/16/23 reflected the neck wound has worsen. He had not been made aware Resident #2 had not received wound care on the dates of 05/04, 05/07, 05/08, and 05/09 as ordered. He was also not informed Resident #2 TAR reflected he refused wound care on 05/10, 05/11, 05/15, and 05/17. Resident #2 was noncompliant with his diabetic food options. Resident #2 would often it unhealthy snacks and juices, which could have affected the wound from healing properly. <BR/>An interview with the DON on 05/23/23 at 11:41 am revealed she was not aware the TAR for May 2023 reflected Resident #2 had not received wound care on the dates of 05/04, 05/07, 05/08, and 05/09 as ordered. The DON did not know why the resident had called 9-1-1 to be taken to the hospital on [DATE]. The nurses were required to notify her when the resident did not get wound care at the scheduled times. The DON stated the wound care was to be completed by each floor (hallway) nurse, before the end of the first shift.<BR/>A review of the facility's Wound care policy dated 10/10 revealed Documentiation:8. Any problems or complaints made by the resident related to the procedure.9. If the resident refused the treatment and the reason why. 10. The signature and titles of the person recording the data. Reporting. 1. Notify the supervisor if the resident refuses the wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident received adequate supervision and interventions for 3 of 6 residents (Resident #1, Resident #3, and Resident #5) reviewed for supervision and interventions.<BR/>1.The facility failed to use a Hoyer sling that was in good condition for Resident #1.<BR/>2. The facility failed to ensure Resident #3's wheelchair was in good condition.<BR/>3. The facility failed to safely supervise and transport Resident #5 to the facility at admission.<BR/>These failures could place residents at risk for accidents and injury.<BR/>Findings included:<BR/>1. Record review of Resident #1's admission record, dated 01/12/2024, revealed a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included cerebral infarction (stroke), vascular dementia, mixed receptive-expressive language disorder (difficulty understanding and using language) and hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) affecting right dominant side.<BR/>Record review of Resident #1's annual MDS, dated [DATE], revealed BIMS was not conducted and Resident #1 had moderate impaired cognitive skills for daily decision making. <BR/>Record review of Resident #1's care plan, dated 08/16/2016 and revised on 11/02/2021, revealed Resident #1 required extensive/total assist with ADL's, r/t hx of CVA, right flaccid with intervention of transfers with support x2 (Hoyer lift).<BR/>Observation on 01/11/2024 at 1:17 p.m., revealed Resident #1 sitting in his wheelchair, with a Hoyer sling underneath him. The green middle loops on both upper straps were broken and the purple and blue loops appeared undamaged. <BR/>Interview on 01/11/2024 at 1:17 p.m., LVN D stated he assisted the aides to get Resident #1 up and they used the purple or blue loops on the sling. He stated the green loops were broken and the straps looked worn. LVN D stated the sling should be inspected before each use for safety. He said residents could fall or worse. He stated the DON just ordered 12 new slings so each resident that required a Hoyer lift will have a personal sling. He said on his side 6 or 7 residents needed to use the Hoyer lift and about 12-13 residents for the whole building. <BR/>Interview on 01/12/2024 at 1:45 pm, the DON stated they just ordered slings earlier in the week. She stated she did not know the loops were broken on Resident #1's sling. She said the staff did not use the green loop but should not have used that sling at all because they had other slings. The DON stated the plan was for each resident to have their own sling [that required one], and two extra slings at the nurse's station. She said the night shift will wash and distribute them. The DON stated the slings must be inspected before use, and if frayed or broken, they would not be used. She stated the CNA should look at the sling to see if it was broken. She said she did not expect laundry to inspect the slings, but if the sling was falling apart, they would let them know because they have done that before. She said if slings were not inspected the resident could be injured. <BR/>Record review of census list dated 01/12/2024, provided by the facility revealed 13 residents required the use of Hoyer lift for transfers.<BR/>Record review of invoice dated 01/10/2024 revealed a purchase order for 11 large sized lift slings and 2 bariatric sized lift slings.<BR/>Observation on 01/12/2024 at 1:16 pm, revealed 12 residents had slings that appeared to be in good condition or new.<BR/>2. Record review of Resident #3's admission record, dated 01/12/2023, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of metabolic encephalopathy (brain dysfunction).<BR/>Record review of Resident #3's admission MDS, dated [DATE], revealed a BIMS of 9, indicating moderate cognitive impairment. <BR/>Observation and interview on 01/11/2024 at 12:56 p.m., revealed the backrest upholstery of the wheelchair appeared torn on Resident #3's left side. Resident #3 said the backing of his wheelchair came off and has been that way for about a week. He stated it was going to get replaced next week. Resident #1 stated he thought it was because of a bag he used on the back of the wheelchair to carry his belongings. <BR/>Interview on 01/12/2024 at 1:45 p.m., the DON stated Resident #3's wheelchair was not safe at all. She said she thought the wheelchair was brought with him and he was very protective of his wheelchair. The DON stated she did not know the wheelchair looked like that and said Resident #3 could fall out, the chair could flip over, and he could be injured. The DON stated Resident #3 was on therapy caseload and would ensure the wheelchair was functioning.<BR/>3. Record review of Resident #5's admission record, dated 01/12/2024, revealed an [AGE] year-old male who admitted on [DATE] with a diagnosis of dementia.<BR/>Record review of Resident #5's Nurse's Note, dated 11/2/2023 at 2:00 p.m., revealed Resident received in room [number], MD notified of new admission, medications verified, and placed on EMAR.<BR/>Record review of Resident #5's Discharge summary, dated [DATE] at 11:20 p.m., revealed Family wanted to take [him] home as they said that they did not approve for the resident to be in this facility.<BR/>Interview on 01/12/2024 at 9:31 a.m., with the Marketer revealed he and the Housekeeping Supervisor brought Resident #5 over because he was just across the street and the other facility's van was busy. He stated Resident #5 was in a wheelchair and had just one bag. <BR/>Interview on 01/12/2024 at 12:13 p.m., the Administrator stated the SW had just briefed him about Resident #5. He stated [facility name] was their next-door neighbor and he was not here at that time, or aware of how Resident #5 was transported. He stated the previous Administrator only came in on the weekends and that was a time when they did not have a daily administrator. He said that the Housekeeping Supervisor was not normally involved in the admission process that way. He stated the facility did not have its own facility van. He said Resident #5 should have been transported by facility van or transport should have been set up with outside companies the facility has a contract with. <BR/>Interview on 01/12/2024 at 1:45 p.m., the DON stated before a resident admits and they come from the hospital, the Marketer gives them the list of contracted transportation companies. If a resident came from another facility, he would give them the name of the company they contract with and tell that facility to contact them to schedule transportation. The DON stated she did not know why the staff members went over to get Resident #5 and expected that transportation be arranged or have the proper personnel from the transferring facility bring the resident. She stated it could have been potential harm, anything could have happened to Resident #5. <BR/>Record review of the facility's policy titled Assistive Devices and Equipment revised July 2017, reflected, in part: Our facility provides, maintains, trains and supervises the use of assistive devices and equipment for residents .1. Devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include but are not limited to: a. Wheelchairs (manual and powered); b. Walkers; and c. Canes .5. The following factors will be addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment .c. Device condition - devices and equipment will be maintained on schedule and according to manufacturer's instructions. Defective or worn devices will be discarded or repaired.<BR/>Record review of the facility's policy titled Admissions Policies, revised 2006, reflected, in part: 1. The primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility. The policy did not reflect guidelines for resident transportation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment, for daily living for four of six residents (Resident #1, #2, #3, and #4) review for environmental concerns. <BR/>The facility failed to clean restrooms in Resident #1, #2, #3 and #4's room.<BR/>This failure could affect residents by exposing them to an unsanitary and unsafe environment. <BR/>Findings included:<BR/>In an observation and interview on 01/11/2024 at 12:36 p.m., revealed the door to shower room [ROOM NUMBER] was ajar, an attempt to open the door revealed the door and bathroom floor made contact requiring door to be opened with force. Observation reflected drag marks on the floor reflecting contact with the door and floor. The shower was clean. Observation reflected there was not an out of order sign on the door. <BR/>Interview with the DON on 01/11/2024 at 12:37 p.m., reflected the shower is not working because of the door. We have someone coming out to repair the bathroom. The DON said all residents are using shower 1 located on hall A.<BR/>Interview with Nurse Aide A on 01/11/2024 at 12:39 p.m., reflected that shower 2 is currently being used by residents. She stated that you can open the door you gotta use your hip. To force open the door. <BR/>In an interview on 01/11/2024 at 12:54 p.m., Resident # 3 stated he uses a wheelchair to ambulate he is unable to use his restroom if he had a bowel movement. He will go the shower room (shower room [ROOM NUMBER] on hall A) to use the bathroom but sometimes he had to wait because it was occupied. He stated that the restroom in his room is not clean. <BR/>Observation on 01/11/2024 at 12:54 p.m., revealed Resident #3's restroom had a continuous drip of water from the bathtub faucet, the spigots have been removed leaving the metal pipes exposed,there was yellowish liquid in the toilet, and the floors in front and on both sides of the the toiled had dark stains . Observation revealed a hole in the wall where an item was removed from the wall (light fixture). There are missing wall tiles next to the soap dispenser. <BR/>Observation on 01/11/2024 at 1:11 p.m., revealed the window in Resident #1 and #2's room located next to Resident #1's bed revealed window with six window panels. The middle window panel on the right side revealed a plastic window panel with a strip of brown tape. The left bottom window panel revealed a crack from the distance of top corner to bottom of panel. <BR/>Observation on 01/11/2024 at 1:14 p.m., revealed Resident #2's nightstand in his room next to bed A was missing the knob leaving an exposed screw. The resident's belongings were observed inside the nightstand. <BR/>Observation on 01/11/2024 at 1:15 p.m., revealed Resident #1 and #2's restroom a wooden covering over the area of the bathtub. There was a strong, foul odor in the restroom. There was a brownish material smeared on the walls. A roll of toilet paper was observed on the back of the toilet with brownish stains. <BR/>Interview with Resident #1 on 01/11/2024 at 1:11 p.m. reflected Resident #1 stated that he is not sure how long the window has been broken but that the maintenance man attempted to repair the broken window by placing the plastic panel but then the panel broke. He stated that it was cold in his room. <BR/>Interview with the Maintenance Director on 01/11/2024 at 1:29 p.m., reflected about 2-3 weeks ago he attempted to replace the broken window panel with a temporary plastic window panel when it broke during install. He stated that he applied tape to the crack as a temporary fix. He stated that the running water in Resident #3 and #4's room can not be turned off because the water source to the building would have to be turned off. He stated that he could not replace the missing wall tiles in Resident #3 and #4's room because they don't have anymore in the store. <BR/>Record Review of Maintenance Log dated 11/01-12/01/23 reflected handwritten entry on 12/06/2023 window duct tape loose. Status: Completed. <BR/>Policy for Homelike Environment dated revised May, 2027 reflected the Facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, home setting. These characteristics include: <BR/>a. Clean, sanitary and orderly environment<BR/>f. Pleasant, neutral scents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment, for daily living for four of six residents (Resident #1, #2, #3, and #4) review for environmental concerns. <BR/>The facility failed to clean restrooms in Resident #1, #2, #3 and #4's room.<BR/>This failure could affect residents by exposing them to an unsanitary and unsafe environment. <BR/>Findings included:<BR/>In an observation and interview on 01/11/2024 at 12:36 p.m., revealed the door to shower room [ROOM NUMBER] was ajar, an attempt to open the door revealed the door and bathroom floor made contact requiring door to be opened with force. Observation reflected drag marks on the floor reflecting contact with the door and floor. The shower was clean. Observation reflected there was not an out of order sign on the door. <BR/>Interview with the DON on 01/11/2024 at 12:37 p.m., reflected the shower is not working because of the door. We have someone coming out to repair the bathroom. The DON said all residents are using shower 1 located on hall A.<BR/>Interview with Nurse Aide A on 01/11/2024 at 12:39 p.m., reflected that shower 2 is currently being used by residents. She stated that you can open the door you gotta use your hip. To force open the door. <BR/>In an interview on 01/11/2024 at 12:54 p.m., Resident # 3 stated he uses a wheelchair to ambulate he is unable to use his restroom if he had a bowel movement. He will go the shower room (shower room [ROOM NUMBER] on hall A) to use the bathroom but sometimes he had to wait because it was occupied. He stated that the restroom in his room is not clean. <BR/>Observation on 01/11/2024 at 12:54 p.m., revealed Resident #3's restroom had a continuous drip of water from the bathtub faucet, the spigots have been removed leaving the metal pipes exposed,there was yellowish liquid in the toilet, and the floors in front and on both sides of the the toiled had dark stains . Observation revealed a hole in the wall where an item was removed from the wall (light fixture). There are missing wall tiles next to the soap dispenser. <BR/>Observation on 01/11/2024 at 1:11 p.m., revealed the window in Resident #1 and #2's room located next to Resident #1's bed revealed window with six window panels. The middle window panel on the right side revealed a plastic window panel with a strip of brown tape. The left bottom window panel revealed a crack from the distance of top corner to bottom of panel. <BR/>Observation on 01/11/2024 at 1:14 p.m., revealed Resident #2's nightstand in his room next to bed A was missing the knob leaving an exposed screw. The resident's belongings were observed inside the nightstand. <BR/>Observation on 01/11/2024 at 1:15 p.m., revealed Resident #1 and #2's restroom a wooden covering over the area of the bathtub. There was a strong, foul odor in the restroom. There was a brownish material smeared on the walls. A roll of toilet paper was observed on the back of the toilet with brownish stains. <BR/>Interview with Resident #1 on 01/11/2024 at 1:11 p.m. reflected Resident #1 stated that he is not sure how long the window has been broken but that the maintenance man attempted to repair the broken window by placing the plastic panel but then the panel broke. He stated that it was cold in his room. <BR/>Interview with the Maintenance Director on 01/11/2024 at 1:29 p.m., reflected about 2-3 weeks ago he attempted to replace the broken window panel with a temporary plastic window panel when it broke during install. He stated that he applied tape to the crack as a temporary fix. He stated that the running water in Resident #3 and #4's room can not be turned off because the water source to the building would have to be turned off. He stated that he could not replace the missing wall tiles in Resident #3 and #4's room because they don't have anymore in the store. <BR/>Record Review of Maintenance Log dated 11/01-12/01/23 reflected handwritten entry on 12/06/2023 window duct tape loose. Status: Completed. <BR/>Policy for Homelike Environment dated revised May, 2027 reflected the Facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, home setting. These characteristics include: <BR/>a. Clean, sanitary and orderly environment<BR/>f. Pleasant, neutral scents.

Based on observation, interview and record review, the facility failed to maintain and effective pest control program to ensure the facility was free of pests for 1 of 2 resident rooms (Resident #3's room) reviewed for pests.<BR/>The facility failed to ensure an effective pest control program was implemented to prevent gnats in resident rooms.<BR/>This could place residents at risk of foodborne illness and/or disease spread by pests.<BR/>Findings included:<BR/>Observation and interview on 01/11/2024 at 12:56 pm in Resident #3's bathroom and bedroom revealed about 3-4 gnats flying around. Resident #3 stated he noticed the gnats and does swat at them. <BR/>Interview on 01/11/2024 at 1:29 pm, the Maintenance Director stated he only goes into the resident bathrooms if the staff put something on the log that needs to be fixed. He stated if they put gnats, he logs that in the pest control book. <BR/>Interview on 01/11/2024 at 1:50 pm, the Administrator stated he had been there since November and in the time here has no complaints about pest issues. He stated he had not actually seen with his own eyes any issues with flies or gnats.<BR/>Interview on 01/11/2024 at 2:28 pm, the Administrator stated he checked with the SW and DOR and no issues or complaints from residents on pest issues. <BR/>Interview and record review on 01/11/2024 at 2:48 pm, the Administrator stated the pest control company comes every month. He stated when they get here, they check in with the Director of Housekeeping and he goes over any items they need for the months. The Administrator stated they could always make a request for service. He said the pest control company should sign in when they arrive at the front desk, but found they were not, so now the Maintenance Director will shadow and make sure they sign the logbook. <BR/>Record review of the Maintenance Request log reflected: on 12/1/23 in the O2 room A Hall that sink plumbing leaking and gnats in room and on 12/5/23 on A Hall O2 room/Ice chest room gnats in O2 room. <BR/>Record review of pest control invoices from September 2023 through December 2023 revealed treatment for flies on 10/27/23 and 11/27/23, but no treatment for gnats.<BR/>Record review of facility policy titled Pest Control revised 2008, reflected Our facility shall maintain an effective pest control program .1. This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe, functional, sanitary and comfortable environment for 1 of 2 shower rooms reviewed for environmental concerns.<BR/>The facility failed to ensure shower room [ROOM NUMBER] was functional.<BR/>This failure could place residents at risk of not receiving showers and living in an unsafe and uncomfortable environment.<BR/>Findings included:<BR/>Observation and interview on 01/11/2024 at 10:45 a.m., of shower room [ROOM NUMBER], revealed the metal threshold of the shower room was loose and appeared dirty. The door did not open fully, and no signage was posted on the door. RN C stated residents did get showers in the room and RN C had to force open the door. <BR/>Interview on 01/11/2023 at 12:39 p.m., CNA A stated the door to shower room [ROOM NUMBER] was hard to open.<BR/>Interview on 01/11/2024 at 1:42 p.m., the Administrator stated residents do not use the tubs in their rooms, they go to the shower room. He stated the shower room on B Hall (shower room [ROOM NUMBER]) was the only one they were actively using. He said the door was broken on the one in the back hall (shower room [ROOM NUMBER]) and vendors had come in two days ago and will be back next week to fix it.<BR/>Observation and interview on 01/11/2024 at 1:50 p.m., revealed shower room [ROOM NUMBER] had an out of order sign posted on the door. Blue tape was on the wall next to the trim and outlet near the bottom right of the door frame. The Administrator stated the vendor was there on Monday and they deemed the shower not usable. He said when the door opens, the wall was open, they took off the brown trim to look behind there and put blue tape over the part they looked at. He stated all nurses were aware the shower was not in order, and they put a sign up today. He stated they intended to get it fixed much sooner and the vendor would get started on the door next week. He said he spoke with the shower aide, and they primarily use the other shower, and he would talk to whoever has been using shower room [ROOM NUMBER] to remind them not to use it. He said if no sign was posted, residents could get hurt if they tried to go in and the door did not open. <BR/>Interview on 01/11/2024 at 2:48 p.m., the Administrator stated he talked with the shower aide and all residents were up to date with their bathing and the shower aide knew not to use the shower on the back hall for the last 2-3 weeks at least. <BR/>Record review of Maintenance request log for November 2023 through December 2023 did not indicate the shower room door needed to be repaired. <BR/>Record review of facility policy titled Quality of Life - Homelike Environment revised May 2017, reflected in part: Residents are provided with a safe, clean, comfortable and homelike environment and encourage to use their personal belongings to the extent possible .2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics include: a. Clean, sanitary and orderly environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to be from abuse for 1 of 4 residents (Residents #1) reviewed for abuse. <BR/>The facility failed to protect Residents #1 from a physical and verbal altercation on 01/22/25 with the Administrator. The Administrator pushed Resident#1, causing Resident#1 to fall. The incident was not reported or documented until after surveyor intervention on 01/23/25.The Administrator was not suspended until 01/23/25 at approximately 11:30 AM. <BR/>An IJ was identified on 01/23/25. The IJ template was provided to the facility on [DATE] at 5:15 PM. While the IJ was removed on 01/25/25, the facility remained out of compliance at a scope of Isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems .<BR/>This failure placed residents at risk of subsequent abuse, mental anguish, and emotional distress. <BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 01/23/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizophrenia (Serious mental health condition that affects how people think, feel and behave), Type 2 Diabetes Mellitus with Diabetic, Unspecified Psychosis not due to substance or known major depressive disorder.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 10/28/24, reflected Resident #1 had a BIMS of 12, which indicated cognition moderate impaired. <BR/>Record review of Resident #1's care plan, revised 09/20/24, revealed the resident at risk for altered status due to a traumatic life experience while at a previous group home or [Nursing Facility]. Certain male figures in authority positions, with similar physical attributes or appearance at times trigger him. Interventions in place included: Administer medication as ordered, approach resident from the front and speak in a calm, unhurried manner .Identify cause/trigger for behavior and reduce factors that may provoke resident .Call [Family Member#1] if need to calm down or get him to comprehend the situation]<BR/> .<BR/>Record review of Record review of Psychological Services Progress Note, dated 10/08/24and completed by Psy services reflected, Resident#1 was negative for Trauma Informed Care. <BR/>Record review revealed no incident/accident report was completed about the incident on 01/22/25.<BR/>Record review of Resident#1 progress noted dated, 11/01/23 to 01/22/25 reflected: Resident#1 had other incidents with other staff but not the Administrator. <BR/>Record review of Resident#1 progress notes revealed no documentation about the incident on 01/22/25.<BR/>Record review of Resident#1 assessments revealed no documentation about incident on 01/22/25.<BR/>Record review of Resident#1 incident provided to surveyor on 01/25/25 reflected: it was initiated on 01/22/25 with no completed/ locked date on the incident report. Incident description section reflected: This [LVN K] was notified by staff after the incident that [Resident#1] slapped [MA N] and physically attacked Administrator and [Resident#1] fell to the floor. Resident description reflected: [Resident#1] stated he was approached by Administrator, in what he felt was an aggressive manner so I just swung on his . Immediate action taken section reflected: [Resident#1] assessed for injuries. None noted, denied pain or any discomfort. Physician notified, In the agencies/people notified section reflected: no notification found,<BR/>An interview on 01/23/25 at 10:20 AM Family Member#1 approached surveyor at the facility and stated the Administrator fought [Resident#1] last night. Family Member#1 stated that was wrong and he is elderly. Family Member#1 stated the Administrator was always picking on him when Resident#1 wanted to play his piano. Resident#1 did not speak to the Administrator when the Administrator would try to speak to him <BR/>An in-person interview on 01/23/25 at 10:45 AM, the Administrator and MA N entered the conference room to explain the incident on 01/22/25. The administrator stated Resident#1 assaulted a medication aide around 7pm on 01/22/25. The Administrator stated the medication aide and himself went to Resident#1s room. Resident#1 was asked why he hit the medication aide. The Administrator stated Resident#1 started punching and kicking the Administrator and made threats. The Administrator stated he put his hands up to protect himself. The Administrator stated Resident#1 tripped over his own leg and fell. The Administrator stated [CNA J], [CNA L] and [LVN P] intervened and pulled Resident#1 away. The Administrator stated he was told by Resident#1 and Family member that he reminded Resident#1 of males from his past that made fun of him and were aggressive towards him because he was gay. The Administrator stated it did not have to be reported because it was an altercation between staff and a resident.<BR/>An interview on 01/23/25 at 10:45 AM, MA N stated Resident#1 took snacks off the snack tray and hit MA N's face when she asked him what he was doing. MA N immediately reported to the Administrator who went to Resident#1 to ask what happened and Resident#1 hit the Administrator. <BR/>An interview on 01/23/25 at 11:00 AM, the DON stated she was not made aware of the incident until after 10:15 AM on 01/23/25 when Resident#1 family member came into her office. The DON immediately called her nurse consultant and informed her of the situation. <BR/>An interview and observation on 01/23/25 at 11:05 AM of the camera in the Administrator office with the PD revealed, Resident was punching and kicking the Administrator. The Administrator open hand pushed Resident#1 face area and caused Resident#1 to fall. Observed a linen cart pushed between the Administrator and Resident#1. Observation of additional staff stepped in between Resident#1 and Administrator. Staff were observed holding the Administrator back and grabbing Resident#1. PD stated an incident would be put on file but no arrest or charges because the resident started the altercation. Surveyor did not recall observing a date and time on the footage. <BR/>An interview on 01/23/25 at 11:30 AM, Ombudsmen stated she had not been notified about the physical altercation between the Administrator and Resident#1.<BR/>An over the phone interview on 01/23/25 at 1:30 PM the Corporate Operations Manager and Nurse Consultant stated they were not made aware of the abuse allegation until 1/23/25 at approximately 10:30 AM. The Administrator (Abuse coordinator) was asked to go home until the investigation was completed. Both stated it did not have to be reported to State since there was not an allegation of abuse at the time of the incident. Operations Manager stated that is the company policy for all that when an investigation of abuse had been reported the staff member would be suspended until the investigation was completed. Corporate Operations Manager and Nurse Consultant both stated the Administrator was suspended until the investigation was completed. Both stated there was no risk to residents, as soon as they found out about the incident the facility took immediate action. <BR/>An interview with Resident#1 on 01/23/25 at 2:15 PM he stated he would not feel safe in the facility if the Administrator returned. Resident#1 stated the Administrator hit him and he hit him back.<BR/>An interview on 01/23/25 at 4:11PM CNA J stated it was chaos in the hallway and he did not see how the incident started. CNA J stated he saw Resident#1 kicking and hitting the Administrator. CNA J stated he tried to intervene but did not want to get hit by Resident#1 so, he pushed a linen cart between them. CNA J stated he did not see how the resident fell. CNA J stated he grabbed Resident#1 and took him outside to smoke. <BR/>An interview on 01/23/25 at 4:20 PM LVN P stated he witnessed Resident#1 swinging both of his arms towards the Administrator LVN P stated they separated Resident#1 and the Administrator. <BR/>An interview on 01/24/25 at 4:30 PM CNA L stated Resident#1 was kicking and hitting the Administrator in the hallway. CNA L stated he did not see how Resident#1 fell but, he jumped back up and continued to attack the Administrator. CNA L stated the Administrator and Resident#1 were separated. <BR/>An interview on 01/24/25 at 4:50 PM DON stated the Administrator who is the abuse coordinator is responsible for completing and reporting investigation to corporate and State office. DON stated while the Administrator was suspended, she would be responsible. <BR/>Record review of facility policy titled; Usual Occurrence Reporting revised 12/07 reflected: H. Other occurrences that interfere with facility operations band affect welfare, safety, or health of residents, employees or vistors.2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations.<BR/>Record review of facility policy titled; Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigating revised 09/22 reflected: <BR/>All reports of resident abuse . Are reported to local state and federal agencies add (current regulations) is thoroughly investigated by facility management . findings of all investigations are documented and reported . Policy interpretation and inflammation reporting allegations to the administrator and authorities upon receiving any allegations of abuse the administrator is responsible for determining what actions (if any) are needed for protection of residents . Investigation allegations 1. all allegations are thoroughly investigated the administrative initiates investigations any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete . 9. the investigator notifies the ombudsman that in abuse investigation is being conducted the ombudsman is invited to participate in the review process B. the ombudsman is notified of the result of the investigations as well as any corrective measures taken . follow up report #1 within 5 business days of the incident the administrator will provide a follow-up investigation report direct action number one all relevant professional and licensing boards are notified when an employee is found to have committed abuse #2 if the investigation reveals that the allegations of abuse are founded the employee is terminated #3 any allegations of its view in our files in the huge employees personal records along with any statement by the employee disputing the allegation if the employee chose make one .<BR/>The Director of Nursing was notified that an Immediate Jeopardy situation was identified and record review request of ANE policy due to the above failure and provided with the Immediate Jeopardy template on 1/23/25 at 5:15 PM. A Plan of Removal was requested.<BR/>The facility's Plan of Removal was accepted on 1/24/2025 at 1:50 PM and included: <BR/>Plan of Removal:<BR/>1. <BR/>Immediate action(s) taken for the resident(s) found to have been affected include:<BR/>Resident # 1 was assessed by the Nurse on 1/22/25 . A thorough investigation was initiated by the Corporate Office and Director of Nursing Services.<BR/>The Medical Director was notified by the DON at 3:33pm and The DON called and left a message for the Ombudsman 1/23/25, at 5:30PM. The RP was notified on 1/22/25 by the Administrator. The accused Team Member was placed on Administrative Leave pending investigation. The Police Department was called and arrived at the facility. The Incident Report was completed on 1/23/25. The SIMS was initiated on 1/23/25 at 2:30pm.<BR/>In-services have been done by the DON for: Completing Incident reports, Notifications to MD/Ombudsman, Reporting Abuse/Neglect, Abuse Policy including timeline for reporting and What to do When a Team Member is accused (investigation requires for Team Member to be placed on Administrative Leave until the investigation is concluded). De-escalation of aggressive behaviors and resident to staff altercations. <BR/>The Post Test will be administered by the DON/designee after education is completed. Staff are required to pass at least 80%. Staff who do not achieve 80% passing rate will be re-educated and will retake the test.<BR/>TEXAS Abuse hotline number, [PHONE NUMBER] posted in strategic areas within the facility, staff made aware of postings.<BR/>2. <BR/>Identification of other residents having the potential to be affected was accomplished by:<BR/>The facility has determined that all residents have the potential to be affected. Supervisor Rounds have been started and will be completed by 1/24/25 to interview residents for issues related to care, respect and dignity. The rounding will be done by the Supervisors and the monitoring will be completed on the Supervisor Daily Rounds form.<BR/>3. <BR/>Actions taken/systems put into place to reduce the risk of future occurrence include:<BR/>An in-service education program was conducted by the Director of Nursing Services and the Assistant Director of Nursing with all staff addressing circumstances that require reporting including appropriate timeframes, reporting to the Corporate Office, reporting to the Ombudsman, timely completion of Incident Reports and SIMS reports and policy regarding Team Member involvement will be completed by 1/24/25. <BR/>The Corporate Nurse Team will conduct a Zoom meeting at 10 am on 1/24/25 with [Facility] Director of Nursing. The purpose of the in-service is to provide education for the following areas:<BR/>Our Abuse/Neglect Policy as it relates to Reporting Timelines to Corporate/State/Law Enforcement/Ombudsman/Medical Director<BR/>Steps to take when a Team Member is involved or is allegedly involved-Contact Corporate HR and place on Administrative Leave pending investigation of Abuse.<BR/>Conducting Education and Training with all Departments<BR/>Follow up and Monitoring that is required such as Rounding on Halls, Talking with Residents and Staff, Re-education with Staff to help Ensure There is No Breakdown in Communication<BR/>Five day follow up with the State Office<BR/>4. <BR/>How the corrective action(s) will be monitored to ensure the practice will not reoccur:<BR/>The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any incidents or injuries are identified, properly investigated and reported to the appropriate entities. <BR/>Findings of this audit will be reviewed in the Resident Council meetings.<BR/>This plan of correction will be monitored at the monthly Quality Assurance meeting until such time the IDT determines consistent substantial compliance has been met. <BR/>On 1/25/25 beginning at 3:00 PM the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of pre/posttest had been completed by1st, 2nd and 3rd shift nursing staff on ANE. <BR/>Record review of Director of Nursing in-services by the Nurse on ANE <BR/>Record review of the Administrator profile reflected, the Administrator was hired on 11/27/23 and terminated on 01/24/25.<BR/>An observation of the facility on 01/25/25 at 2:00 PM revealed 1-800 HHSC hotline number for abuse was posted at the entry of the facility, social workers door, display board in hallway and employees break room. <BR/>All staff were able to provide competency regarding in-service over ANE. All staff were able to provide policy, procedure, protocols, appropriate interventions, and when and who to report abuse to. All staff were to provide an example of ANE. <BR/>Staff interviewed on 01/24/25 between 9:00 AM to 2:00 PM CNA A, CNA B, LVN C (overnight shift) and CNA G, CNA H, LVN I (1st shift) and CNA J, CNA L LVN K, RN O, LVN P (2nd shift).<BR/>Staff interviewed on 01/25/25 3:40 AM to 3:00 PM: CNA D, CNA E, LVN F, RN N (Weekend shift) and laundry aide M.<BR/>An interview on 01/25/25 at 3:45PM the Director of Nursing stated she was in-serviced by the Corporate Nurse on 01/24/25 at 10:00 AM. The Director of Nursing stated she is currently the abuse coordinator. The Director of Nursing stated staff have been in-service and pre/posttest have been completed. <BR/>The Director of Nursing was informed the Immediate Jeopardy was removed on 01/25/25 at 3:00 PM the facility remained out of compliance at a scope of potential of minimum harm and a severity level of isolated, due to the facility's need to evaluation the effectiveness of the corrective systems. <BR/>An interview on 02/12/25 at 9:30 AM, Resident#1 stated that he was doing good and did not have any concerns and wanted to stay at the facility.<BR/>An over the phone interview on 02/12/24 at 9:52 AM Family member stated she was going by what [Resident#1] told her (Previous admin would tell him to stop playing his piano and pick on him that way.). Family member stated the previous Administrator [Current facility] favored someone from [Resident#1] past, but the sister did not know exactly who and people in general would make fun of [Resident#1] because he was gay. Family member stated he was previously, in a group home and wanted to stay there but, he could not care for himself. Since, previous admin is gone there has not been any more issues. Family Member stated he came from a group home, and he was happy there and did not want to leave. <BR/>Attempted to call PCP on 02/13/24 at 9:27 AM<BR/>Attempted to call Psy services on 02/13/24 at 9:52 AM<BR/>An observation and interview on 02/13/25 at 11:30 AM Resident#1 stated [Name] the Administrator hit him last week and he did not know why. Surveyor asked Resident#1 if he knew the previous Administrator name at the current facility that he stayed at and he said that was [Name] Resident#1 stated he felt safe and did not have any concerns.<BR/>Record review of Psy Subsequent assessment dated [DATE] and completed by Psy services reflected, <BR/>The provider asked the patient to tell him what transpired since the last few days. The patient replied nothing happened. The provider reframed the question and asked the patient if he had any altercation with anyone in the facility a few days ago. He replied someone pushed me. The provider asked the patient how the incident happened or what prompted the altercation. He replied, I do not know . <BR/>Record review of Psychological Services Progress notes dated ,01/30/25 on Resident#1 completed by Psy services reflected, Resident#1 was negative for Trauma Informed Care.<BR/>The Director of Nursing was informed the Immediate Jeopardy was removed on 01/25/25. The facility remained out of compliance at a scope of actual harm and a severity level of isolated, due to the facility's need to evaluation the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan 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 for one of 5 residents (Resident #2) reviewed for comprehensive resident centered care plans. <BR/>The facility failed to ensure the comprehensive resident centered care plan for Resident #2 was implemented by not putting a fall mat in Resident #2's room. <BR/>This failure could place residents, that are at risk for falls, to be injured by not putting interventions listed in resident's care plan. <BR/>Findings include:<BR/>Record review of Resident's #2s Face Sheet dated 3-5-2024 indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had a primary diagnosis of Hemiplegia (paralysis) and Hemiparesis (loss of strength in limbs) following a cerebrovascular disease (condition affecting blood flow to the brain) affecting the right dominant side, unspecified visual loss, seizures, and dysarthria (difficult or unclear articulation of speech) following cerebral infarction (stroke). <BR/>Record Review of Resident #2's medical record, in Resident #2's MDS, dated [DATE], indicated a Brief Interview Mental Status (BIMS) Score of 10, indicating moderate mental impairment. <BR/>Record Review of Resident #2s Care Plan, dated 2-26-2024, revealed Resident #2 was at risk for falls and at risk for injury due to having a seizure disorder. The care plan stated Resident #2 had a fall on 2-26-2024. Resident #2s care plan revealed that Resident #2 have a fall mat, in his room, while in bed. Record Review of Nursing notes for Resident #2, dated 2-24-2024 thru 3-5-2024, indicated Resident#2 was not offered a fall mat before 3-5-2024. <BR/>In an observation/interview, on 3-5-2024 at 2:20 PM, Resident #2 was observed to be lying on his bed. Resident #2 was observed to be a right leg amputee above the knee. Resident #2 stated he had poor vison and had never been offered a fall mat nor has he ever had a fall mat in his room. <BR/>In an interview on 3-9-2024, with LVN-A, at 1:00 PM, who was the charge nurse for Resident#2s hall, revealed she did not know why Resident #2 did not have a fall mat.<BR/>In an interview with the DON on 3-9-2024, at 3:4 PM, revealed her expectation was for Resident #2 to have what his care plan called for. The DON stated if Resident #2's care plan indicated he should have a fall mat, while in bed, then she expected Resident #2 to have had it in place. The DON did not know why Resident #2 did not have a fall mat in his room. <BR/>In an interview with the Administrator, on 3-9-2024, at 4:10 PM, revealed that he had high expectations that care plans be followed by staff and that the DON is ultimately responsible that care plans are implemented. <BR/>Record Review of the facility's care plan policy dated 12-2016, revealed:<BR/>A comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .#8 the comprehensive, person-centered care plan will (b) describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #54) of five residents reviewed for pharmacy services. <BR/>1. The facility failed to ensure the MAR and TAR for Resident #54 was initialed immediately after administering their narcotic medication. <BR/>This failure placed residents at risk of not having their MARs/TARs signed after receiving their medication which could lead to overdose of the medication.<BR/>Findings included:<BR/>Review of Resident #54's Face sheet, not dated, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of low back pain.<BR/>Record Review of Resident #54's Order Summary Report, dated March 2023, reflected:<BR/>Norco 5/325mg every 6 hours as needed for pain.<BR/>Record review of Resident #54's narcotic count sheet, dated March 2023, reflected the resident received a dose of Norco 5/325mg on 03/27/23 at 10:00 AM and 9:30 PM by LVN A. <BR/>Record review of Resident #54's MARs/TARs, dated March 2023, reflected no documented evidence the resident received Norco 5/325mg on 03/27/23. <BR/>An interview on 03/29/23 at 1:15 PM with LVN A reflected he administered Norco 5/325mg to Resident #54 on 03/27/23 two times. He said he forgot to sign out the doses on the MAR/TAR. He said there was a risk to the resident of receiving a double dose of medication if it was not documented as given. <BR/>An interview on 03/30/23 at 9:37 AM with the DON revealed the nurse was supposed to document on the MAR/TAR after a medication was given to a resident. The DON said she periodically checked MARs/TARs for missed initials. She said if a dose of medication was not documented the resident could be overmedicated.<BR/>Record Review of the facility policy, Medication Administration, dated 2022 reflected:<BR/>17. Sign MAR after administered

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #54) of five residents reviewed for pharmacy services. <BR/>1. The facility failed to ensure the MAR and TAR for Resident #54 was initialed immediately after administering their narcotic medication. <BR/>This failure placed residents at risk of not having their MARs/TARs signed after receiving their medication which could lead to overdose of the medication.<BR/>Findings included:<BR/>Review of Resident #54's Face sheet, not dated, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of low back pain.<BR/>Record Review of Resident #54's Order Summary Report, dated March 2023, reflected:<BR/>Norco 5/325mg every 6 hours as needed for pain.<BR/>Record review of Resident #54's narcotic count sheet, dated March 2023, reflected the resident received a dose of Norco 5/325mg on 03/27/23 at 10:00 AM and 9:30 PM by LVN A. <BR/>Record review of Resident #54's MARs/TARs, dated March 2023, reflected no documented evidence the resident received Norco 5/325mg on 03/27/23. <BR/>An interview on 03/29/23 at 1:15 PM with LVN A reflected he administered Norco 5/325mg to Resident #54 on 03/27/23 two times. He said he forgot to sign out the doses on the MAR/TAR. He said there was a risk to the resident of receiving a double dose of medication if it was not documented as given. <BR/>An interview on 03/30/23 at 9:37 AM with the DON revealed the nurse was supposed to document on the MAR/TAR after a medication was given to a resident. The DON said she periodically checked MARs/TARs for missed initials. She said if a dose of medication was not documented the resident could be overmedicated.<BR/>Record Review of the facility policy, Medication Administration, dated 2022 reflected:<BR/>17. Sign MAR after administered

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to provide or obtain laboratory services only when ordered by the physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State Law, including scope of practice laws and promptly notify the ordering physician of the results for one (Resident #1) of two residents reviewed for labs. <BR/>1. Nursing staff did not ensure that labs (CBC, CMP, lipid, Valproic acid) were drawn every six months for Resident #1. <BR/>2. Nursing staff did not ensure that labs (Hgb and A1C) were drawn every three months for Resident #1. <BR/>These failures could place residents at risk of a delay in receiving the necessary interventions to treat their medical condition. <BR/>Findings included: <BR/>Review of Resident #1's face sheet dated 06/18/25 revealed a [AGE] year-old male with an admission date of 12/15/2023. Diagnoses included: metabolic encephalopathy (condition when brain dysfunction occurs), severe protein-calorie malnutrition (condition of inadequate intake of both protein and calories), anemia (blood doesn't have enough healthy red blood cells), type 2 diabetes mellitus (the body has trouble controlling blood sugar and using energy), dipolar disorder (episodes of mood swings ranging from depressive lows to manic highs) and paranoid disorder (unrealistic distrust of others). <BR/>Review of an MDS assessment dated [DATE] revealed Resident #1 had a BIMS (Brief Interview for Mental Status) score of 3 indicating severe cognitive impairment.<BR/>Review of Resident #1's care plan with date initiated of 12/16/23 with a target date of 08/23/25 revealed Focus: Anemia, Goal: Lab work will be within normal limits during this quarter, Interventions/Tasks: Obtain lab as ordered, report abnormal values to physician .<BR/>Review of Resident #1's electronic physician orders for June 2025 revealed an ordered dated 10/17/24 for CBC (measures varies components of your blood), CMP (blood test that measures fourteen different substances in the blood), lipid (broad group of organic compounds which include fats, waxes, sterols, fat-soluble vitamins, monoglycerides, diglycerides, phospholipids, and others), and Valproic acid (is a blood test to measure the concentration of valproic acid in the bloodstream) every six months and Hgb (a protein in red blood cells) and A1C (is a blood test that provides an average of blood sugar levels over the past 2-3 months) every three months. <BR/>Review of Resident #1's electronic clinical record from June 1 - June 30, 2025 revealed there were no labs results for April 2025 for the CBC, CMP, lipid and Valproic acid and no lab results for January 2025 or April 2025 for the Hgb and A1C.<BR/>Interview on 06/18/25 at 12:00 PM with the DON revealed after searching she did not find the lab results ordered for Resident #1 for January 2025 or April 2025. The DON stated Resident #1 has a history of refusing care and will become combative with staff however in this case I don't have documentation to support that the blood draw completed or was refused by Resident #1. The DON stated all physician orders including labs should be completed as ordered. The DON stated if a lab was refused it should be documented. The DON stated the risk of not doing the labs as ordered could result in not having a clear picture of the resident. <BR/>Interview on 06/18/25 with the Administrator was not obtained since he was out of the facility that day.<BR/>Review of the facility policy titled Lab and Diagnostic Test Results-Clinical Protocol, revised November 2018 revealed The physician will identify, and order diagnostic lab testing based on diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. <BR/>Review of the facility policy titled Medication and Treatment Orders, revision date of July 2016 revealed Orders for medications and treatments will be consistent with principles of safe and effective order writing .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the facility's only registered dietitian carried out the functions of food and nutrition services dietitian, according to the facility's Consultant Dietitian: Retainer Agreement. The facility failed to ensure that the registered dietitian worked a minimum of 16 hours a month and/or adjusted hours based on the facility's census. This failure could result in residents not maintaining or achieving optimal nutrition status. Findings included: An interview on 08/01/2025 at 9:19AM with the registered dietitian revealed that she had been working at the facility for 22 years and worked 12 hours a month. She explained it always had been 12 hours a month; if the census was around 60 residents, she would be expected to work at least 8 hours, if the census is 61-90 residents, she'd work 12 hours. She further stated she usually does more than 12 hours a month. Record review of the Consultant Dietitian: Retainer Agreement, dated 1/1/2026 reflected: This agreement is being entered on the 1ST day of [DATE]. Consultant ResponsibilitiesCoordinate the overall functions of the facility's consultant services in that the dietitian shall: .10. Provide a minimum of 16 hours in the facility, based on census.(Approx. 8 hours (+/- based on resident acuity) for every 30 patients) .Financial Arrangements1. The consultant agrees that he/she shall devote a sufficient number of hours based upon the census of the facility, to carry out the responsibilities outlined in this agreement.The agreement was signed by the owner of the consultant group and the facility administrator on 1/1/2016. Record review of the facility's census on 08/01/2025 was 75 residents, with a licensed capacity for 98 residents. An interview on 08/01/2025 at 10:47AM with the ADM, he had thought the agreement was for the registered dietitian to work a minimum of 12 hours a month. He said the contract between the facility and the consultant group the registered dietitian worked for was signed by the consultant group owner.

Based on observation, interview and record review, the facility failed to maintain and effective pest control program to ensure the facility was free of pests for 1 of 2 resident rooms (Resident #3's room) reviewed for pests.<BR/>The facility failed to ensure an effective pest control program was implemented to prevent gnats in resident rooms.<BR/>This could place residents at risk of foodborne illness and/or disease spread by pests.<BR/>Findings included:<BR/>Observation and interview on 01/11/2024 at 12:56 pm in Resident #3's bathroom and bedroom revealed about 3-4 gnats flying around. Resident #3 stated he noticed the gnats and does swat at them. <BR/>Interview on 01/11/2024 at 1:29 pm, the Maintenance Director stated he only goes into the resident bathrooms if the staff put something on the log that needs to be fixed. He stated if they put gnats, he logs that in the pest control book. <BR/>Interview on 01/11/2024 at 1:50 pm, the Administrator stated he had been there since November and in the time here has no complaints about pest issues. He stated he had not actually seen with his own eyes any issues with flies or gnats.<BR/>Interview on 01/11/2024 at 2:28 pm, the Administrator stated he checked with the SW and DOR and no issues or complaints from residents on pest issues. <BR/>Interview and record review on 01/11/2024 at 2:48 pm, the Administrator stated the pest control company comes every month. He stated when they get here, they check in with the Director of Housekeeping and he goes over any items they need for the months. The Administrator stated they could always make a request for service. He said the pest control company should sign in when they arrive at the front desk, but found they were not, so now the Maintenance Director will shadow and make sure they sign the logbook. <BR/>Record review of the Maintenance Request log reflected: on 12/1/23 in the O2 room A Hall that sink plumbing leaking and gnats in room and on 12/5/23 on A Hall O2 room/Ice chest room gnats in O2 room. <BR/>Record review of pest control invoices from September 2023 through December 2023 revealed treatment for flies on 10/27/23 and 11/27/23, but no treatment for gnats.<BR/>Record review of facility policy titled Pest Control revised 2008, reflected Our facility shall maintain an effective pest control program .1. This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe, functional, sanitary and comfortable environment for 1 of 2 shower rooms reviewed for environmental concerns.<BR/>The facility failed to ensure shower room [ROOM NUMBER] was functional.<BR/>This failure could place residents at risk of not receiving showers and living in an unsafe and uncomfortable environment.<BR/>Findings included:<BR/>Observation and interview on 01/11/2024 at 10:45 a.m., of shower room [ROOM NUMBER], revealed the metal threshold of the shower room was loose and appeared dirty. The door did not open fully, and no signage was posted on the door. RN C stated residents did get showers in the room and RN C had to force open the door. <BR/>Interview on 01/11/2023 at 12:39 p.m., CNA A stated the door to shower room [ROOM NUMBER] was hard to open.<BR/>Interview on 01/11/2024 at 1:42 p.m., the Administrator stated residents do not use the tubs in their rooms, they go to the shower room. He stated the shower room on B Hall (shower room [ROOM NUMBER]) was the only one they were actively using. He said the door was broken on the one in the back hall (shower room [ROOM NUMBER]) and vendors had come in two days ago and will be back next week to fix it.<BR/>Observation and interview on 01/11/2024 at 1:50 p.m., revealed shower room [ROOM NUMBER] had an out of order sign posted on the door. Blue tape was on the wall next to the trim and outlet near the bottom right of the door frame. The Administrator stated the vendor was there on Monday and they deemed the shower not usable. He said when the door opens, the wall was open, they took off the brown trim to look behind there and put blue tape over the part they looked at. He stated all nurses were aware the shower was not in order, and they put a sign up today. He stated they intended to get it fixed much sooner and the vendor would get started on the door next week. He said he spoke with the shower aide, and they primarily use the other shower, and he would talk to whoever has been using shower room [ROOM NUMBER] to remind them not to use it. He said if no sign was posted, residents could get hurt if they tried to go in and the door did not open. <BR/>Interview on 01/11/2024 at 2:48 p.m., the Administrator stated he talked with the shower aide and all residents were up to date with their bathing and the shower aide knew not to use the shower on the back hall for the last 2-3 weeks at least. <BR/>Record review of Maintenance request log for November 2023 through December 2023 did not indicate the shower room door needed to be repaired. <BR/>Record review of facility policy titled Quality of Life - Homelike Environment revised May 2017, reflected in part: Residents are provided with a safe, clean, comfortable and homelike environment and encourage to use their personal belongings to the extent possible .2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics include: a. Clean, sanitary and orderly environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe, functional, sanitary and comfortable environment for 1 of 2 shower rooms reviewed for environmental concerns.<BR/>The facility failed to ensure shower room [ROOM NUMBER] was functional.<BR/>This failure could place residents at risk of not receiving showers and living in an unsafe and uncomfortable environment.<BR/>Findings included:<BR/>Observation and interview on 01/11/2024 at 10:45 a.m., of shower room [ROOM NUMBER], revealed the metal threshold of the shower room was loose and appeared dirty. The door did not open fully, and no signage was posted on the door. RN C stated residents did get showers in the room and RN C had to force open the door. <BR/>Interview on 01/11/2023 at 12:39 p.m., CNA A stated the door to shower room [ROOM NUMBER] was hard to open.<BR/>Interview on 01/11/2024 at 1:42 p.m., the Administrator stated residents do not use the tubs in their rooms, they go to the shower room. He stated the shower room on B Hall (shower room [ROOM NUMBER]) was the only one they were actively using. He said the door was broken on the one in the back hall (shower room [ROOM NUMBER]) and vendors had come in two days ago and will be back next week to fix it.<BR/>Observation and interview on 01/11/2024 at 1:50 p.m., revealed shower room [ROOM NUMBER] had an out of order sign posted on the door. Blue tape was on the wall next to the trim and outlet near the bottom right of the door frame. The Administrator stated the vendor was there on Monday and they deemed the shower not usable. He said when the door opens, the wall was open, they took off the brown trim to look behind there and put blue tape over the part they looked at. He stated all nurses were aware the shower was not in order, and they put a sign up today. He stated they intended to get it fixed much sooner and the vendor would get started on the door next week. He said he spoke with the shower aide, and they primarily use the other shower, and he would talk to whoever has been using shower room [ROOM NUMBER] to remind them not to use it. He said if no sign was posted, residents could get hurt if they tried to go in and the door did not open. <BR/>Interview on 01/11/2024 at 2:48 p.m., the Administrator stated he talked with the shower aide and all residents were up to date with their bathing and the shower aide knew not to use the shower on the back hall for the last 2-3 weeks at least. <BR/>Record review of Maintenance request log for November 2023 through December 2023 did not indicate the shower room door needed to be repaired. <BR/>Record review of facility policy titled Quality of Life - Homelike Environment revised May 2017, reflected in part: Residents are provided with a safe, clean, comfortable and homelike environment and encourage to use their personal belongings to the extent possible .2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics include: a. Clean, sanitary and orderly environment .

Based on observation, interview, the failed to provide a private meeting space for residents' monthly Resident Council Meeting for 7 of 10 confidential residents reviewed Resident Council.<BR/>The facility failed to provide a private space area for the monthly Resident Council Meetings.<BR/>This failure could place residents who attend the monthly Resident Council Meetings at risk of not being able to voice their concerns due to a lack of privacy.<BR/>Findings included:<BR/>In an interview on 03/29/2023 at 12:06 PM, the Activity Director revealed the monthly Resident Council Meetings were always held in the Dining Hall. The Activity Director revealed the Dining Hall was not closed for privacy and was open on one side. <BR/>In an Interview on 03/29/23 at 1:57 PM, the Activities Director revealed the Resident Council Meeting on 03/29/203 would be held in a private area with a door. <BR/>In an interview on 03/29/2023 at 2:00 PM during a confidential Resident Council Group Meeting with 7 residents present, each resident revealed in the meeting that their monthly Resident Council Meetings were held in the Dining Hall. The 7 residents revealed the Dining Room had 2 doors that were closed on one hallway, but the other hallway was s open and did not have any doors. The residents in the Resident Council Meeting were informed that the meeting on 03/11/2023 was changed from the Dining Hall to an empty resident room due to privacy. The residents reported that they did not have any concerns regarding their privacy regarding their monthly meetings being held in the Dining Room. The residents were advised that the their monthly Resident Council Meetings would not be held in the Dining Room due to privacy and they stated that they understood.<BR/>Observation of the Dining Hall on 03/29/2023 at 2:50 PM revealed there were two doors on the hallway adjacent to the A Hall can be closed. The adjacent hallway, C Hall is open and did not have any doors.<BR/>In an interview on 03/29/2023 at 3:06 PM, the Activity Director stated he had been employed at the facility since 10/13/2020. He stated the Resident Council meets once a month on the last Thursday of every month and reported that up to 17 residents attend the monthly meetings. He stated prior to the beginning of the monthly Resident Council meetings, he will close the double doors on A Hall and post signs on the double doors advising Do Not Disturb due to Meeting in Progress. He stated that during previous Resident Council Meetings, he had been unable to close off the hallway near the Dining Hall that has access to C Hall due to the hallway being exposed and there not being any doors on the hallway. He stated that in the past, he has been present during the Resident Council Meetings and occasionally, there have been staff members and other residents entering the C Hall and he has to redirect and have them exit the meeting. The Activity Director revealed during the spring, he sometimes has the monthly Resident Council Meeting outside in the enclosed patio area depending on the weather. The Activity Director revealed he understands that the residents that attend the monthly Resident Council Meetings should feel free to express their opinions about what they need to discuss amongst each other. He revealed that harm could be caused to the residents during monthly Resident Council Meetings if there was a chance for the subject matter being discussed was overheard by another resident or staff member, which can cause retaliation and an unsafe environment for the staff and residents. The Activity Director reported that he had not received any concerns from the residents in Resident Council regarding their privacy during their monthly meetings.<BR/>In an interview on 03/29/2023 at 3:22 PM, the Administrator revealed been he had been employed at the facility since 10/13/2022. He revealed the residents have their monthly Resident Council Meetings in the Dining Hall. He stated that he was unaware the location of Resident Council Meeting needed to be in a private setting. He stated that he understood the need for residents to feel safe and secure while at the facility and not have to worry about the potential of retaliation from staff and residents. <BR/>In an interview on 03/29/2023 at 3:30 PM, the Administrator revealed the facility did not have a policy regarding Resident Council Meetings.