Flatonia Healthcare Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to treat each resident with respect and dignity and failed to provide care for each resident in a manner and environment that promoted the maintenance or enhancement of quality of life for 2 (Resident #12, Resident #17) of 10 residents reviewed for dignity.The facility failed to ensure that Resident #12 and Resident # 17 were provided dignified and individualized feeding assistance during the lunch meal on 12/02/2025.This failure could place residents at risk of diminished dignity and negatively affect their quality of life. Record review of Resident #12 Face sheet dated 12/03/2025, reflected she was a [AGE] year-old female, who was admitted to facility on 03/08/2025 with diagnoses of unspecified dementia (memory loss), major depressive disorder unspecified (feel sad, hopeless), and anxiety disorder. Record review of Resident # 12's MDS assessment, dated 10/31/2025, reflected she had a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. Record review of Resident # 12's care plan, dated 12/03/2025 reflected Feeding Assistance: Supervision with 1 person and Resident has a swallowing problem related to dementia, Caregiver training on proper positioning, cueing and device use during meals for maximization of po intake and safe po.Record review of Resident #17's Face sheet dated 12/02/2025, reflected he was a [AGE] year-old male, who was admitted to facility on 06/11/2025 with diagnoses of unspecified dementia (memory loss),acute respiratory failure with hypoxia (lungs can't get enough oxygen in the blood), metabolic encephalopathy (brain dysfunction due to internal metabolic issues), and critical illness myopathy (severe muscle weakness), dysphagia (swallowing disorder), and mood disorder.Record review of Resident # 17's MDS, dated [DATE], indicated a Brief Interview for Mental Status (BIMS) was not conducted. The Staff Assessment for Mental Status revealed 3 indicating severely impaired cognition (never/rarely made decisions).Record review of Resident # 17's care plan dated 12/02/2025 reflected resident has a swallowing problem, and he should be monitored during meals for choking, holding food in mouth, several attempts at swallowing and appears concerned during meals.Observation of the facility's dining room on 12/2/2025 between 12:00 PM and 12:54 PM, revealed that at 12:26 PM, Resident #12 and Resident #17 were being fed their lunch meal at the same time by CNA C. CNA C did not wash her hands, nor did she use any hand sanitizer at the table between the two residents. Continued observation on 12/2/2025 at 12:40 PM revealed CNA C picked up Resident #17's cornbread with her bare hand and placed it on the table in front of him. CNA D signaled to CNA C the procedure was incorrect. CNA C then picked the cornbread back up from the table and placed it back on plate. CNA C proceeded to feed the cornbread to the resident directly from her fingers. CNA C would feed one, then switch to the other resident she did not engage in communication with Resident #12 and Resident # 17. She continued the process until both had finished their meal. Interview conducted 12/04/2025, at 3:30 PM, revealed CNA C had been a certified nursing assistant for a few months at the facility. CNA C stated she has been trained on the facility's abuse and neglect, resident rights, and promoting/maintaining resident dignity procedures. She provided examples of each. CNA C revealed she was aware residents had the right to be treated with dignity and respect during meals. She stated she had been instructed to feed one resident at a time. However, on the day of the incident, 12/02/2025, she sat between two residents and fed both at the same time. CNA C was asked if residents have the right to eat in a safe environment. She stated, 'Yes.' When asked if a resident could potentially aspirate or choke while staff assisted another resident, she stated, yes.' CNA C stated it would be considered a failure to provide a safe environment. CNA C was asked how residents might feel if they must wait with food in front of them while the CNA assisted another resident. She stated they would 'probably feel horrible and anxious.' CNA C stated she realized what she did was wrong.Interview conducted 12/04/2025 at 5:18 PM, with CNA D revealed she worked as a CNA for 15 years. CNA D stated she was trained on resident rights and dignity. CNA D stated it was not appropriate to feed two residents at the same time. CNA D stated a facility staff could accidentally use the same feeding utensils for both residents, which would create a cross-contamination issue as well as a dignity concern. CNA D stated she witnessed the incident involving Resident #12 and Resident #17 being fed at the same time. She also stated she tried correcting CNA C about the cornbread. Interview conducted 12/04/2025 at 5:45 PM, the DON stated she was trained on resident rights, abuse and neglect and the facility's dignity policy. She stated herself and the ADM streamlined learning for the CNAs on dignity. The DON stated the ADON, herself, and CNA instructor trained the CNAs on meal assistance. The DON was asked if she considered it a rights and dignity concern if two residents were being fed at the same time by one CNA. The DON stated, yes, it could make the residents feel ignored. DON stated residents should have the right to a safe environment during mealtimes. The DON stated aspiration, or choking could be a potential accident, she also stated one resident could be giving the other residents' spoon which would create another issue. The DON stated staff needed to focus on one resident if they required feeding assistance. When asked about residents' right to a safe environment during mealtimes, the DON stated feeding two residents at the same time had infection control implications and could also be a safety concern. She explained that if a resident choked or aspirated while staff assisted another resident, it posed a safety risk. Additionally, she stated residents may feel unloved, uncared for, or extremely frustrated if they must wait for assistance while food sat in front of them.Interview conducted 12/04/2025 at 6:05 PM, the ADM stated the administrator and the DON were responsible for training staff on resident rights and dignity policies. The ADM stated the DON trains the CNAs on meal assistance. The ADM stated she feels feeding two residents at the same time violates their right to be treated with dignity and respect during meals. The ADM stated that potential harm could occur if attention is not paid to one resident while the staff looks away to the other resident, she stated a resident could still be chewing his or her food and possibly aspirate or choke. The ADM stated a resident could feel neglected if food just sat in front of them while they waited for assistance. The ADM stated she once was a CNA for 12 years; she was taught a tray is not supposed to be placed in front of a resident until someone is ready to feed them.Record review of the facility's policy on Resident Rights, dated February 2021, stated: Policy StatementEmployees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:1. a dignified existence2. be treated with respect, kindness, and dignity3. be free from abuse, neglect, misappropriation of property, and exploitation

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen.1. The facility failed to properly store raw chicken in its kitchen on 12/02/2025.2. The facility failed to properly store, label, and date all food items located in the facility refrigerators, freezers and in the dry food pantry area on 12/02/2025, 12/03/2025 and 12/04/2025. 3. The facility failed to discard outdated food items located in the refrigerator on 12/02/2025,12/03/2025, and 12/04/2025. 4. The facility failed to ensure the first upright kitchen freezer maintained a safe storage temperature and did not allow food items to thaw.These failures could place residents who received meals from the kitchen at risk of foodborne illnesses. Observation during the initial tour of the kitchen on 12/02/2025 beginning at 8:54 AM revealed the following:1 silver pan containing raw chicken sitting on dish sanitizing area.Refrigerator:1 pan of cooked ground taco meat dated 11/28/2025, no discard/use by date1 storage bag of cooked hamburger patties dated 11/29/2025, no discard/use by date1 storage bag of cooked pork dated 11/30/2025, no discard/use by date3 opened gallon containers of salad dressings, no discard dates. One was marked 9/4/2025, one marked opened 11/21/20251 carton of chicken broth opened 11/26/2025, no discard date.1 opened storage bag of honey ham, marked 11/30/2025, no discard date1 opened bag of turkey breast dated 1 opened bag of sliced cheese dated 11/29/2025, no discard date1 silver pan covered with foil marked tomatoes and lettuce for hamburgers dated 11/30/2025, no discard/use by date1 storage bag of tator tots, not labeled or dated1 storage bag marked hamburger meat dated 12/1/25, no discard/use by dateFreezer 1:Observed 4 storage bags opened out of their original packaging, no labels or dates.Freezer 2:Observed to have a temperature of 38 degrees1 storage bag marked churros with date of 11/11/25, do discard date, item was thawing3 bags of thawing Brussel sproutsStorage bag of about 12 thawing sherbertsDry Food Pantry area:Opened Hawaiian rolls placed in storage bag dated 11/26/2025, no discard date1 opened hamburger buns, no open or discard date.1 opened package of muffin mix dated 4/12, no discard date1 opened package of corn meal with a date of 11/11/25, no discard/use by date1 opened bag of flour, no open date or discard date1 opened bag of instant potatoes, no discard/use by date1 opened pancake mix, no discard/use by date3 opened cake mixes, no discard/use by dates1 opened bag of grits, no discard/use by dates1 large container of macaroni, no discard/use by dates1 large container of corn meal, marked 9/23/25 no discard/use by datesObservation and interview conducted 12/2/2025 at 3:03 PM. Observed freezer 2 at 38 degrees, the temperature should be zero degrees Fahrenheit to 18 degrees Celsius. Dietary Manager was asked did she know the temperature was not correct for the freezer. Dietary Manager stated she noticed the sherbert thawing and the Brussel sprouts were thawed out. Dietary Manager stated she threw out the Brussel Sprouts and she is checking the temperature. Surveyor advised her the temperature is the same as it showed in the morning. Dietary manger stated a box was blocking an area in the freezer this morning and she is trying to see if it cools down, she stated they check the temp in the morning, mid day, and in the evening and record on the log. Surveyor advised Dietary Manger surveyor will need to notify ADM as the new delivery is being placed in the freezer.On 12/2/2025 at 3:15 PM, ADM was notified of the freezer issue and came to the kitchen. ADM brought a Maintenance staff with her to check the freezer. ADM asked Dietary Manager to move food items from the thawing freezer.Observation during the follow up tour of kitchen on 12/03/2025 beginning at 11:00 AM, revealed the following:Refrigerator:1 pan of cooked ground taco meat dated 11/28/2025, no discard/use by date1 storage bag of cooked hamburger patties dated 11/29/2025, no discard/use by date1 storage bag of cooked pork dated 11/30/2025, no discard/use by date3 opened gallon containers of salad dressings, no discard dates. One was marked 9/4/2025, one marked opened 11/21/20251 carton of chicken broth opened 11/26/2025, no discard date.1 opened bag of turkey breast dated 1 opened bag of sliced cheese dated 11/29/2025, no discard date1 silver pan covered with foil marked tomatoes and lettuce for hamburgers dated 11/30/2025, no discard/use by date1 storage bag of tator tots, not labeled or dated1 storage bag marked hamburger meat dated 12/1/25, no discard/use by dateFreezer 1:Observed 4 storage bags opened out of their original packaging, no labels or dates.Dry Food Pantry area:1 opened package of muffin mix dated 4/12, no discard date1 opened package of corn meal with a date of 11/11/25, no discard/use by date1 opened bag of flour, no open date or discard date1 opened bag of instant potatoes, no discard/use by date1 opened pancake mix, no discard/use by date3 opened cake mixes, no discard/use by dates1 opened bag of grits, no discard/use by dates1 large container of macaroni, no discard/use by dates1 large container of corn meal, marked 9/23/25 no discard/use by datesObservation on 12/3/2025 at 3:41 PM, on Memory Care Refrigerator: Observation of several food items belonging to residents and some food items belonging to staff.1 bottle of coffee creamer labeled with staff name with open date of 11/30/2025, no discard date1 carton of half and half labeled with a resident name, open date of 11/3/2025, no discard date1 salad dressing, open date, no discard/use by date3 opened cheese packages with no open date, no discard date1 frozen meal, no name, no dateObservation during the final follow up tour of the kitchen on 12/04/2025 beginning at 9:20 AM, revealed the following:Refrigerator:1 storage bag of cooked burritos labeled 12/3/2025, no discard date.1 half storage bag of green beans labeled 12/3/2025, no discard date1 pan of cooked ground taco meat dated 11/28/2025, no discard/use by date1 storage bag of cooked hamburger patties dated 11/29/2025, no discard/use by date1 storage bag of cooked pork dated 11/30/2025, no discard/use by date3 opened gallon containers of salad dressings, no discard dates. One was marked 9/4/2025, one marked opened 11/21/20251 carton of chicken broth opened 11/26/2025, no discard date.1 opened bag of turkey breast dated 1 opened bag of sliced cheese dated 11/29/2025, no discard dateInterview conducted with [NAME] A on 12/03/2025, at 1:18 PM. [NAME] A stated she had been employed at the facility for five months. [NAME] A stated she knew the required temperatures for the refrigerators and freezers, and staff record temperatures on the logs daily. [NAME] A was asked if she was aware that room-temperature thawing of meat could cause bacterial growth, and she stated yes. [NAME] A was asked about the chicken observed thawing in a pan on 12/02/2025. She stated she had only allowed the chicken to sit out for a few minutes, and she placed it in the oven prior to the surveyor leaving the kitchen area. [NAME] A stated they typically thaw meat in the refrigerator. She stated the chicken was not placed under running water because it had already thawed. [NAME] A stated the potential harm that could occur if food is not stored properly is that a resident could get a bacterial infection.Interview conducted with CNA E on 12/03/2025, at 3:50 PM. CNA E stated she forgot to label her lunch meal she placed in the refrigerator that day. CNA E stated she was employed at the facility as a CNA for six months. She reported that on the memory care unit, staff use the same refrigerator as the residents. She stated she had not been informed that a separate refrigerator was available for staff use. CNA E stated she was supposed to label the meal she brought from home for her lunch.Interview conducted with the ADM on 12/03/2025, at 4:05 PM. The Administrator was asked whether staff and residents used the same refrigerator on the memory care unit. The Administrator stated the refrigerator located on memory care was for residents only. She reported there is a separate refrigerator for staff members located in the break room. The Administrator stated she will have staff remove any personal food items from the memory care refrigerator.Interview conducted with the Kitchen Aide on 12/04/2025 at 2:11 PM. The Kitchen Aide stated she has been employed at the facility for one year and four months. She stated she was initially trained by the previous Dietary Manager, and there have been four other managers since that time. The Kitchen Aide stated all staff are responsible for labeling and dating food items. She reported staff are expected to write the date received, the date opened, and the discard date, which is three days after the product is opened. The Kitchen Aide stated the potential harm that could occur if food is not discarded properly is that a resident could become very sick.Interview conducted with the Dietary Manager on 12/04/2025, at 2:18 PM. Dietary Manger stated she started in June with the facility. Dietary Manager reported that food items are labeled with the date received, and once they are opened, they are labeled with the open date but not always a discard date. Dietary Manger stated everyone knows the opened food is to be discarded in 3 days, she stated they rarely have leftovers that stay after 3 days. Surveyor showed her leftover food items that remained in the refrigerator that were not discarded, Dietary Manager stated the items should have been discarded, and she would throw them out. When asked about storage of thawing meats, the Dietary Manager stated items are placed in a container on the bottom shelf of the refrigerator. When provided an example of chicken thawing in a sink area, she explained that thawing chicken should be in the refrigerator. The surveyor advised her of the thawed chicken that was observed sitting out on 12/02/2025. The Dietary Manager acknowledged the item was not stored properly. Dietary manager acknowledged they would notify maintenance right away if the temperatures on the refrigerator and freezers are not properly working. Dietary Manager stated the potential harm that could occur if food is not properly stored under correct temperatures, label, dated, and discarded properly, is that residents could become very sick. Interview conducted with CNA F on 12/04/2025 at 3:53 PM. CNA F stated she has been employed at the facility since March or April. She reported she does not remember if she was trained on the facility's outside food policy. CNA F stated staff are expected to label food items brought in by family members with the date and time the item was brought in and, if opened, a discard date of three days. She stated that if a perishable item is brought in unopened, staff will still discard it after three days.Interview conducted with the DON on 12/04/2025, at 5:45 PM. The DON stated all food items should be labeled with date received, date opened, and a discard date of 3 days. The DON stated the teas and juices should be labeled with the date and time, and discard after use. The DON stated not properly labeling and discarding food timely could lead to potential problems, and residents could become ill.Interview conducted 12/04/2025, at 6:05 PM, the ADM stated that all food items should be labeled each time they are opened with a sticker showing the date opened, expiration date, and name of the product. The ADM stated that all expired food should be discarded immediately. She acknowledged that if expired food is served, residents could potentially experience negative side effects such as stomach aches or illness. The ADM stated raw chicken should not be sitting out, she stated it should be at the bottom of the refrigerator. She stated it could lead to e coli and cause residents to become very ill.Record review of the facility's policy named Preventing Foodborne Illness-Food Handling revealed:Policy Statement Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized.1. This facility recognizes that the critical factors implicated in foodborne illness are:a. Poor personal hygiene of food service employees;b. Inadequate cooking and improper holding temperatures;c. Contaminated equipment; andd. Unsafe food sources.2. With these factors as the primary focus of preventative measures, this facility strives to minimize the risk of foodborne illness to our residents.3. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents.Record review conducted 12/04/2025 of facility policy named Refrigerators and Freezers revealed:1. Acceptable temperature ranges are 35 F to 40 F for refrigerators and less than 0 F for freezers.2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures.3. Monthly tracking sheets will include time, temperature, initials, and action taken. The last column will be completed only if temperatures are not acceptable.4. Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening.5. The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted.6. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened.7. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes.Record review 12/04/2025 of facility policy named Food receiving and Storage revealed:Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices.8. Dry foods that are stored in bins will either be removed from their original packaging, placed in a clean and dry bin, labeled and dated, or left in its original packaging with the proper date on the packaging. 9. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).10. Refrigerated foods must be stored below 41 F unless otherwise specified by law.11. Refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers. Refrigerators/walk-ins will not be overcrowded.12. The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing.13. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements.14. Uncooked and raw animal products, including raw eggs) and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods.15. Food items and snacks kept on the nursing units must be maintained as indicated below:All food items to be kept below 41 F All foods belonging to residents must be labeled with the resident's name, the item and the use by date. Refrigerators must have working thermometers and be monitored for temperature according to state-specific guidelines. Beverages must be dated when opened and discarded after twenty-four (24) hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to prepare food by methods that conserve nutritive value and flavor for 1 kitchen reviewed for food and nutrition services.The facility failed to ensure [NAME] A refrained from adding an unmeasured amount of liquid to country pork tips with gravy, parslied noodles, and herb butter roll pureed meals during lunch service on 12/03/2025.This failure could place residents who received a pureed diet at risk for diminished or altered nutritional status and potential weight loss.Observation and interview on 12/03/2025, at 11:09 AM, revealed [NAME] A poured an unmeasured amount of milk into the parslied noodles without measuring after mixing one time, [NAME] A added another unmeasured amount of milk. [NAME] A was then observed preparing 3 herb butter rolls, adding an unmeasured amount of milk. Followed by [NAME] A adding an unmeasured amount of milk 3 different times to 3 large spoons of country pork tips. The mixture did not resemble the color of pork. When she was done, the pork appeared as a loose milky white mixture. [NAME] A was asked how much liquid was used per serving, she responded she did not know how much was used. [NAME] A stated, I just eyeball it, we do not have measuring cups. Surveyor asked to see recipe book, and the Dietary Manager brought it over. Dietary Manager mentioned the recipe book was used here and there with certain recipes. Surveyor asked [NAME] A if she used the recipe book, she stated she only referred to the recipe when she had questions. The recipe book showed the parslied noodles to require only 1/8 teaspoon of liquid per 1/3 cup serving. The country pork tips called for 0.5 ounce of liquid per 1/3 cup serving. The recipe book showed the meat should be pureed with broth, or other appropriate sauce/gravy from menu.A Test tray was requested and received on 12/03/2025 at 12:40 PM. The meal served was country pork tips with gravy, parslied noodles, green beans, and roll. The test tray was received for a regular texture diet. The parslied noodles had no flavor; the pork tips had a little flavor but had a few tough meat areas.A follow up interview was conducted with [NAME] A on 12/03/2025, at 1:18 PM. [NAME] A stated she had been employed at the facility for five months. [NAME] A stated she was trained by [NAME] B on pureed diets when she started at the facility. [NAME] A stated she did not use the recipe book often, and confirmed she was being honest about this. She reported that after she pureed the pork tips, she realized when surveyor asked the question about the liquids used, she could have used gravy instead of milk. [NAME] A stated she had not been trained on following recipes. [NAME] A stated that most of the time she looks up recipes online or asks the manager for assistance. She reported the kitchen does not have any measuring cups, so she eyeballs the amounts used in recipes. [NAME] A stated a dietitian recently came by to sample the pureed foods. She also stated another dietary manager from [NAME] comes to the facility to provide training as needed. [NAME] A reported that she and the current kitchen manager started working at the facility at the same time. [NAME] A stated she has always been told to use milk to puree foods, except for vegetables, for which she was instructed to use broth. [NAME] A was asked what potential harm could occur if she does not follow the recipes. [NAME] A stated the flavor of the food may change. She stated she does not know of any other harm that may be caused. [NAME] A stated When asked about potential effects of not following the recipe, [NAME] A stated it could change the flavor of the food and potentially create chewing issues, choking hazards, or risk of aspiration for residents.Interview conducted with the Dietary Manager on 12/04/2025, at 2:18 PM. Dietary manager stated she was unsure whether the cooks had been properly trained in preparing diet textures, as the cooks were employed at the facility prior to her assuming the role of Dietary Manager. Dietary Manger stated she started in June with the facility. She stated she understood she is responsible for enforcing kitchen procedures but reported she is still learning the facility's processes while completing her dietary management training. Dietary Manager stated she receives assistance from a Dietary Manger at a sister facility who comes to the facility to work with her on procedures. She stated that going forward, the Dietary Manager will be responsible for training all dietary staff. The Dietary Manager stated she had been trained that liquids other than milk may be used to puree foods. When asked why the facility's recipe books were not consistently followed by staff, the Dietary Manager stated she personally follows the recipe books and reported that the other cooks had been at the facility before her. When asked how cooks verify portion sizes and measurements when preparing food according to recipes, the Dietary Manager stated that staff use measuring cups for accuracy. The Dietary Manager stated the kitchen plans to add broth and gravy into pureed meat recipes to enhance flavor. She stated the potential risk of harm from not following recipes includes food lacking flavor, which may result in residents losing their appetite and could contribute to weight loss.Interview conducted with the DON on 12/04/2025, at 5:45 PM. DON was asked, how are physician-ordered diets (such as pureed diets) communicated to nursing and dietary staff. DON stated they are put on a diet communication form and sent to the kitchen. DON was asked what systems are in place to ensure residents consistently receive the prescribed diet texture, she responded that the tray ticket and food are checked by the nurse before being given to the residents. DON stated they have a dietician that comes often to complete assessments. When asked if she knew what should be used to puree food, she stated she was unsure. DON stated she expects the dietary department to follow the recipes. When asked what could happen if the puree diet recipe was not followed, she stated that residents could potentially not receive the right amount of nutrients or lose calories if too much liquid was used. DON stated the residents can lose weight; muscles could deteriorate and could lead to possible death. DON also added that the taste and nutritional value of the food may be affected.Interview conducted with the ADM on 12/04/2025, at 6:05 PM, ADM stated her expectation was for dietary staff to follow the recipes as written. She stated they have measuring cups in the kitchen. ADM explained that if the pureed diet was not prepared according to the recipe, the food could lose its flavor and not taste good. She stated the potential harm to residents was that they may not receive the correct caloric intake and the resident could lose weight. ADM stated the pureed diet should be of a pudding, consistency and if the resident received the wrong texture they could aspirate.Interview conducted with [NAME] B on 12/04/2025, at 6:23 PM. [NAME] B stated she has worked at the facility for almost two years. [NAME] B stated she was trained on puree diets by a previous dietary manager. [NAME] B stated she trained [NAME] A when she first started at facility. [NAME] B stated she followed the recipe book, and she use the measuring cups for milk. [NAME] B stated she was taught only to use milk to puree food as it contains protein. [NAME] B stated using too much liquid could take away the flavor and the residents may not want to eat their food. [NAME] B stated if the resident did not eat their food, they could lose weight and possibly get sick.Record Review of the facility's diet order, conducted on 12/03/2025, revealed there were 3 residents on pureed diets. A facility pureed diet policy was requested from ADM on 12/04/2025 at 1:50 PM, the policy was not received at time of exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of 5% or greater. There were two (2) medication errors in 26 opportunities for an error rate of 7.69% by 1 of 3 staff members observed (LVN) administering medications to 1 of 7 residents. (Resident #28). LVN attempted to administer Resident #28 Potassium Chloride Extended Release Oral Capsule Extended Release 10 milliequivalents, crushed with pudding. Order stated, Potassium Chloride ER Oral Capsule Extended Release 10 MEQ (Potassium Chloride) Give 1 capsule by mouth two times a day for supplement do not crush, may dissolve in 4-6oz (ounces) of water. Medication was attempted to be administered in the incorrect dosage form. LVN administered hydroCHLOROthiazide Oral Tablet 25 MG (milligrams). The order stated, hydroCHLOROthiazide Oral Tablet 25 MG (Hydrochlorothiazide) Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION HOLD IF SBP (systolic blood pressure) IS < (greater than)110 [millimeters of mercury], AND DBP (diastolic blood pressure) IS < (less than) 50 [millimeters of mercury] OR HR (heart rate) < (less than) 60 [beats per minute] NOTIFY MD (medical director). Medication was administered without a blood pressure or pulse reading assessed prior to the administration of the medication per the physician order. This failure could place residents at risk of not receiving medications as ordered and not receiving therapeutic benefits. Findings include: Record review of Resident #28's Face sheet dated 12/03/2025 reflected a [AGE] year-old female, admitted to the facility on [DATE]. Diagnoses included dementia, dysphagia (difficulty swallowing), and hypertension (high blood pressure). Record review of Resident #28's Quarterly MDS (minimum data set) assessment dated [DATE] reflected she was rarely or never understood. Dysphagia (difficulty swallowing) was listed as an active diagnosis. She was dependent on staff for eating and received speech therapy for eating or swallowing for 7 days of the previous review period. Record review of Resident #28's physician orders reflected an order for hydrochlorothiazide oral tablet 25 mg with a start date of 10/24/2024. The directions for the order reflected, Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION HOLD IF SBP (systolic blood pressure) IS < (greater than)110 [millimeters of mercury], AND DBP (diastolic blood pressure) IS < (less than) 50 [millimeters of mercury] OR HR (heart rate) < (less than) 60 [beats per minute] NOTIFY MD (medical director). There was another order for potassium chloride extended release capsule with a dose of 25 mg. The directions reflected, Give 1 capsule by mouth two times a day for supplement do not crush, may dissolve in 4-6oz (ounces) of water. Record review of Resident #28's blood pressure reflected her last blood pressure was taken on 11/14/2025 at 9:22AM and was 118/71 mmHg (millimeters of mercury). Record review of Resident #28's blood pressure reflected her last pulse rate was taken on 11/14/2025 at 9:22AM and was 74 beats per minute. Record review of Resident #28's Progress Notes dated 11/03/2025 to 12/04/2025 reflected no hospitalizations or episodes of low blood pressure. Observation of medication administration on 12/03/2025 at 9:22AM with LVN G revealed she dispensed the medications for Resident #28 appropriately and crushed them to mix with pudding. There was no blood pressure or pulse taken for Resident #28 during the observation process. The administration process was interrupted prior to resident receiving the medications. In an interview with the CMA H, she stated that she should not have crushed the potassium chloride. She stated that per the orders, she should have dissolved it in water. She stated that Resident #28 was able to swallow thin liquids. She stated that the impact to the resident of not administering it in the correct form could be that the medication might not work as well. She wasted the medications per the facility policy and administered the potassium chloride dissolved in 6 ounces of water. Observation and interview with LVN G on 12/03/2025 at 10:38AM revealed that Resident #28's blood pressure was 140/94 mmHg and pulse was 89 beats per minute. She stated that potassium chloride extended-release tablets should not be crushed. She stated that they should be dissolved in water. She stated that it was a medication error to administer the medication crushed. She stated that the medication record usually will not let them document the medication administration for medications with parameters unless they added the parameters at the time they administered it. She stated she was not sure how the requirements for blood pressure and pulse were added to the medication administration records. She stated that if staff did not check the blood pressure and pulse prior to administering a medication with parameters, their blood pressure could be too low or too high, and the nursing staff would not know. In an interview with the DON on 12/3/2025 at 10:51AM, she stated that the medication administration record for Resident #28 should have an area where staff were required to document the blood pressure and pulse before giving the hydrocholorothiazide. She stated that she would fix it right away. She stated that the last blood pressure documented for Resident #28 was on 11/14/2025. She stated that staff should check the order prior to administering the medication and notify her if there was not a place to document the blood pressure and pulse. She stated that even without the prompt from the medication administration record, the nurses and CMAs should know to document the blood pressure and pulse. She stated that if the blood pressure and pulse were not charted, she would have to assume that it was not done. She stated that the impact to the resident was that the staff could lower the blood pressure and would not know. In an interview with CMA H on 12/3/2025 at 2:48PM, she stated that she had spoken to the DON about the blood pressure and pulse for Resident #28. She stated that she did not see the parameters on the order. She stated that on all the other residents with blood pressure medications there was a prompt for her to enter the blood pressure and pulse if it was required. She stated that she was not told when she trained, on medications, that Resident #28 needed to have her blood pressure and pulse taken with her morning medications. She stated that she would have done it if she had seen it on the medication order. She stated that she saw the parameters for the medication order after she clicked on the medication summary, but not when she was clicking the administration. She stated it was a mistake. She stated that even without the prompt, she should have checked the order for a medication that affected blood pressure. She stated that the impact to the resident of not checking the blood pressure and pulse before administering a blood pressure medication was that it could lower an already low blood pressure. Record Review of facility policy for Medication Administration dated 4/19/2019 reflected: Medications are administered in a safe and timely manner, and as prescribed.Policy interpretation and Implementation.4. Medications are administered in accordance with prescriber orders, including any required time frame.11. The following information is checked/verified for each resident prior to administering medications:a. Allergies to medications, andb. Vital signs, if necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents, staff and public for one (room # 411 vent) of seven vents observed and reviewed for environment. The facility failed to ensure the vent in room [ROOM NUMBER] was clean and free of dust particles. These deficient practices placed residents at risk for illness and decreased quality of life.Findings included:During an interview on 10/13/2025 at 2:03 pm the Maintenance Director stated the vent/AC register was responsible for directing the air. The Maintenance Director looked at the picture of the vent from room [ROOM NUMBER], and he stated that it was probably dust and needed to be cleaned. The Maintenance Director stated he would think it would have an impact on the residents, dust in their room, but was not sure of medical issues. The Maintenance Director said the dust in the vent of room [ROOM NUMBER] was not brought to his attention.During an interview on 10/13/2025 at 2:50 pm the DON looked at the picture of the vent in room [ROOM NUMBER] and stated that it was a vent with all dust and it could cause respiratory problems. She stated that meant the facility was not cleaning the vents. The DON stated Housekeeping and Maintenance were responsible for cleaning the vents in the building. The DON stated the managers should be checking the vents during their morning rounds.During an interview on 10/13/2025 at 3:34 pm the housekeeping supervisor stated she gives her staff a daily schedule. Housekeeping supervisor stated cleaning the vent was part of their daily cleaning schedule, with the duster on the surface, but they couldn't get thorough cleaning. The Housekeeping supervisor stated they have to get maintenance to open the vent for thorough cleaning. The Housekeeping supervisor stated she has climbed on the ladder and taken the vent cover out to clean thoroughly but that was about a year ago. The Housekeeping supervisor stated she was not sure if cleaning the vent had an impact on the residents' health.During an interview on 10/13/2025 at 4:03 pm the Administrator stated the facility had been working on the vents in the facility but did not know the vent in room [ROOM NUMBER] was that dirty. The Administrator stated the dirty vent could potentially cause respiratory issues, but she had not had complaints regarding vents.Review of facility's policy revised June 2011 titled cleaning and disinfecting non-critical Resident -Care items reflected: Purpose--The purpose of this procedure is to provide guidelines for disinfection of non-critical resident-care items.Preparation--Assemble the equipment and supplies as needed.Review of facility's policy dated revised 06/30/2025 titled Cleaning and Disinfection of Resident-Care Items and Equipment reflected: Policy Statement --Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. for 1 of 1 kitchen observed in that:The facility failed to ensure the water dispenser in the main dining hall was clean.The facility failed to ensure the sinks in the kitchen were clean.The facility failed to ensure the Resident's drink area in the kitchen was clean.The facility failed to ensure the vent in the kitchen was closed and clean.The facility failed to ensure there were no broken tiles in the kitchen.These deficient practices placed residents at risk for illness and decreased quality of life.Findings included:Observation on 10/13/2025 at 10:02 am reflected the water dispenser/drinking fountain in the main dining area had brown-colored liquid in the drip tray that looked slimy with tiny particles. Observation on 10/13/2025 at 10:05 am the kitchen sink was brown-colored and there were two small brown pellets on the drain strainer. The sink had black area at the back directly under the faucet.Observation on 10/13/2025 at 10:07 am kitchen vent without cover and the other vent was cover with dust.Observation on 10/13/2025 at 10:08 am the countertop of the drinks area had brown stains.Observation on 10/13/2025 at 10:09 am revealed there were cracked tiles in the kitchen under the sinks which created tripping hazard for staff. During an interview on 10/13/2025 at 12:34 pm, the Administrator stated the water dispensers were checked at least daily and she checked it daily on her daily morning rounds. The Administrator stated she expected the water dispenser to be clear, clean, no residual. The Administrator stated housekeeping staff was supposed to make sure the water dispenser was clean. The Administrator stated most of the Residents drink from the water dispenser due to the hard water system in the city. During an interview on 10/13/2025 at 12:55 pm the Dietary aide said everybody in the kitchen was responsible for the cleaning. The Dietary aide looked at the picture of the kitchen sink and counter area and stated she had never seen an area like that. She also stated she did not know who was responsible for cleaning the water dispenser in the dining area. The Dietary aide stated one of the vents in the kitchen had been open for a while, but she couldn't recall how long. During an interview on 10/13/2025 at 1:05 pm the [NAME] stated everyone was responsible for cleaning certain things in the kitchen. The [NAME] stated the Dietary aide was responsible for cleaning the drinks area. The aide was responsible for cleaning that sink because that was her area. The [NAME] said the Dietary manager was responsible for ensuring tasks were completed in the kitchen based on the cleaning list. The [NAME] stated dietary staff had to initial once their cleaning task was completed. The [NAME] stated the vent in the kitchen had been opened since she started working at the facility about 3 months ago. The [NAME] stated she spoke with the Dietary Manager about the vent being opened. The [NAME] stated the vent was supposed to have a filter to prevent dust or anything else from coming in. The [NAME] also stated the cracked tiles had been like that since she started working at the facility and the Administration was aware. During an interview on 10/13/2025 at 1:22 pm the Dietary Manager stated she started a cleaning log in August 2025 to make sure the staff were cleaning their work areas. The Dietary Manager stated she checked the cleaning log daily. The Dietary Manager looked at the picture from the kitchen sink and the drinks area and stated the drinks area was [NAME], and the sink had mold, and it was like that when she started her position and had gotten better. The Dietary Manager stated the mold was not supposed to be in the sink, it was gross, it could cause sickness to the residents. The Dietary Manager stated the Dietary aide was responsible for cleaning the sink and the drinks area and she was responsible for ensuring the cleaning was completed. The Dietary Manager stated the vent in the kitchen had been open for a while and it was not ok to remain open because anything like debris could come in. The Dietary Manager stated the Maintenance Director was aware of the open vent. The Dietary Manager stated she was told the Maintenance Director and the Housekeeping Supervisor were responsible for cleaning the water dispenser. The Dietary Manager stated she checked the water dispenser in the dining area at about lunchtime, and it had coffee in the drip tray. When the Dietary Manager looked at the pictures and stated, no, this is not what I saw, this is not coffee, this was dirt. The Dietary Manager stated the water dispenser was clean now, she had cleaned it. During an interview on 10/13/2025 at 2:03 pm the Maintenance Director stated there were 2 water dispensers in the facility, 1 in the dining area and 1 in the lobby. The Maintenance Director stated he checked the water dispensers every morning and when they were dirty and he let the housekeeper know to clean it. The Maintenance Director stated he checked the water dispenser in the lobby and the Dietary Manager checked this morning and it didn't seem dirty. The Maintenance Director looked at the picture of the water dispenser and stated it did not look like that yesterday; it looked clean. The Maintenance Director stated the water dispenser did not look good, it was dirty, it was going to have an impact on the residents; it needed to be clean. The Maintenance Director stated he had not checked the rooms' vents since he had been in the facility for about 2 months and it was not on his to-do list. He stated he was not sure if it was supposed to be checked. The Maintenance Director stated the vent/AC register was responsible for directing the air. The Maintenance Director stated the vent in the kitchen was brought to his attention about a week or 2 weeks ago and he was working on it. The Maintenance Director stated the vent/AC register in the kitchen needed to be replaced. The Maintenance Director stated the air will not be directed properly due to the vent being opened. During an interview on 10/13/2025 at 2:50 pm the DON stated she sometimes looked at the water dispenser and refills them. The DON looked at the water dispenser pictures and stated it was gross. The DON stated she wouldn't get water from the water dispenser like that because it might have bacteria or mold. The DON stated about 1/2 of the residents in the facility get their own water from the water dispenser. The DON stated she hasn't gone into the kitchen since the new manager started. The DON looked at the photos of the kitchen and stated 1 was the sink next to coffee pot and the black substance was a mildew not from the hard water, and the sink looked like it had not been cleaned. The DON looked at the other picture and stated that was the countertop by the juices. The DON stated it looked greasy. The DON stated Housekeeping and Maintenance were responsible for cleaning the vents in the building. The DON stated the managers should be checking the vents during their morning rounds. The DON stated the vent in the kitchen was from the roofers and they were supposed to come back and fix it. The DON stated there was food in the kitchen, and there shouldn't be an open hole. During an interview on 10/13/2025 at 3:34 pm the housekeeping supervisor stated she gives her staff a schedule daily. Housekeeping supervisor stated cleaning the vent was part of their daily cleaning schedule, with the duster on the surface, but they couldn't get thorough cleaning. The Housekeeping supervisor stated they have to get maintenance to open the vent for thorough cleaning. The Housekeeping supervisor stated she has climbed on the ladder and taken the vent cover out to clean thoroughly but that was about a year ago. The Housekeeping supervisor stated she was not sure if not cleaning the vent had an impact on the residents' health. The Housekeeping supervisor stated she did not know who was responsible for cleaning the water dispensers in the dining area. She stated the water dispenser in the lobby was cleaned by the housekeeper, the one in the kitchen she didn't know. The Housekeeping supervisor stated she did not know if housekeepers or maintenance were supposed to be cleaning the water dispensers. During an interview on 10/13/2025 at 4:03 pm the Administrator stated the vent in the kitchen had addressed numerous times with corporate, she had been going back and forth with the corporate office and it had been like that since she had been in the facility for about a month. The Administrator stated there was a hole in the kitchen from the vent covering not being present, dust and debris could come in and that was not safe, it was a huge concern. The Administrator stated she took pictures of the flooring in the kitchen, the cracked tiles and sent them to the Maintenance Director. The Administrator stated the tile was loose in the kitchen and that was a slip hazard for staff which was unsafe. The Administrator stated the sink in the kitchen looked like it had rust, could potentially grow mold due to being moist. The Administrator stated she saw stains by the juice machine; they look rusty, it should be clean. The Administrator stated the Dietary Manager did not use the sink with the rust and the mold. Review of facility's policy dated revised August 2025 titled Sanitization reflected: Policy Statement --The food service area shall be maintained in a clean and sanitary manner.Policy Interpretation and Implementation-- All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. FIXED EQUIPMENT-1. Fixed equipment will be routinely cleaned and maintained in accordance with the manufacturer's directions.2. Staff members will be trained in the cleaning and maintenance of all equipment.3. Food contact equipment will be cleaned and sanitized after every use.4. Non-food contact equipment will be clean and free of debris15. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime.16. The Food Services 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 areas during all tasks, and to clean after each task before proceeding to the next assignment. Review of facility's policy dated December 2009 titled Maintenance Service reflected: Policy Statement--Maintenance service shall be provided to all areas of the building, grounds, and equipment.Policy Interpretation and Implementation1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.2. Functions of maintenance personnel include, but are not limited to:1. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.2. maintaining the building in good repair and free from hazards.3. maintaining the fire alarm system and emergency generator system in good working order.4. maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order.5. maintaining lighting levels that are comfortable and assuring that exit lights are in good working order.6. establishing priorities in providing repair service.7. maintaining the paging system in good working order.8. maintaining the grounds, sidewalks, parking lots, etc., in good order.9. providing routinely scheduled maintenance service to all areas.10. others that may become necessary or appropriate.3. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.4. A copy of the maintenance schedule shall be provided to each department director so that appropriate scheduling can be made without interruption of services to residents.5. Maintenance personnel shall follow the manufacturer's recommended maintenance schedule.6. Changes in maintenance schedules must be approved by the maintenance director.7. Maintenance personnel shall follow established infection control precautions in the performance of their daily work assignments.8. The maintenance director is responsible for maintaining the following records/ reports.1. Inspection of building.2. Work order requests.3. Maintenance schedules.4. Authorized vendor listing; and5. Warranties and guarantees.9. Records shall be maintained in the maintenance director's office.10.Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned. Review of facility's policy revised June 2011 titled cleaning and disinfecting non-critical Resident -Care items reflected: Purpose--The purpose of this procedure is to provide guidelines for disinfection of non-critical resident-care items. Preparation--Assemble the equipment and supplies as needed. Review of facility's policy dated revised 06/30/2025 titled Cleaning and Disinfection of Resident-Care Items and Equipment reflected: Policy Statement --Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all drugs to meet the needs of each resident for one resident (Resident #1) of four residents reviewed for medication administration in that: Resident #1 was not administered her Clonazepam 0.5 MG (anti-anxiety medication-- is a benzodiazepine medication used to treat panic disorders, certain seizure disorders, and movement disorders) for 3 days from 09/23/2025 to 09/25/2025 due to the facility not obtaining medication from the pharmacy. This failure could place residents on anti-anxiety medication at risk for increased anxiety and depression and change in ADLs.Findings included:Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted on [DATE] with the following dx. Major Depressive Disorder, recurrent, moderate (a mood disorder that causes a persistent feeling of sadness and loss on interest), Panic Disorder [episodic paroxysmal anxiety] (a panic disorder is a sudden episode of intense fear that triggers severe physical reactions when there is no real danger or apparent cause), Generalized Anxiety Disorder (a condition characterized by excessive or unrealistic anxiety about two or more aspect of life), Bipolar Disorder, recurrent episode mixed (a condition where a person experiences episodes that contain both manic and depressive symptoms at the same time and that these episodes happen repeatedly).Review of Resident #1's quarterly minimum data set (MDS) assessment dated [DATE] reflected a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment. Section I, Active Diagnoses reflected: Anxiety Disorder, Depression, Bipolar Disorder. Section N, Medications reflected antidepressant and Anticonvulsant medications were given in the last 7 days. Antianxiety and antipsychotic were not checked.Review of Resident #1's care plan initiated 12/24/2024 reflected Resident #1 required staff assistance for meeting emotional, intellectual, physical and social needs related to physical limitations. Care plan initiated 09/25/2024 reflected, resident uses anti-anxiety medications Clonazepam and Hydroxyzine related to Anxiety with intervention to administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT.Review of complaint file with HHSC dated 10/02/2025 reflected: From 09/19/2025 to 09/24/2025, The Resident [Resident #1] was without her CLONAZEPAM, for anxiety, because the facility was unable to get her medication from the pharmacy.Review of Resident #1's physician orders reflected an order dated 09/22/2025 for Clonazepam Tablet 0.5 MG Give 1 tablet by mouth at bedtime related to BIPOLAR DISORDER, CURRENT EPISODE MIXED, MILD, to start 09/23/2025.Review of Resident #1's Narcotic count sheet reflected 30 pills of Clonazepam Tablet 0.5 MG was delivered for Resident #1 on 08/18/2025, started taking on 8/19/2025 and was completed on 09/22/2025, zeroing out. It was also revealed that Resident #1's next Clonazepam Tablet 0.5 MG pills were delivered on 09/26/2025.Review of Resident #1's MAR for the month of September reflected:Clonazepam Tablet 0.5 MG Give 1 tablet by mouth at bedtime related to BIPOLAR DISORDER, CURRENT EPISODE MIXED, MILD and for the dates of 09/23/205, 09/24/2025 and 09/25/2025 signed by RN A, it indicated the number 6. The meaning for the number #6 on the MAR reflected: other/see progress notes.Review of Resident #1's progress notes dated 09/23/2025 at 10:54 pm, 09/24/2025 at 10:46 pm and 09/26/2025 at 00:02 am written by RN A reflected: Clonazepam Tablet 0.5 MG Give 1 tablet by mouth at bedtime related to BIPOLAR DISORDER, CURRENT EPISODE MIXED,on order.Review of Resident #1's progress notes dated 09/25/2025 at 3:19 pm written by LVN B reflected: Spoke with [XXX] at Pharmacy, to send Clonazepam today.Review of Resident MAR indicated behavior monitoring dated 09/24/2025 which reflected : Behavior monitoring Anti- Psychotic Q Shift: 0.None 1.Afraid 2.Agitated 3.Angry 4.Anxious 5.Mood change 6.Noisy 7.Restless 8. Withdrawn/crying 9.Crying 10.Combative 11. every shift related to BIPOLAR DISORDER, CURRENT EPISODE MIXED, MILD. There were no monitoring done on 09/24/2025 and the nurses indicated 0 on 09/25/2025 meaning no behavior noted. Review of Resident #1's progress notes from 09/22/2025 through 09/26/2025 did not reflect staff notifying Resident 's NP/MD for Clonazepam Tablet 0.5 MG.During an interview on 10/13/2025 at 10:31 am Resident #1 stated the staff usually do not give her medication and would say she refused her medication.Observation on 10/13/2025 at 1:55 pm reflected there were 13 pills of Clonazepam Tablet 0.5 MG left on the blister packet of pills for Resident #1 which was delivered on 09/26/2025.During an interview on 10/13/2025 at 2:25 pm, LVN B stated she called the local pharmacy on 09/25/2025 regarding Resident #1's Clonazepam Tablet 0.5 MG to be delivered. LVN B stated she was not sure if Resident #1 was out of Clonazepam Tablet 0.5 MG or if she was low on her Clonazepam Tablet 0.5 MG. LVN B stated the medication aides would know if Resident #1 was out of Clonazepam Tablet 0.5 MG. LVN B stated the process for reordering a narcotic medication was to call the pharmacy to see if a new prescription was needed or whatever, if new prescription was needed, contact the physician. LVN B stated all narcs needed a new prescription from the MD. LVN B stated an authorized agent could call the pharmacy for resident's narcotics and the DON was the only authorized agent in the facility. LVN B stated she did not notify the DON of Resident #1 needing Clonazepam Tablet 0.5 MG.During an interview on 10/13/2025 at 2:50 pm the DON stated Resident #1 did not get the Clonazepam Tablet 0.5 MG on 09/23, 09/24 and 09/25/2025, because the pharmacy did not send the medication. The DON stated Resident #1's Clonazepam Tablet 0.5 MG decreased from BID to once a day at night on 09/22/2025. The DON stated she was not made aware that Resident #1's Clonazepam Tablet 0.5 MG was not available or not delivered by the pharmacy. The DON stated she should have been made aware because she was the only agent in the facility to call the pharmacy for narcotic medication reordering. The DON stated Resident #1 not taking her Clonazepam Tablet 0.5 MG could make her more depressed, mood will be different and will have increased anxiety. The DON stated if she had known, she would have done a medication error report and trained her nurses. The DON stated nighttime medications were given by the night shift nurses.During an interview on 10/14/2025 at 08:29 am, RN A stated she worked with Resident #1 on 09/23/2025 through 09/25/2025. RN A stated Resident #1 had ordered Clonazepam Tablet 0.5 MG to be given at bedtime, but the medication was not available for those 3 days. RN A stated she documented in Resident 1's progress notes that Clonazepam Tablet 0.5 MG was on order. RN A stated, that was her mistake; she should have called the pharmacy to find out and then call the DON to call the medication in to the pharmacy. RN A stated she did not notify the DON that the medication was not available, and she did not notify the NP/MD. RN A stated Resident #1 had other medications for sleep and anxiety, so she was not anxious during those 3 days. Review of facility's policy dated 10/01/2025 titled Ordering and Receiving Medications from Pharmacy- Ordering and Receiving Non-Controlled Medications reflected: PolicyAll medication orders will be faxed to the pharmacy or submitted via EHR using the 'MOST ORIGINAL order. The most original order may be a telephone order, new admission physician order sheet or an interim physician order sheet. All medications are ordered and dispensed in the most efficient and cost-effective manner. The supply quantity and packaging will be in accordance with pharmacy policy unless otherwise specified by physician order. The facility maintains accurate records of medication order and receipt. It will be the responsibility of the facility to re-order the medication to avoid any lapse in therapy. Direction Change order for existing residentsA. The Most Original order must be faxed to the pharmacy along with any relevant discontinuation order.B. Indicate the time that the doses are due on the Physician's Order Sheet. Medications will be sent to meet the next dose time requirements.3. ReadmissionA. The Most Original order must be faxed to the pharmacy with a face sheet and cover sheet to clarify a resident's status.B. Nurses MUST COMMUNICATE to the pharmacy which medications need to be dispensed based on the readmission medication list. Review current medication stock to avoid duplication and the patient's pay plan upon readmission.C. Use a fax cover sheet and indicate the time that the next doses are due, for the medications that are needed.Review of facility's policy dated 10/01/2025 titled Medication Monitoring-Medication Error and Incident Reporting reflected: PolicyTo define the process for reporting an actual or potential event that is inconsistent with usual operating procedures or pharmaceutical care, or an accident or incident that poses a potential hazard. Injury does not necessarily occur. The perception of a client, visitor, or associate's potential for injury and/or property damage is sufficient to document on a medication error report. Examples of reportable incidents include but are not limited to:5. Non-Compliance6. Customer/Client Complaint7. Transportation Issue (i.e., failure to deliver contracted services)8. OtherReview of facility's policy revised 10/01/2019 titled Medication Policies- Ordering and Receiving Medications from Pharmacy- Ordering Controlled Substances and CII Original Prescriptions reflected: PolicyBefore a controlled drug can be dispensed, the pharmacy must be in receipt of a clear, complete, and signed written or e-prescribed prescription from a person lawfully authorized to prescribe. A chart order is not equivalent to a prescription for controlled drugs. Therefore, the prescriber issuing the chart order must also provide the pharmacist with a valid prescription. The written prescription may be faxed to the pharmacy for long-term care facility residents.To facilitate effective communication, documentation, and aid in prevention of medication errors, medication orders should be clear and concise and free of potentially dangerous abbreviations.ProcedureThe director of nursing and the consultant pharmacist maintain the facility's compliance with Federal and State Laws and Regulations in the handling of controlled medications. Only authorized licensed nursing, medical and pharmacy personnel have access to controlled medications.2. Schedule II controlled medications prescribed for a specific resident are delivered to the facility only if a written or e-prescribed prescription has been received by the pharmacy prior to dispensing. When reordering Schedule II controlled substances, order at least 7 days in advance of need to allow for transmittal of the required written prescription to the pharmacist. Suggest reorder in 5 days for Schedule III -V. The prescriber is contacted for directions when delivery of a medication will be delayed, or the medication is not or will not be available.Review of facility's policy revised 10/01/2019 titled Medication Policies- Ordering and Receiving Medications from Pharmacy- Receiving Controlled Substances reflected: PolicyMedications included in the Drug Enforcement Administration (DEA) classification as controlled substances and medications classified as controlled substances by state law are subject to special ordering, receipt, and record keeping requirements by the facility in accordance with federal and state laws and regulations.The Director of Nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized, licensed nursing and pharmacy personnel have access to controlled substances.Controlled substances are reordered when a 5-day supply remains to allow for transmittal of the required written prescription to the pharmacist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the residents were free from physical abuse for two (Resident #2 and Resident #3) of six residents reviewed for abuse. 1. The facility failed to ensure Resident #2 was not attacked by Resident #1 with a pencil on 08/11/25 causing slight bleeding and the facility failed to ensure Resident #2 was not hit over the head by Resident #1 with a metal object on 08/15/25, no physical injury, causing Resident #2 to be afraid of Resident #1.2. The facility failed to ensure Resident #1 did not slap Resident #3 on the back on 08/20/25.3. The facility failed to ensure a nurse, on 09/01/25, when pushing Resident #3 in her wheelchair to her room, did not tell the resident it hurt the nurses her back to push her and the nurse was going to need a forklift to move Resident #3An Immediate Jeopardy (IJ) situation was identified on 08/30/25. While the IJ was removed on 09/02/25, the facility remained out of compliance at a scope of isolated that with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of continued abuse, injury, hospitalization, trauma, and psychosocial injury.The findings include:Review of Resident #1's face sheet dated 08/30/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including schizophrenia (a chronic mental illness characterized by a combination of positive, negative, and cognitive symptoms that significantly impair a person's daily functioning and social relationships), schizoaffective disorder, bipolar type (a mental health condition that combines symptoms of schizophrenia and bipolar disorder (a chronic mental health condition characterized by extreme mood swings between episodes of mania (highs) and depression (lows) ), and unspecified dementia (a general term for a group of conditions that cause a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), severe, with anxiety (a severe form of unspecified dementia with the added symptom of anxiety).Review of Resident #1's care plan reflected focus;1. 07/08/25 Resident #1 had a behavior problem aggressive r/t schizophrenia and had potential to be physically aggressive r/t schizophrenia2. 07/08/25 Resident #1 had potential to be physically aggressive r/t schizophrenia3. 07/08/25 Resident #1 had potential to be verbally aggressive r/t schizophrenia and DementiaResident #1's MDS Nursing Home Comprehensive dated 06/16/25 reflected a BIMS score of 00 indicating severe cognitive impairment. Section A1510 Level II Preadmission Screening and Resident Review (PASRR) Conditions reflected serious mental illness. Section A1805 Entered From reflected Inpatient Psychiatric Facility (psychiatric hospital or unit). Review of Resident #2's face sheet dated 08/30/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline), schizophrenia, unspecified dementia, unspecified severity, with other behavioral disturbance (a description combining symptoms of schizophrenia with unspecified dementia and a behavioral disturbance). Review of Resident #2's care plan reflected focus;1. 07/30/24 Resident #2 was PASRR level 2 d/t schizophrenia and major depressive disorder, recurrent2. 12/26/24 Resident #2 had potential to be physically aggressive (throwing cups, trash) r/t schizophrenia and TBI3. 12/26/24 Resident #2 had potential to be verbally aggressive calling staff bitches and niggers r/t schizophrenia and TBI4. 01/15/24 Resident #2 had a communication problem r/t HOH and used an amplifier. 5. 01/15/24 Resident #2 had a mood problem r/t schizoaffective disorder. Resident #2's Quarterly MDS dated [DATE] reflected a BIMS score of 12 indicating moderate cognitive impairment. Review of Resident #3's face sheet dated 09/02/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including major depressive disorder (mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life), unspecified psychosis not due to a substance or known physiological condition (psychotic symptoms (like hallucinations or delusions) but a specific diagnosis cannot be made because there isn't enough information or the symptoms don't fit another established category), and schizoaffective disorder, depressive type (a mental health condition that combines symptoms of schizophrenia with those of major depression).Review of Resident #3's care plan reflected focus dated 08/31/25 reflected Resident #3 had potential to be verbally aggressive, shouting at staff or other residents r/t dementia, mental or emotional illness. Resident #3's MDS Quarterly assessment dated [DATE] reflected in section A1805 Resident #3 entered the facility from inpatient psychiatric hospital. Review of Resident #3's brief interview for mental status reflected a BIMS score of 00, indicating severe cognitive impairment.Observed Resident #1, Resident #2, and Resident #3 in the secured unit of the facility. Observation of Resident #1's right hand reflected no marks on his skin. Record review Resident #1 progress note dated 08/11/25 by LPN A reflected, Resident was sitting at the dining room table with several other residents when he started to stick his middle finger up at that the TV. The Resident next to him asked him politely not to do that and then he proceeded to say some cuss words and pull his pencil out of his pocket [and struck] the other resident a few times in his arm. Lorazepam given at this time. [name of NP notified and ordered risperidone 0.5mg bid at this time and said to go ahead and try to send him for eval Record review of Resident #1 progress note dated 08/11/25 by LPN A reflected, Weekly Skin Check Summary Resident is in facility and available for scheduled skin check. Resident allowed clinician to complete today's skin check. Resident does not have any skin or wound issues.Record review of Resident #1 progress noted dated 08/11/25 by RN reflected, this resident run after the CNA down to the office so mad and pushed hard the door and hit the CNA on her chest. CNA took his pen and gave it to this nurse. He got mad and kicked the nurse so hard on her thigh. reason why resident not to have pen on his possession was that he stabbed a resident on his hand several times. noted he has more pens and pencils and was confiscated. his reason for having those pens and pencils was to use to stab the gorilla.Record review of Resident #1 progress note dated 08/14/25 by LPN A reflected, start of Shift 6 Am resident was hitting the wall and yelling in his room. Nurse attempted to offer him a snack/ Drink He refused. He was then asked if he wanted to go [outside] and walk around in the [courtyard] he refused at this time as well. Resident said he was going back to sleep. Never went back to sleep. lab staff came in to draw his labs but he refused and hit nurse at this time. Was then yelling [and] cussing at everyone who walked by and the nurse. Saying thing in Spanish and English. Saying everyone was calling him names. No one was.Record review of Resident #1 progress note dated 08/14/25 by ADON reflected, Resident continues to pace up and down the hallway most of the morning, Keeps saying some [inappropriate] things to other resident and staff. Hit nurse again when I was trying to redirect him about punching air around other people he could hit someone. he [got flustered] with another resident saying that someone one was gonna fight them and that he needed to get up and fight back. [Offered] him more food he has refused at this time. Offered him to go outside [which] he did for about 5 mins but came back in. Offered for him sit with nurse and watch the movie on TV he did for a few minutes but got up several time in a 15 min period. Has changed [changed] 4 times since 6 am. He is now laying in his bed resting at this time.Record review of Resident #1 progress note dated 08/15/25 by ADON reflected, Resident was outside with another resident, they started cussing at each other and [Resident #1] hit the other resident in the head with an object. No injuries were noted. DON aware.Record review of Resident #1 progress note dated 08/17/25 by LPN A reflected, Resident has been cussing the staff out most of the morning. Very aggressive toward staff and other resident. Swing his arm and trying to box everyone who walks by. Yelling at the TV again, [Yelling] at other resident and staff when he walks by. Started bang on the door to the other unit saying he saw his wife and that she needs to come to see him now. When asked to move away from the door. He became even more aggressive. Ativan was given with him morning medication. No effective at this time. We have offered him several snack/ drinks. Offered to let him go for a walk out in the [courtyard] witch he did but was still aggressive. put him back on one on one for now. Attempted to contact [psych NP] no answer at this time. Also notified DON at this time.Record review of Resident #1's progress notes reflected no 1:1 monitoring (a healthcare intervention where a single, qualified staff member continuously provides direct, visual observation of a high-risk patient to ensure their safety and prevent harm. This method is implemented for patients exhibiting behaviors or conditions such as cognitive impairment, high suicide risk, aggressive tendencies, or other safety threats, requiring constant, immediate intervention) put in place for Resident #1. Record review of Resident #2's progress reflected no note of incident with a pencil and Resident #1 on 08/11/25.Record review of Resident 2's progress note dated 08/11/24 by LPN A reflected, Right hand (back) - has 3 small puncture wounds to his right wrist and hand area. Review of Resident #2's progress note type wound dated 08/12/25 by LPN A reflected, Wound Location/Wound Description: Right hand (back) - Small wounds to his wrist and hand [from] a pencil. Wound Number: 1 Status: This wound/skin condition is not resolved/healed. Resident is in facility and available for scheduled wound assessment/wound care. There were no family and/or friends present during today's wound care/assessment. The resident allowed clinician to complete wound/skin condition weekly assessment and treatment. This wound was acquired while a resident of this facility.Review of Resident #2's progress note type incident dated 08/12/25 by LPN A reflected, Residents [RP] was notified by DON today about incident for yesterday. He was very thankful for the call and [stated] that the resident handled the situation very well.Review of Resident #2's progress note type incident dated 08/15/25 by LPN A reflected Resident was outside with another resident, they started cussing at each other, The other resident did hit [Resident #2] in the head with an object, no injuries were noted. DON was made aware.Review of Resident #2's progress note type wound dated 08/19/25 by DON reflected late entry, Weekly Wound Observation Summary Note: Wound Location/Wound Description: Right hand (back) - Small wounds to his wrist and hand form a pencil. Wound Number: 1 Status: This wound/skin condition has resolved/healed. Review of facility Behaviors Documentation Chart Memory Care Unit reflected the following:08/11/15 Resident #1 threw a pencil across from his room to hall. Very aggressive.08/13/25 Resident #1 he was being behavioral issues w/staff & residents. Hitting walls not [listening] 08/15/25 Resident #1 [Resident #1] & [Resident #2] outside [Resident #1] hit [Resident #2] in the head08/15/25 Resident #1 Didn't hit/kick anyone but continues to punch/kick the air08/17/25 Resident #1 slapped & then kicked my left hand (I had asked him to give me the weapons he had)08/17/25 Resident #1 5:30 am in room beating on the wall08/20/25 Resident #1 walked by [Resident #3] and slapped him on the back.08/25/25 Resident #2 [Resident #1 purposely bumped into [Resident] when passing in the hallInterview on 08/30/25 at 11:00 am with Resident #2 reflected Resident #1 grabbed a mental rod and hit him in the head and another time he stabbed him with a pencil and when he was stabbed with the pencil it drew blood. He reflected he told the DON that he wanted to press charges, but she called his RP, and his RP told him to calm down. He said he and Resident #1 were not allowed to walk in the courtyard together at the same time. Resident #1 said it was wrong for Resident #1 to have stabbed him and hit him and he should not have to be afraid of someone here. He said it hurt both times when Resident #1 hit him.Interview on 08/30/25 at 7:20 pm with Resident #2 reflected he was in the courtyard area alone with Resident #1 and he went to Resident #1 cursing him and asked Resident #1 why Resident #1 stabbed him with the pencil and Resident #1 pulled up an iron rod and hit him with it. He wanted to know if the DON was going to call the police and report Resident #1.Attempted interview on 08/30/25 at 11:15 am with Resident #1. Resident #1's responses to questions were unintelligible.Attempted interview on 08/30/25 at 11:15 am with Resident #3. Resident #3 was not interviewable. Interview on 08/30/25 at 11:44 am with CNA B reflected Resident #1 had calmed down some after the incident with Resident #1 and Resident #2 and the pencil. She said staff was alert around Resident #1 all the time because he attacked Resident #2. She said she was working at the time of the pencil incident but did not see it happen. She said Resident #2 was upset about the incident when Resident #1 attacked Resident #2 with the pencil and believed Resident #2 was still upset about the incident. She said (date unknown) on one occasion at dinner Resident #1 and Resident #2 were yelling at each other and she jumped up and got between them. She said she was not there with the situation with Resident #1 and Resident #2 and the iron bar. She said she was concerned about Resident #1 hitting residents. She said Resident #2 asked her if he should press charges. She said that Resident #1 was on 1:1 monitoring a couple of shifts. She said the Administrator and DON were aware of the incident with the pencil. Interview on 08/30/25 at 12:28 pm with facility Psych NP reflected there was no problem with Resident #1, but he has had his issues. She said she was aware of the incident with the pencil and Resident #2 but Resident #2 was scrapped with a pencil and it was a superficial injury taken care of with soap and water. She only knows of the incident with the pencil and that was the only incident that was reported to her. She was not aware of any issues with Resident #1 yelling at staff, hitting staff, or yelling or hitting other residents. She said Resident #1 was put on 1:1 after the incident with the pencil and Resident #2 but did not know for how long and when she saw it was a superficial scratch, she felt she was given wrong information, and the nurse overreacted. She said could not speak on anything else involving Resident #1 because she was not aware of any other issues and was not informed about Resident #1 hitting Resident #2 with a metal object. She was not aware of any additional behaviors involving Resident #1 and other residents. She said if there was problem with a resident and another resident at the facility the DON would notify her. Interview on 08/30/25 at 1:13 pm with CNA C reflected she was not at the facility when the incident occurred between Resident #1 and Resident #2 and the pencil. She said she was concerned because Resident #2 was not the same anymore, he seems scared. She said the other day Resident #1 was coming at Resident #2 for no reason and Resident #2 was backing up scarred. She said the other residents are getting hit for not reason and none of the residents hit other people. She said she wrote resident behaviors on a behaviors chart, and she reported the behavior to the nurse. She said the behavior chart was for CNAs only and it was their personal log to keep documentation of what was happening. She did not know if the DON was aware of the behavioral chart, and she did not know when it started. She said she felt like Resident #1 was still aggressive and she did not feel like 1:1 would help. She said she felt like telling Resident #1 to stop his behaviors was useless, but she did not think he was malicious. She had not directly told the DON about Resident #1's behaviors. She said her chain of command was to tell the nurse and the nurse relayed it to the DON. She said she would consider the situation between Resident #1 and Resident #2 abuse because Resident #1 was known to be kind of violent and Resident #2 was scarred when he walked around the secured unit because Resident #1 physically harmed Resident #2 twice. She has observed Resident #1 hit Resident #3 in the back. Resident #3 was going to his room and Resident #1 hit him in the back. When Resident #3 was hit by Resident #1 he jolted forward and Resident #3 turned around, but Resident #1 was laughing and walked away. Resident #3 was not physically harmed when he was hit in the back by Resident #1.Interview on 08/30/25 at 1:48 pm with LVP A reflected she was the charge nurse on duty on 08/11/25 and witnessed the incident with the pencil between Resident #1 and Resident #2. She said she was charting next to the table where both Resident #1 and Resident #2 were sitting together. She was watching them because Resident #1 got upset at the TV and started cursing at the TV and giving the finger to the TV and Resident #2 said don't do that. Resident #1 had a pencil in his hand and took his pencil and struck Resident #2 three times on the back on one time on the top of Resident #1's right hand. She Resident #2 no longer had marks on his hand. She said he bled very little and after she cleaned them there was no additional bleeding. She said Resident #1 was placed on 1:1 but did not know how long he was monitored 1:1. She said they did not document Resident #1's 1:1 monitoring. She said Resident #2 was very calm about the incident but annoyed and he said it should not have happened and he was irritated. She said she had not seen Resident #1 hit other residents. She saw him swing at other residents but never make physical contact. She said she spoke with the Psych NP about the issue with the pencil and told her Resident #1 continued to have behaviors. She said she told the Psych NP he was cussing, had delusions, and was screaming at staff. She said she told the DON about the incident with the pencil and the DON told her she was going to tell the Administrator. LNP A said she had been trained by the facility in abuse and neglect, and she would consider the incident with the pencil between Resident #1 and Resident #2 to be abuse. She said if one resident hit another resident it was abuse. Interview on 09/02/25 at 6:02 pm with the ADON via phone reflected on 08/15/25 she was passing pills to other residents and saw Resident #1 and Resident #2 outside and she asked a staff member (staff member unknown) to let them inside. She said that Resident #2 told her he was going toward Resident #1 and was cursing at Resident #1 asking him why he hit him with a pencil and Resident #1 hit him in the head. She did not see Resident #1 hit Resident #2 with an object. She said she went outside with Resident #2 and Resident #2 pointed to a yard decoration (an yard decoration with a frog on it) that was lying on the ground and told her Resident #1 hit him in the head with it to it. She said she was frustrated because of issues with Resident #1's behavior and showed the DON to object and said Resident #2 said that Resident #2 hit him with it. She said that Resident #2 was scared of Resident #1. She said she was not present on 08/11/25 during the incident with Resident #1 and Resident #2 and the pencil but she saw the wound on his arm and said there were two little stab wounds from the pencil and it incident did draw blood. She said Resident #2 was kind of afraid of Resident #1 because he tried to stay away from Resident #1. She said Resident #2 did not say he was afraid of Resident #1, but she said Resident #2 was watchful and kept his eyes on Resident #1 because there have been incidents where Resident #1 had hit the nurses. She did feel like Resident #2 was let down because she told the DON that Resident #1 was not stable, and Resident #1 had a lot of behaviors when they changed Resident #1's medication. Resident #1 had a lot of behaviors when he was taken off his medications and she told both the Administrator and the DON. She said she reported Resident #1's cussing at staff and residents and punch and kicking the air behind the staff and residents. Interview on 09/02/25 at 9:04 pm with the LP reflected she was aware of the incident with Resident #1 and Resident #2 and the pencil, and she understood that it was originally reported as a worse situation than it was. She understood that Resident #2 was scratched with a pencil by Resident #1 and did not leave any marks on his arm. She said that she had not observed any behaviors out of the ordinary with Resident #1, but he had been inappropriate trying to kiss staff. She said that a resident going towards another resident with a pencil, no matter the extent of the injury, was abuse. She said she would have wanted to hear Resident #1's behaviors on staying up all night and hitting the walls. She said he probably should have been on 1:1 monitoring based upon his behaviors. Interview on 08/30/25 at 2:35 pm with the DON reflected she was aware of the incident between Resident #1 and Resident #2 and the pencil. It was her understanding that Resident #2 was at the table and Resident #1 walked by and kind of scratched Resident #2 with a pencil. She said the charge nurse removed the pencil from Resident #1. She said the facility trained her on abuse and neglect. She said that the secured unit was a special unit and the residents in that unit had behaviors but even though they are in that unit, they should be safe. She said Resident #1's act towards Resident #2 was an aggressive act toward another resident. She said the fact that Resident #1's pencil made contact with Resident #2's skin had never been in question. She said she notified the Administrator, the Abuse and Neglect Coordinator, as soon as she was aware of the incident. She agreed the facility policy read that abuse meant the willful infliction of injury and given this definition, the incident was abuse. She said the Psych NP was notified and Resident #1 was placed on 1:1 monitoring. She said there was not an order for 1:1 monitoring. She said when a resident had an altercation with another resident policy was to implement 1:1 monitoring to make sure everyone was protected. She said she did not know exactly how long Resident #1 was on 1:1 monitoring, maybe through the next night or next day. She said that Resident #1 should have been continued on 1:1 monitoring until given the behaviors that were reflected in his progress notes and on the behavioral chart. She said that she knew Resident #1 had aggressive behaviors and they were working on a medication change. She said Resident #1 had not had any aggressive behaviors toward her. She said Resident #1 should have been on 1:1 monitoring until his medication changes reflected his behavior was stabilized. She said she was not aware that Resident #1 hit Resident #2 in the head with a metal object, staff did not tell her. She said she was not aware of either the Behaviors Documentation Cart Memory Care Unit or many of Resident #1's behaviors documented in that chart. She said she did know that both residents were outside alone unsupervised on 08/15/25 when Resident #2 said Resident #1 hit him with a metal object. She said staff told her that Resident #1 and Resident #2 were outside alone, and Resident #2 was cursing at Resident #1, but was not aware that Resident #1 hit Resident #2 with anything even though it was in Resident #1's progress notes. Interview on 08/30/25 at 3:57 pm with the Administrator reflected she was aware of the situation between Resident #1 and Resident #2 and the pencil that occurred on 08/11/25. She heard about it from her DON. She did not know about the incident with Resident #1 and Resident #2 and the metal object that occurred on 08/15/25. She said they did place Resident #1 on 1:1 monitoring after the 08/11/25 incident but there were no 1:1 monitoring logs, and it was not recorded in the eMAR resident progress notes. She said she did not see it as abuse herself personally because Resident #1 was going through medication adjustment, and he was reacting to a lot of things, and he was not himself. She said she did not see any intent in his actions towards Resident #2 because she did not think Resident #1 knew what he was doing and did not see his action as willful but now looking back on the criteria it was abuse. Review of facility Abuse Prohibition Policy reviewed on 06/02/25 reflected INTENT:This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse.POLICY:The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. The facility will designate a qualified staff member to oversee the abuse prohibition program.DEFINITIONS:Abuse means the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Physical abuse includes, hitting, slapping, kicking, shoving, pinching and controlling behavior through corporal punishment.Abuse Prohibition Program:The facility's abuse prevention program includes the following components:screening, training, prevention, identification, investigation, protection and reporting/response.Prevention:Residents, families and staff will be able to report concerns, incidents and grievances without fear of retribution, staff will be instructed to report any signs of stress from individuals involved with the residents that may lead to abuse/neglect and intervene appropriately, facility staff will immediately correct and intervene in reported or identified situations in which abuse/neglect is at risk for occurring, residents identified as exhibiting abusive behaviors will be reviewed and have their treatment plans modified as appropriate.Identification:Any allegation of abuse/neglect, made by residents/staff/visitors shall be reported to the Abuse Coordinator and investigated immediately, the facility will track all occurrences, trends or patterns that could potentially constitute abuse or neglect, the facility supervisory staff will monitor behavior of staff members/residents to identify potential for abuse, neglect, and misappropriation of resident funds. Protection: All residents will be immediately protected from harm, all allegations involving staff will necessitate suspension without pay, pending investigation, if the allegation is substantiated, the employee will be terminated immediately without pay retroactive to the date of removal from employment. If the allegation is not substantiated, the employee will be reinstated with retroactive pay, if another resident is the alleged perpetrator, they shall immediately be assessed for treatment options. The safety and protection of other residents is the facility's primary concern. Resident to Resident Incidents: The following guidelines will be implemented when resident to resident incidences occur:1. The staff observing the incident will immediately separate the residents involved2. The charge nurse will assess the victim to determine any injury3. Physician and family of both victim and perpetrator will be notified of incident.4. An incident report will be completed for the perpetrator and the victim5. The Abuse Coordinator will be immediately contacted.6. The interdisciplinary team will make the determination on what course of action needs to be taken with the perpetrator such as, but not limited to the following - immediate discharge from the facility due to potential for harm to other residents, can the behavior be controlled by location monitoring and need for referral to a psychologist/psychiatrist. The family and physician of the perpetrator will be notified of the next step.7. If the perpetrator is placed on location monitoring, staff will be instructed on reason for monitoring and targeted behaviors being monitored.8. If the perpetrator is on a behavioral contract, facility staff will be in serviced accordingly, and the resident and family will be notified of consequences.9. If the perpetrator continues to exhibit inappropriate behaviors/or violates the behaviors identified on the behavioral contract, staff will immediately notify the Administrator /DON10. The team will conduct an emergency review to determine further course of action such as immediate discharge11. The victim will be seen by Social Services to determine further psychological support needed as well as follow up with physician/family12. The Ombudsman will be notified of incident /allegations as appropriate.This was determined to be an Immediate Jeopardy (IJ) on 08/30/25 at 6:28 pm. The Administrator was notified at 6:28 p.m. The ADM was provided with the IJ template on 08/30/25 at 6:28 p.m.The following Plan of Removal submitted by the facility was accepted on 09/01/25 at 8:05 am. PLAN OF REMOVALPlan of RemovalOn 08/30/2025, an Immediate Jeopardy was identified at the facility due to a resident-to-resident abuse allegation.Action StepsThe following immediate actions were implemented Resident #1 was placed under 1:1 supervision immediately. Resident's care plan updated to reflect changes in monitoring. The 1:1 will remain in place until the IDT will be held on 9/2/2025, including physician, psychiatric input determines that it is safe to discontinue the cadence of supervision. If this is not deemed attainable, the facility will explore opportunities for discharging resident to an alternate setting. IDT meeting will be held weekly to discuss resident #1. Resident #1 was seen by psych services on 8/18, 8/26 and will continue with weekly visits until behaviors are improved.Residents 2 and 3 were assessed by DON for evidence of injury.Resident #2 was seen by the psych NP via telemedicine for evaluation of impact. A trauma informed assessment was completed on residents 1, 2 and 3. Care Plans updated for resident 1, 2, and 3. No negative outcomes found in resident assessment. Nursing Administration conducted resident record review, resident interviews to determine that no other residents were affected by the deficient practice. Direct care staff are trained on resident care plans through a combination of orientation, ongoing in-service education, and real-time instruction from licensed nursing staff. During orientation, staff receives instruction on individualized resident needs, the purpose of the care plan, and how their daily assignments connect to the plan of care. Supervisors and charge nurses review care plan updates with staff as changes occur, and education is reinforced during shift huddles, staff inservicing, etc. This ensures staff understand their role in implementing interventions outlined in each resident's care plan. Each incident was reported to HHSC via self-report email template. The incident for 8/11 was emailed on 8/30 @ 10:25PM. The incident for 8/15 was emailed 8/31 at 7:57am. The return emails from HHSC sending us the intake number has not been received yet. It typically takes 24-48 hours from time of submission.Start Date: 08/30/2025Completion Date:8/30/2025Responsible: Director of Nursing (DON), AdministratorFollowing the notification of immediacy, the Administrator and Director of Nursing received immediate elaborate retraining on abuse reporting requirements, the facility's abuse policy, and leadership responsibilities in responding to allegations. To validate that the retraining was effective and sustained, the Regional [TRUNCATED]

Based on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of five residents (Resident #4) reviewed for quality of care.The facility failed to ensure that Resident #4 was taken to her MD referred pulmonary and dermatology appointments referral date 02/24/25.These failures could place residents at risk for unassessed changes in conditions that could lead to permanent impairment, including decreased quality of life.Findings included:Record review of Resident #4's MD orders dated 02/24/25 reflected, refer to pulmonology DX COPD and refer to dermatology for rash.Interview on 09/01/25 at 4:26 pm with Resident #4 reflected she had not been taken to her specialist appointments of either the dermatologist or the pulmonologist.Interview on 09/02/25 at 5:29 pm with the LPN A reflected it was the responsibility of the charge nurse to follow up on scheduling specialist appointments when the MD made an order for the resident to see a specialist. She said the appointments should be made within the next couple of days of receiving the order from the MD. She said it was the responsibility of the ADON and DON to make sure that the doctor's orders for specialists were followed up with and scheduled. She said the possible negative effects of not following through the MD order for specialist appointments was that Resident #4's breathing would not get better. She said Resident #4 had sensitive and it tore really easily, and it was important to see a dermatologist for her thin skin.Interview on 09/02/25 at 5:48 pm LVN C reflected either the MDSC, or the DON were responsible for making sure residents' specialist appointments were scheduled. She said it was not good practice for MD orders for resident specialist appointments not to be scheduled. It is important to follow through with all MD orders. The possible negative consequences for not following up with specialty appointments for resident orders to go to a specialist was they could become ill.Interview on 09/02/25 at 6:02 pm with the ADON reflected if the MD wanted Resident #4 to see a specialist, it was the responsibility of everyone to make sure the appointment was schedule and Resident #4 was taken to see the specialist. The negative consequences for no follow through with scheduling specialist appointments would be Resident #4 could potentially suffer medically and it was not good quality of care to not to follow up with the MD. Interview on 09/02/24 at 4:35 pm with the facility MD reflected Resident #4 should have been taken to her specialist pulmonary and dermatologist appointments. She said she was not too worried that Resident #4 did not go to the dermatologist. She was more concerned because she did not go to the pulmonary specialist because she was wheezing more than she had been. She said Resident #4 had reactive airway disease and she needed her medications adjusted by a pulmonary MD. She said her current medications were not working as well as they should have and people who have reactive airway disease often needed medication adjustments. She said anytime an order was given for a resident, and it was not acted upon she was concerned about it. Interview on 09/02/25 at 7:24 pm with the DON reflected the MD orders for Resident #4 to go to a dermatologist and pulmonary specialist were not carried out. She said, the ball got dropped. She said it was the responsibility of the person who put the order into the eMAR to schedule the appointment, but they did not have a system and no one person was responsible. She said the possible negative consequences of Resident #4 not attending her specialist appointments were that she could die from pulmonary complications. She said Resident #4 wanted to go to the dermatologist for cosmetic reasons only. Interview on 09/02/25 at 6:22 pm with the Administrator reflected they did not take Resident #4 to her specialty pulmonary appointment because they could not find a pulmonologist for Resident #4 and there was a transportation issue. She said it was the responsibility of the nursing staff arrange for resident specialist appointments. She said she did not know how the ball was dropped. She said the possible negative consequences of not getting Resident #4 to a specialist could be that she might have had a worsening medical condition, or the disease process could accelerate. Review of facility policy Medication and Treatment Orders dated July 2016 reflected order for medications and treatment will be consistent with principles of safe and effective order writing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the resident's right to be free from misappropriation for 1 of 3 residents reviewed for misappropriation of property. (Resident #1)
The facility failed to protect Resident #1 from misappropriation/exploitation by allowing AAD-C C to take money from Resident #1 for AAD-C's own well-being and personal expenses, exact date unknown. Resident #1 felt excluded from activities and became upset after AAD-C began avoiding the resident who was asking for her money to be paid back.
This failure could place residents who resided in this facility at risk of misappropriation of property causing financial hardship.
Findings included:
Record review of a face sheet, undated, reflected Resident #1 was an [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included bilateral primary osteoarthritis of knees (both knees have a degenerative joint disease-causing loss of cartilage), gout (defective metabolism of uric acid), and major depressive disorder (mood disorder causing sadness).
Record review of the MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 15 which indicated Resident #1 did not have cognitive impairment.
Record review of the care plan dated 12/20/23 reflected Resident #1 had the focus area of use of an antidepressant for depression. The goals include decreased episodes of signs and symptoms of depression.
Record review of the facility Grievance Report, dated 8/15/24, written by the ADM, reflected the following:
Received call from [DON] stating [MA B] reported to her and [AD] that [Resident #1] told her that [AAD C] borrowed money from her and had not paid her back. She [DON] also reported that [Resident #1] told her that [AAD-C]] was avoiding her. [DON] called administrator at 3:36pm informing me of events. [DON] went to [Resident #1] with administrator on the phone to inquire if [AAD-C] had borrowed money from her. [Resident #1] stated yes and said [AAD-C] hadn't paid her back. [DON] thanked [Resident #1] and I told [Resident #1] I would be back to the building in a few minutes and would come visit with her. I returned at approximately 4:00 and went to visit with [Resident #1]. [Resident #1] stated that [AAD-C] had borrowed money from her on 3 different occasions over the past couple of months. She [Resident #1] stated the 1st time was right after [AAD-C] bought her car and was for $10 for [AAD-C] to be able to get something to eat because she couldn't afford to eat. She [Resident #1] stated the 2nd time was after she [AAD-C] wrecked her car, she [Resident #1] again loaned her $10 for 'something to eat. [Resident #1] stated the 3rd time she [AAD-C] asked [Resident #1] gave her the last of her money at the time and it was $13. [Resident #1] is adamite [sic] that [AAD-C] had borrowed $33 and had not paid her any of the money back. [Resident #1] states that [AAD-C] has been avoiding her. [Resident #1] states she hasn't been invited to activities in a long time. When asked how long she stated a couple months.
Record review of a form titled Disciplinary Action Record, dated 8/15/24, revealed the form was a notice of suspension for AAD-C who wrote her statement that read [Resident #1] gave me $20 dollars for gas (offered) I refused at first and then she said, everyone needs help and gave me the $20. I have given the $20 back as soon as I got paid and haven't heard any complaints until today.
Attempts to interview AAD-C were unsuccessful, three attempts were made to reach her by telephone on 9/5/24 at 10:47 am, 11:45am, and 3:39 PM. The number goes to the phone voicemail automatically which then states the voicemail has not been set up. There was no opportunity to leave a message. No return call was received.
In an interview on 9/5/24 at 9:56 am with Resident #1 revealed she did not remember the dates, about 3 months ago or more, but she had thought she was just letting AAD-C borrow money to eat. AAD-C did not ask for the money the first time. Resident #1 stated she offered because she did not want AAD-C to go without eating. Resident #1 stated she cared about the staff. AAD-C had told her she would pay her back. Resident #1 stated she gave AAD-C eight dollars, she's not certain now of the amount. The second time was ten dollars. AAD-C came to her room and told her that she had an accident in her car and had no money again and would not be able to eat. Resident #1 stated we talked about this just being a loan and that I did not have much money. The third time AAD-C came into my room and asked if she could borrow ten dollars again. She had told me she would catch up with me when she got her next paycheck. Resident #1 stated she gave her ten more dollars. Resident #1 explained to AAD-C that was the last of her money. Resident #1 stated after she paid for her care at the facility, she only got a small amount of money each month. Resident #1 stated she used her limited money to order food to be delivered a few times a month. Resident #1 stated she had not realized that when she started asking AAD-C for the money back that she would no longer be invited to activities and that AAD-C would start avoiding her. Resident #1 stated it did hurt her feelings because she had thought they were friends. Resident #1 stated on the day she was crying she had heard AAD-C asking MA B to come into her (Resident #1's) room so that she did not have to see Resident #1. Resident #1 stated by then it had been a couple of months since she had attended an activity, which did bother her. Resident #1 stated that once the DON and ADM found out about the money, they made sure she got the money back and AAD-C was no longer working there. Resident #1 stated she now knew that residents were not to ever give any staff any money. Resident #1 stated it was not really the money loss that bothered her as much as how she was treated. Resident #1 stated she no longer trusted people.
In an interview on 9/5/24 at 2:55pm with MA B revealed that she had been told by Resident #1 previously about AAD-C borrowing money, but she had assumed it was that AAD-C had just forgotten to give her the change when she had bought something for her. MA B stated she assumed it had been taken care of the next time she worked. On 8/15/24 they had a scheduled visit with the Psychiatrist that day. AAD-C usually carried around a tablet so the Psychiatrist could talk to the residents via facetime. MA B stated on that day AAD-C asked her to take the tablet in Resident #1's room for her because she did not want to see the resident. MA B stated she had never heard AAD-C say that before, but she had refused because she was doing something else. MA B stated that a minute later Resident #1 called MA B to her room and told her that AAD-C did not want to see her because she owed her money. MA B stated she did end up helping with the tablet and planned to go tell the DON who was the person in charge that day. MA B stated before she made it to the DON, the DON found Resident #1 crying in her room. MA B stated that AAD-C and Resident #1 had been close and were frequently together when AAD-C worked. MA B stated she could tell that Resident #1 had been hurt that AAD-C treated her that way. She stated Resident #1 stayed in her room more and rarely came out for quite a while.
In an interview on 9/5/24 at 2:05pm with the facility DON revealed on 8/15/24 she was getting ready to leave for the day, so she had been doing a final round of the facility which she does daily and found Resident #1 in her room crying. The DON stated Resident #1 told her about AAD-C borrowing money from her and that AAD-C was avoiding her and not inviting her to activities. Resident #1 also told her about hearing AAD-C asking MA B to go help Resident #1, so she did not have to see her. The DON stated she went to talk to AAD- C who did not deny that she had borrowed money from Resident #1. She admitted she had been avoiding the resident because Resident #1 was asking her when she was going to pay the money back. AAD-C claimed that she had paid Resident #1 back some of the money. The DON stated AAD-C knew she should not take money from a resident. She (AAD-C) had been the one to do a resident counsel meeting with the residents last year when a housekeeper had kept the change from Resident #1's request for items from the store, and the housekeeper was fired. The DON stated she had AAD-C fill out a statement then sent AAD-C home and walked her out to her car to leave. AAD-C has not answered calls since then. The DON stated Resident #1 has just recently started attending activities again and leaving her room more frequently.
In an interview on 9/5/2024 at 2:45pm with the facility Administrator revealed she found out about the allegation from the call from the DON. She stated she does rounds every morning and Resident #1 had never mentioned a concern with staff or having loaned money. The Administrator stated all staff were required to sign the Employee handbook after reading. The Handbook contained information on misappropriation and that they were not allowed to accept gifts or money from residents. She stated they also had an incident last year when a housekeeper kept Resident #1's change after a trip to the store to buy items for her. AAD-C did meetings with the residents to make sure they were aware not to loan or give money or gifts. The Administrator stated per the facility policy the AAD-C's employment was terminated. They interviewed every other resident and did not find anyone else that AAD-C or anyone else that had given money to staff. She stated she expected the staff to follow the policy and code of conduct that they agreed to when hired .
Review of the facility Employee Handbook, dated, 8/14/2017, included the following:
Acceptance of Gifts, Tips, and Fees Acceptance of any gifts, tips, fees, or other form of remuneration from resident, family members, clients, suppliers, lenders, landlords, etc. is not permitted unless disclosed and approved by the Facility Administrator. Under no circumstances are associates allowed to borrow or ask to borrow, from residents or resident family members. This includes money, personal items, etc. Solicitation of tips or gratuities of any kind is strictly prohibited.
Review of the facility policy titled Abuse Prohibition Policy, revised 1/1/24, reflected the following:
Misappropriation of property/financial abuse/Exploitation is defined as taking advantage of a resident for personal gain through the use of manipulation, intimidation,
threats, or coercion.
Involuntary Seclusion is defined as separation of a resident from other residents or from
her/his room or confinement to her/his room (with or without roommates) against the
resident's will, or the will of the resident representative.
Abuse Prohibition Program:
The facility's abuse prevention program includes the following components:
? Screening
? Training
? Prevention
? Identification
? Investigation
? Protection
? Reporting/ Response

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the facility established and maintained an infection prevention program designed to provide a safe environment and to help prevent the transmission of communicable diseases for one of one staff observed for insulin administration (LVN A ).
LVN A failed to clean Resident #16's fingertips with alcohol prep pad before puncturing the fingertip with a lancet for a blood sugar reading.
This failure could place residents at increased risk of infection and inaccurate blood sugar readings.
Findings included:
Review of Resident #16's Face Sheet reflected she was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses including Diabetes Mellitus Type 2.
Review of Resident #16's quarterly MDS dated [DATE] reflected a BIMS score of 04 which indicated she was severely impaired cognitively.
Review of Resident #16's Care Plan (no date) reflected; Resident #16 had Diabetes Mellitus and she was to receive the diabetes medication as ordered by the doctor.
Observation on 07/31/2024 at 11:46 AM revealed LVN A administered Humalog insulin 06 units to Resident #16's left upper abdomen. Before LVN A checked Resident #16's blood sugar, she did not wipe the resident's finger with alcohol before applying the lancet to the finger.
In an interview on 07/31/2024 at 01:25 PM LVN A stated she has been told in the past by State employees during surveys that she was not required to use alcohol before lancing the resident's fingers. She stated she was taught to wipe the finger with alcohol before lancing. She stated the potential risk to the resident if she did not lance the finger with alcohol would be possible infection risks.
In an interview on 07/31/2024 at 01:31 PM the DON stated the facilities policy was that staff were to wipe the residents' fingers with alcohol before lancing it when checking blood glucose levels. The DON stated the possible risk for the resident when you do not lance the finger with alcohol would be inaccurate readings.
Review of the policy Fingerstick policy and procedure with no date; Steps in the procedure number 5. Wipe the area to be lanced with an alcohol pledget.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for foods safety for two of two staff reviewed for food safety and sanitation.
The facility failed to ensure two staff, [NAME] B and [NAME] C wore beard restraints .
This failure placed residents at risk of foodborne illness.
Findings included:
Observation on 07/30/2024 at 9:20 AM during the initial kitchen tour, [NAME] B had a beard and was not wearing a beard restraint.
Observation and interview on 07/30/2024 at 12:05 PM during meal service in the kitchen, [NAME] B and [NAME] C had beards and were not wearing beard restraints. [NAME] B stated the Dietary Manager was on sick leave and was not available for an interview. He stated he was not aware of any beard restraints in the kitchen for staff to wear.
In an interview on 07/31/2024 at 10:00 AM the ADM stated the men in the kitchen did not have beards until this month. She stated the kitchen did not have beard covers until it was brought to her attention. She stated the staff had been in-serviced on wearing beard restraints, and the staff were wearing beard restraints. She stated the facility had ordered beard restraints. She further stated she did not think their policy said anything about covering beards.
In an interview on 07/31/2024 at 2:08 PM [NAME] B stated hair could fall in food if he was not wearing a beard restraint. He stated hair could contaminate the food and it could make the residents angry to see hair in their food. He further stated he had been told about the beard restraint policy, but they didn't have them available to wear.
In an interview on 07/31/2024 at 2:12 PM [NAME] C stated he had never been told about a beard restraint policy and there had not been any beard restraints available. He further stated the potential risk to the resident was hair in their food and it could contaminate the food.
In an interview on 07/31/2024 at 2:22 PM the interim DM stated she had worked at a sister facility for nine years and would assist at the facility when requested. She stated she had conducted an in-service on hair and beard restraints that morning. She stated staff were required to wear hair and beard restraints. She further stated hair could fall in the food and cause a food borne illness.
In an interview on 08/01/2024 at 10:36 AM the ADM stated she had worked at the facility for one year and two months. She stated the kitchen staff were supposed to cover any facial hair. She stated hair could cause food borne illness and it was a sanitation issue. She stated residents might get upset if they saw hair in their food.
Record review of a facility policy and procedure titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices dated October 2022 and reviewed 6/12/2024 reflected 1. All employees who handle, prepare, or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment for 1 of 5 residents reviewed for environment.
The sink in Resident #1's room did not produce hot water.
This failure placed residents at risk of discomfort and poor hygiene.
Findings included:
Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hemiplegia with hemiparesis, sequelae of cerebral infarction (pathological conditions resulting from stroke), morbid obesity due to excess calories, cognitive communication deficit (difficulty communicating due to impaired cognition), muscle spasm, insomnia, polyneuropathy (damage to peripheral nerves), chronic idiopathic constipation (constipation with no known cause), anxiety disorder, major depressive disorder, attention deficit hyperactivity disorder, chronic pain, rheumatoid arthritis, pain in right shoulder, abnormalities of gait and mobility, repeated falls, and malaise.
Review of the quarterly MDS assessment for Resident #1 dated 01/04/24 reflected a BIMS score of 15, indicating an intact cognitive response.
Review of grievances from October 2023 to 01/09/24 reflected a grievance filed by Resident #1 on 11/06/23 about the hot water in his room. The nature of the complaint was as follows: When are we going to have hot water 'nobody is fixing shit around here.' The grievance was investigated by the ADM, and the findings were as follows: Explained to (Resident #1) that two new pumps have been ordered and that (plumbing company) will be here today. Resolution of the complaint was as follows: Will follow up after repairs are complete.
Review of the maintenance log from October 2023 to 01/09/24 reflected no open maintenance requests having to do with Resident #1's hot water.
Review of invoices from the plumbing company from 06/06/23 to 01/09/24 reflected one dated 11/08/23 that contained the following: Facility called us out to look at a number of different issues. We talked options for several different problems facing the facility. After our discussion, we obtained approval for some further diagnostic on a faulty (sewage) pump. We took apart the unit and found the wiring was causing issues. We put everything back together correctly and it functioned correctly. There were no other invoices from the plumbing company that pertained to the hot water delivery system.
During an interview on 01/09/24 at 10:05 AM, Resident #1 stated the water in his bathroom was not heating up, and he could not wash his hands and face, shave, or rinse out his coffee cup. Resident #1 stated he had talked to the ADM about the problem and had met with the MAINT about it, as well. Resident #1 stated the MAINT did not have any idea how to fix the problem. Resident #1 stated it had been going on for more than one month. Resident #1 stated no one had offered him a room change, but he preferred not to move rooms, as he had a lot of belongings and had his room set up the way he wanted it. Resident #1 stated not having hot water in his room was a big deal to him. He stated if the facility were fixing it, that would be one thing, but they had done nothing to try to figure out the problem. He stated they had a meeting in the ADM's office, and she showed him an invoice for an inline water pump they had ordered, but the water pump was not what they needed. Resident #1 stated he had been educated in homebuilding, and he knew hot water did not move by a pump. He stated he was not sure exactly what the pump was for, but it would not have been to restore hot water to his room. Resident #41 stated there were other sinks in the building that had hot water, but he chose not to seek those out and use them.
Observation on 01/09/24 from 10:20 AM to 10:30 AM revealed the sink faucet in Resident #1's room ran cold water for ten minutes without the water ever warming up at all. There was a bottle of alcohol-based hand rub on the television console just outside of his bathroom.
During an interview on 01/09/24 at 02:58 PM, the MAINT stated he was not sure why the hot water was not going to Resident #1's room. He stated he had replaced the pumps on the water heaters and followed the pipe up into the roof. He stated nothing was broken or missing along the pipes, but the water was just not getting to certain spots. The MAINT stated there were issues on the 400 hall, especially in Resident #1's room. The MAINT stated he was trying to figure out how the water would travel, but he was by no means a plumber. He stated the plumbing company had been to the building many times recently and had not offered a solution. The MAINT stated they told him once when they came out that it was possible Resident #1's room was not even plumbed for hot water, but the MAINT had not made time to open up the wall and check. The MAINT stated the plumber had been there, and all the water pumps were working, and he did not know what was wrong. The MAINT stated he had been in the ceilings trying to get the hot water to move.
During an interview on 01/09/24 at 03:10 PM, the office manager for the plumbing company stated the company had been to the building many times in recent months, but most of the visits were for drains not draining. She stated the pump mentioned in the 11/08/23 invoice was for pumping sewage out of the building and clearing pipes that drain out. She stated this pump was also known as an inline water pump, and it had nothing to do with the hot water delivery system in the facility. She stated the only work that had been done on the hot water delivery system was a replacement water heater for 100 and 200 halls. She stated nothing had been done for the hot water delivery on 400 hall, and there was nothing in any of the notes about a specific residents room. She stated if the facility had requested, they work on the resident room, that would have been in the plumber's documentation system.
During an interview on 01/09/24 at 03:41 PM, the ADM stated she had been aware of the lack of hot water in Resident #1's room, but that had been fixed. She stated she believed it had been fixed, because the MAINT had told her he fixed it. She stated there was a pump ordered, and she thought the MAINT had everything he needed. She stated the plumbers had been to the facility several times. She stated she was shocked to learn the plumbers had not worked on the hot water in Resident #1's room and that the pump they had ordered was not related in any way. The ADM stated she monitored that maintenance requests were fulfilled by speaking with the MAINT during morning meeting and trusting that he completed the tasks when he said he did. She stated the potential negative impact of not having hot water in a resident's room was the resident might not be hygienic.
Policy on hot water, maintenance requests, and safe/clean/comfortable/homelike environment was requested from the ADM on 01/09/24 at 04:05 PM and not provided by the time of exit.

Based on observation, interview and record review, the facility failed to ensure residents had a safe, clean, comfortable and homelike environment for one of seven anonymous residents reviewed for homelike environment.
The facility failed to ensure the shower room on the 300 hall was free of a black substance.
This failure placed residents at risk of having an unclean environment.
Findings included:
During a confidential meeting on with residents on 6/13/2023, a resident reported the shower room on the 300-hall had mold.
During an observation and interview on 6/13/2023 beginning 3:30 p.m., the shower room on the 300-hall appeared to have a black cloudy-looking substance in the cracks and corners of the floor where the floor met the wall on the right side of the shower room. CNA C stated he had not encountered mold before and did not know what the black substance was in the shower room but he did not think it was mold because he thought that would smell bad and there was no odor. CNA C stated housekeeping was supposed to clean the shower room every day but he was not sure whether they did because he was not there every day. CNA C stated he worked during the day and the shower room was in use during the mornings.
During an interview on 6/13/2023 at 3:26 p.m., HK A stated she tried to clean the shower room every day and most of the time it got cleaned every day. HK A stated she cleaned the toilet, the seat residents sat on during showers, the shower bed, and the floor. HK A stated housekeeping staff scrubbed the shower with a brush. HK A stated she tried to clean the black dirt off but it did not come off. HK A stated she thought it was just old dirt but it could be mold. HK A stated she told the Housekeeping Supervisor about it and the Housekeeping Supervisor tried to use different techniques to remove it and it helped a little bit. HK A stated she thought the Housekeeping Supervisor had reported the concern to the Maintenance Supervisor.
During an interview on 6/13/2023 at 3:33 p.m., the Housekeeping Supervisor stated she thought the black substance in the shower room on 300 hall was a mixture of mold and dirt. The Housekeeping Supervisor stated she first reported this to the Maintenance Director in October 2022 and he told her he would get to it. The Housekeeping Supervisor stated yes she believed eight months was too long for the issue to be resolved. The Housekeeping Supervisor stated she had not submitted a written work order for the issue but had communicated it via word of mouth to the Maintenance Supervisor. The Housekeeping Supervisor stated the shower room did get cleaned every day and she was the one who did it. The Housekeeping Supervisor stated lately she had been more of a full time driver for the facility more than anything and she felt her staff had become more laide back since she had starting driving and was not in the facility as often. The Housekeeping Supervisor stated she felt things had been slipping through the cracks. The Housekeeping Supervisor stated since the new company took over in April of 2023, she no longer completed her supply orders and it had been a fighting battle to get things she needed such as the right trash bags. The Housekeeping Supervisor stated she used the pink stuff to clean the dirt in the shower room and these chemicals were left over from the previous company-she did not explain what kind of cleaner the pink stuff was. The Housekeeping Supervisor stated she had bought a lot of stuff for the facility out of her pocket. The Housekeeping Supervisor stated she had told the Administrator the shower room floors were really bad. The Housekeeping Supervisor stated when someone in the past had made an allegation about there being mold in the kitchen, the facility had a crew come in and deep clean the kitchen but no one has done that for the shower room. The Housekeeping Supervisor stated yes that all 27 residents used that shower room. The Housekeeping Supervisor stated she had not given many in-services to housekeeping staff because she did not have any in-service templates to pull like she used to since the old company left. The Housekeeping Supervisor stated she was told to use CDC data to train housekeeping staff. The Housekeeping Supervisor stated she did not feel like she had everything she needed to be successful.
During an interview on 6/13/2023 at 4:50 p.m., the Maintenance Director stated he started working in the facility in 2016 or 2017 and stopped working his position full time in January 2023 due to health concerns. The Maintenance Director stated he had put in a resignation in May 2023 and 6/02/2023 was supposed to be his last day working in the facility, but he continued to work there when he could because he liked the residents. The Maintenance Director stated the Housekeeping Supervisor had never reported to him a maintenance issue about the shower room on 300 hall. The Maintenance Director stated he usually only went in the shower room to fix the toilet.
During an interview and observation of the 300-hall shower room on 6/13/2023 beginning at 5:01 p.m., the Maintenance Director stated the black substance in the shower room looked like mildew. The Maintenance Director stated, I don't want to say it's mold and said he did not know the difference between mold and mildew. The Maintenance Director stated he monitored the building by checking lights and checking the perimeter of the building-he stated he did not monitor the shower room regularly and had never seen mildew. The Maintenance Directors stated he would expect housekeeping staff to monitor the shower room and let him know if there was mildew but the Housekeeping Supervisor had never reported that to him. The Maintenance Director stated he did not have mildew remover but he could go get some.
During an interview on 6/14/2023 at 10:52 a.m., CNA D stated she had worked in the facility for about a month and had noticed the black substance in the shower room. CNA D stated, kinda sorta that she had first noticed when she started working in the facility.
During an interview on 6/14/2023 at 3:33 p.m., the DON stated, we want [residents] to have a clean environment and have them safe and comfortable. The DON stated yes she had seen the shower room corners and floor and it was addressed immediately. The DON stated she first became aware of the issues the day prior (6/13/2023) when she observed staff being interviewed by a surveyor in the shower room. The DON stated she believed the black substance in the 300 hall shower room was mildew, that she went in there every day, and did not remember seeing it in the past. When asked if she believed having a black substance in the shower room was sanitary, the DON stated it did not take away from homelike environment and it's going to be on my rounds every day so it's not an issue. When asked if old dirt or a black substance seemed clean to her, the DON stated she had had mildew in her bathroom and that's not going to be an issue again. The DON stated that as the Infection Preventionist, she was responsible for monitoring the shower room to ensure it was clean and sanitary. When asked what a potential negative resident outcome was if shower rooms were not kept clean, the DON stated it would not happen again, there had not been any repercussions or skin issues, and she would have to research exposure to mildew. The DON stated, there haven't been any repercussions and there won't be because we'll take care of it.
During an interview on 6/14/2023 at 4:52 p.m., the Administrator stated she began working in the facility on 4/01/2023 and only recently had she been able to spend time out there. The Administrator stated the facility's policy on homelike environment included keeping the facility safe, homelike and sanitary and I think there are some areas we haven't gotten to yet. The Administrator stated yes she had seen the shower room corners and floors. The Administrator stated the Activity Director brought it to her attention about a week ago because she wanted to know if it looked like mold. The Administrator stated when she went into the shower room on the 300 hall there was a black substance concentrated in the grout and corners of the shower room but it was not fuzzy The Administrator stated she had not paid attention to the right side of the shower room until the day prior (6/13/2023) when CNA C brought it to her attention. The Administrator stated she did not believe old dirt or mildew in the shower room was unsanitary and for her, it was homelike. The Administrator stated housekeeping staff should be cleaning the shower room every day. The Administrator stated she made rounds in the facility daily but a lot of times the shower room door was shut. The Administrator stated nursing staff were the ones bathing residents so they needed to let us know if it needs extra attention. The Administrator stated it was everybody's responsibility to oversee cleanliness of the shower room and obviously we failed on that one. The Administrator stated that moving forward, she would check the showers every day. The Administrator stated mildew was a discoloration and mold was a growth. The Administrator stated if the substance in the shower room were mold, it could make people sick and if it were mildew, there could be an impact. The Administrator stated at home, she cleaned her bathroom because she did not want to leave mildew there and stated she did not want to leave it there for residents either.
A record review of work orders from October 2022 to present (6/14/2023) reflected no work orders related to excessive dirt or a black substance in the shower room on 300-hall.
A record review of the facility's policy titled Homelike Environment dated February 2021 reflected the following:
Policy Statement
Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their
personal belongings to the extent possible.
Policy Interpretation and Implementation
2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that
reflect a personalized, homelike setting. These 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 organize and participate in resident groups in the facility for seven of seven anonymous residents reviewed for resident council.
The facility failed to facilitate resident council meetings regularly and as scheduled per their resident council policy.
This failure placed residents at risk of not having the right to participate in resident groups.
Findings included:
A record review of Resident #14's face sheet dated 6/14/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of cerebral palsy (movement disorder), atrial fibrillation (irregular heartbeat), bipolar disorder (extreme mood swings), major depressive disorder (depression), and muscle weakness.
A record review of Resident #14's MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment.
A record review of Resident #14's care plan last revised on 4/17/2023 reflected she had little or no activity involvement related to wanting to stay in her room for long periods of time related to manic depressive bipolar disease.
A record review of Resident #13's face sheet dated 6/14/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of CHF, morbid obesity (extremely overweight), bipolar disorder (extreme mood swings), hypertension (high blood pressure), lymphedema (swelling of legs), and gastro-esophageal reflux disease (acid reflux).
A record review of Resident #13's MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment.
A record review of Resident #13's care plan last revised on 4/17/2023 reflected he required staff assistance for meeting emotional, intellectual, physical, and social needs related to immobility.
During an observation and interview on 6/12/2023 at 11:47 a.m., Resident #14 was observed sitting in her room. Resident #14 stated she was the facility's resident council president.
During an interview on 6/13/2023 at 9:57 a.m., the Corporate Clinical Specialist stated the new company took over the facility on 4/01/2023 and that the old company had their stuff packed when they left and she could not find any resident council minutes from 2022 or from prior to April 2023. The Corporate Clinical Specialist The Corporate Clinical Specialist stated her team had been doing resident council since they took over the building. When asked who was responsible for ensuring the new company had access to the facility's documents, the Corporate Clinical Specialist stated she could find out. The Corporate Clinical Specialist stated the importance of having the facility's records was they could follow up on concerns and provide residents with better quality of life. The Corporate Clinical Specialist stated new systems were put in place on 4/01/2023 such as an open communication system.
During an interview on 6/13/2023 at 10:55 a.m., the DON stated the previous company boxed up their own records and had shredder trucks come by to pick up the old records.
During an interview on 6/13/2023 at 11:08 a.m., the Corporate Clinical Specialist stated the previous activity director may have had resident council minutes and may have put them into the electronic health records system the facility used previously prior to 4/01/2023.
During a confidential meeting of residents, residents reported the Dietary Manager used to be the activity director and they did not have any resident council meetings because the Dietary Manager was busy in the kitchen. Residents stated the Dietary Manager was doing kitchen and activities but the facility kept losing cooks so she started working more in the kitchen. Residents stated the Dietary Manager would schedule resident council meetings but then she would have to end up working in the kitchen so the meetings would not happen as scheduled. Residents reported the previous administrator did not allow residents to meet at a good time that worked for them and stated the previous administrator never helped to facilitate resident council meetings. Residents stated the previous administrator would say tell them to talk to the Dietary Manager and then the Dietary Manager would schedule the meetings but the facility would be short on staff that day and the meetings would not occur as scheduled because there was no one available to get residents up. Residents reported when they did meet for resident council, it was in the dining room, which they stated was not very private because there were no doors between the dining room and the rest of the facility. Residents reported that the Activity Director had too many responsibilities because she did social work, was a driver, did marketing and activities.
During an interview on 6/13/2023 at 4:05 p.m., the Administrator stated she had in-serviced staff because not having regular resident council meetings was inexcusable. The Administrator stated she found out from AD B, the previous activity director, that she had only done one resident council meeting because of COVID-19.
During an interview on 6/13/2023 at 5:04 p.m., AD B stated she worked at the facility as the activity director from the middle of February 2023 until March 2023. AD B stated she tried to do a resident council meeting in February 2023 but no one showed up. AD B stated she facilitated a resident council meeting in March 2023 and left the resident council meeting notes on the desk in the activity room when she stopped working for the facility. AD B stated no that the previous administrator was not helpful with getting residents up for resident council.
During an interview on 6/14/2023 at 8:29 a.m., the Therapy Coordinator stated July 2023 would mark eight years of her working in the facility. The Therapy Coordinator stated the facility did not do resident council meetings during covid and that they started doing them again in March 2023. When asked if this meant there had not been any resident council meetings from 2020-2022, the Therapy Coordinator stated she did not remember the facility having any resident council meetings during that time because everyone was locked down for covid and they couldn't meet in groups.
During an interview on 6/14/2023 at 11:25 a.m., the Activity Director stated she started working in the facility on 4/06/2023. The Activity Director stated she was responsible for organizing and accommodating resident council meetings. When asked why resident council did not meet on Wednesday 6/07/2023, as scheduled per the activity calendar, the Activity Director stated because Resident #14 was out of the facility on pass that day, Resident #13 was in bed all day, and because Resident #13 did not want to have the meeting without Resident #14. The Activity Director stated she usually tried to have resident council meetings on the first Tuesday of every month.
During an interview on 6/14/2023 at 11:35 a.m., the Dietary Manager stated she had worked in the facility for 30 years in different positions and worked as activity director before starting as Dietary Manager in October of 2022. The Dietary Manager stated when she was activity director, she worked on and off in the kitchen. The Dietary Manager stated from January 2022 onward, she was doing both activities and kitchen but was mostly working in the kitchen. The Dietary Manager stated she coordinated resident council meetings but sometimes they did not have them because she was always stuck in the kitchen.
During an observation and interview on 6/14/2023 beginning at 11:53 a.m., Resident #14 was observed lying in bed. Resident #14 stated she only went out of the facility on pass on Tuesdays and Fridays, and that was why resident council was scheduled for Wednesday. When asked why resident council did not meet as scheduled on 6/07/2023, Resident #14 stated because the Activity Director probably was not in the facility that day and I can't make the nurses get everyone up. Resident #14 stated the facility gave the Activity Director too many jobs to do so she did not have the time or energy to set up resident council.
During an interview on 6/14/2023 at 3:33 p.m., the DON stated she started working in the facility on 4/20/2023, was still learning the policies, but knew they were supposed to have resident council every month. The DON stated the Activity Director was responsible for planning and coordinating resident council meetings. When asked how the facility assisted with planning and coordinating resident council meetings, the DON stated the day of resident council, the Activity Director would announce it to residents and then all of us will make sure they're toileted and get up. The DON stated nursing staff assisted residents to get up for meetings. The DON stated she did not do anything with resident council and when asked who oversaw staff to ensure resident council was meeting, the DON stated, I will defer to the Administrator because I'm the DON. The DON stated yes that she felt there were enough staff to get residents up for resident council. The DON stated resident council met in the dining room. When asked if the dining room was private and whether it had a door to shut it off from the rest of the facility, the DON stated there was not and she stated she guessed that was a consideration they would have to discuss. The DON stated if resident council did not meet regularly, residents would not be able to share their ideas, plan meal of the month, plan activities, and their voices would not be heard.
During an interview on 6/14/2023 at 4:54 p.m., the Administrator stated resident council was a big deal and was very important to residents and important for finding out what residents needed and what their complaints were. The Administrator stated, if you don't do resident council, you can't make residents happy. The Administrator stated the Activity Director was the one who coordinated and held resident council, and that she was new to the role. The Administrator stated the Activity Director did activities and social work and when asked f she had enough time to do both, the Administrator stated it was difficult. The Administrator stated when the census reached 40 residents, the facility would split those roles and have both a social worker and an activity director. The Administrator stated she expected resident council to meet every month or more often if residents wanted. The Administrator stated she was responsible for ensuring resident council was done. When asked why resident council had not met as scheduled on 6/07/2023, the Administrator stated that was her first time hearing about it and that the Activity Director had been out of the facility doing marketing. The Administrator stated the Activity Director did marketing, social work, activities and admissions. The Administrator stated the Activity Director was out doing marketing on Wednesday 6/07/2023 but that resident council still should have happened. The Administrator stated someone should have stepped in, she should have stepped up, and there was a breakdown in communication.
During an observation and interview on 6/14/2023 beginning at 4:19 p.m., Resident #13 was observed lying in bed. Resident #13 stated he was the vice president of resident council. When asked why resident council did not meet the week prior on 6/07/2023, Resident #13 stated he did not know about it. Resident #13 stated if they did have meetings, no one wanted to get him up or no one felt like getting him up. Resident #13 stated no one had informed him that resident council was scheduled for 6/07/2023. Resident #13 stated no that he did not feel there were enough staff to get everyone up for resident council. Resident #13 stated he would have gone if he had been notified and sometimes he did not catch some of the notifications.
A record review of the facility's activity calendar dated June 2023 reflected Resident Council Meeting was scheduled for 10:30 a.m. on 6/07/2023.
A record review of resident council minutes from 2023 reflected resident council met on 4/14/2023 and on 5/03/2023. There were no meeting minutes for January 2023 - March 2023 or for June 2023.
A record review of the facility's policy titled Resident Council dated February 2021 reflected the following:
Policy Statement
The facility supports residents' rights to organize and participate in the resident council.
Policy Interpretation and Implementation
1. The purpose of the resident council is to provide a forum for:
a. residents, families and resident representatives to have input in the operation of the facility;
b. discussion of concerns and suggestions for improvement;
c. consensus building and communication between residents and facility staff; and
d. disseminating information and gathering feedback from interested residents.
2. All residents are eligible to participate in the resident council. The facility staff encourages residents who
are willing to participate. Staff, visitors, or other guests may attend resident council meetings if invited by
the respective resident group.
3. The resident council group is provided with space, privacy and support to conduct meetings.
5. Council meetings are scheduled monthly or more frequently if requested by residents. The date, time and
location of the meetings are noted in the activities calendar.