**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 of 3 resident hallways (Hallway 100), and 1 of 1 kitchen reviewed for environmental concerns, in that: 1. The facility failed to ensure resident room [ROOM NUMBER], located on hallway 100, had repaired 3 and 5 foot wall scrapes near bed-A and had removed dust and lint from the bathroom ceiling vent. 2. The facility failed to ensure resident room [ROOM NUMBER], located on hallway 100, had repaired a 3x3 inch bathroom door penetration and had repaired an unsecured bathroom wall vent. 3. There was a 4.5- foot piece of floor baseboard molding under the prep table on the right side of the main kitchen that was missing. 4. There was a 7.0- foot piece of floor baseboard molding behind the ice machine and juice bar on the left side of the main kitchen that was not attached to the wall. 5. There were 2 broken 1x1 ft floor tiles in the main kitchen area that were cracked. 6. There were 2 eight- foot florescent ceiling lights in the main kitchen area that did not have protective sleeve covers. 7. There were 4 three- foot florescent ceiling lights in the dry storage room that did not have protective sleeve covers. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. Findings included: 1. During observation rounds with the Maintenance Director and Administrator on 03/7/25 from 12:50 pm - 12:55 pm revealed the following: a. In room [ROOM NUMBER] on hallway 100 there were two wall scrapes near Bed-A with one scrape measuring 3 ft in length and the other measuring 5 foot in length. b. In room [ROOM NUMBER] on hallway 100 there was a bathroom ceiling vent that was covered with dust and lint. c. In room [ROOM NUMBER] on hallway 100 there was a 3x3 inch penetration on the bathroom door. d. In room [ROOM NUMBER] on hallway 100 there was a bathroom ceiling vent was not fully attached to the ceiling wall surface. 2. During observation rounds in the kitchen with the Administrator and Maintenance Director on 3/5/25 from 1:40 pm -2:00 pm the following was noted a. There was a 4.5- foot piece of floor baseboard molding under the prep table on the right side of the main kitchen that was missing. b. There was a 7.0-foot piece of floor baseboard molding behind the ice machine and juice bar on the left side of the main kitchen that was not attached to the wall. c. There were 2 broken 1x1 ft floor tiles in the main kitchen area that were cracked. d. There were 2 eight- foot florescent ceiling lights in the main kitchen area that did not have protective sleeve covers. e. There were 4 three- foot florescent ceiling lights in the dry storage room that did not have protective sleeve covers. During an interview with the Maintenance Director and Administrator on 3/7/25 at 1:00 pm the Maintenance Director stated that he makes monthly rounds on all of the resident rooms. He stated that staff communicate the need for repairs on the work order TELS system and he was not aware of the needed repairs in rooms [ROOM NUMBERS]. The Administrator stated that making the noted repairs would improve the homelike environment for the residents. The Maintenance Director further stated that he made monthly rounds in the kitchen and was aware of the noted areas needing repaired. The Maintenance Director stated the kitchen light bulbs without sleeves could allow glass spillage onto the kitchen floor if the ceiling light bulbs break. The Administrator stated that all of the noted areas needing repair in the kitchen could affect employee safety and general food preparation. Record review of the undated TELS weekly, bi-weekly, and monthly maintenance task form revealed that there was not a resident room inspection task listed, and there was not a kitchen inspection task listed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 2 of 8 residents (Resident #2 and #37) reviewed for advanced directives, in that: 1. Resident #2's attending physician had not printed his name on the OOHDNR when it was signed on [DATE], rendering the document invalid. 2. Resident #37's attending physician had not dated the OOHDNR when it was signed by the family on [DATE] or when the order was written on [DATE], rendering the document invalid. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings include: 1. Record review of Resident #2's face sheet, dated [DATE], revealed an admission date of [DATE] and diagnoses which included: dementia, with other behavioral disturbance, other malaise (general feeling of being unwell), anemia and essential hypertension (high blood pressure that has no clearly identifiable cause). Further review of Resident #2's face sheet, revealed under the section, ADVANCE DIRECTIVE: DNR (Do Not Resuscitate). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 03, which indicated severe cognitive impairment. Record review of Resident #2's Care Plan, with last review completed on [DATE], revealed, Resident is a DNR. Date initiated: [DATE]. Review of the Care Plan revealed an intervention to include the DNR in Resident #2's medical record. Review of Resident #2's Order Summary Report, Active Orders as of [DATE], revealed an order, DNR, dated [DATE] with no end date. Record review of Resident #2's electronic clinical record revealed an OOH-DNR for Resident #2, signed by Resident #2's RP, two witnesses, a notary and physician all dated [DATE]. Further review revealed the physician had not printed his name in the Physician's Statement section of the OOH-DNR. 2. Record review of Resident #37's face sheet, dated [DATE], revealed an initial admission date of [DATE] with a recent admission of [DATE] and diagnoses which included: focal/partial symptomatic epilepsy (affect initially only one hemisphere of the brain), mild intellectual disabilities, dysphasia with oral and oropharyngeal phase (swallowing problems occurring in the mouth and the throat), acute kidney failure. Further review of Resident #37's face sheet, revealed under the section, ADVANCE DIRECTIVE: DNR (Do Not Resuscitate). Record review of Resident #37's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 03, which indicated severe cognitive impairment. Record review of Resident #37's Care Plan, with last review completed on [DATE], revealed, [Resident] is a DNR. Date initiated: [DATE]. Review of the Care Plan revealed an intervention to include the DNR in Resident #37's medical record. Review of Resident #37's Order Summary Report, Active Orders as of [DATE], revealed an order, DNR (Do Not Resuscitate), dated [DATE] with no end date. Record review of Resident #37's electronic clinical record revealed an OOH-DNR for Resident #37, signed by Resident #37's family member and two witnesses and dated on [DATE]. Further review revealed the physician had signed the OOH-DNR however had not dated his signature in the Physician's Statement section of the OOH-DNR. In a record review and interview with the SSD on [DATE] at 2:05 p.m., the SSD confirmed Resident #2's OOH-DNR was missing the physician's printed name and Resident #37's OOH-DNR was missing the date for when the physician signed the document. The SSD stated all sections of the OOH-DNR must be fully completed to be valid. The SSD revealed she and the contract SW had recently reviewed the OOH-DNRs on file, including Resident #2's and must have overlooked the physician's name missing. The SSD stated an incomplete or invalid OOH-DNR could put a resident at risk of not having their wishes followed in the event of an emergency. In an interview with the Administrator and RRN on [DATE] at 3:23 p.m., the Administrator stated the SSD and contract SW were responsible for ensuring all OOH-DNR were completed correctly. The RRN stated there had been confusion among the staff regarding when a resident was considered DNR. The RRN stated the corporate SW had educated staff that residents were DNR upon making their wishes known even prior to obtaining the OOH-DNR. The RRN stated she was not aware the completed OOH-DNR had to in the facility with the physician's signature before the resident's code status could change. Record review of the facility's policy titled, Resident' Rights Regarding Treatment and Advance Directives, date implemented [DATE], revealed, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion, for 1 of 1 resident (Resident #34) reviewed for abuse, in that: CNA P was identified in a recorded video transferring Resident #34 from a wheelchair to a bed, against Resident #34's will; evidenced by his calling out Owww! and simultaneously grabbing the wheelchair he was seated in and attempting to stop CNA P from the transfer. This failure could place residents at risk for abuse by denying residents of their rights. The findings included: A Record review of Resident #34's admission record dated 01/24/2024 revealed an admission date of 12/11/2023 with diagnoses which included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A record review of Resident #34's admission MDS assessment, dated 12/11/2023, revealed Resident #34 was a [AGE] year-old male admitted for long term care and could not be assessed with a BIMS due to cognitive impairment. A record review of Resident #34's care plan dated 1/23/2024, revealed, Problem: (Resident #34) has an ADL self-care performance deficit r/t Impaired balance, impaired vision, behaviors. Known to resist care .TRANSFER: The resident requires total assistance by 2 staff to move between surfaces. May use (brand name) lift when uncooperative .Revision on: 11/17/2023 .Encourage the resident to participate to the fullest extent possible with each interaction . A record review on 01/12/2024 of the Texas Unified License Information Portal website, accessed 01/24/2024, revealed no facility related report for Resident #34's allegations of neglect and/or mistreatment for the allegations made on 11/21/2023 and 11/22/2023. A record review of the facility's in-service record, dated 11/22/2023, revealed 15 nursing staff were in-serviced specifically for resident #34 for Topic: Resident #34; contents or summary of training session: When providing care for Resident #34 we should be mindful. staff should always communicate what they are doing when providing care. there must be two staff members when transferring resident #34 (gate belt or lift transfer). if resident is agitated allow him time to calm down. let the nurse know so she can assist with care if needed. all residents must be turned and repositioned every two hours. incontinent care should be given at this time During a record review and interview on 01/23/24 at 02:48 PM Resident #34's Representative stated on Sunday 11/19/2023 Resident #34 was ambulating in his wheelchair without any complaints of pain. Resident #34's Representative stated on 11/20/2023 Resident #34 was complaining of pain with transfers from bed to wheelchair. Resident #34's Representative stated Resident #34 had a camera in his room. Resident #34's representative stated she reviewed the camera recordings and discovered an unidentified CNA was attending to Resident #34 around 08:45 PM on Sunday 11/19/2023 and was forcing Resident #34 from his wheelchair to his bed while Resident #34 was refusing and calling out in pain. Resident #34's Representative stated she reported the mistreatment to the facility's Physical Therapy Director on Tuesday morning 11/21/2023 and further reported to the Administrator and the DON with an email on 11/22/2023 at 12:33 PM. Resident #34's Representative stated the DON replied with an email, on 11/22/2023 at 12:47 PM, and stated she would look into the issues and in-service the staff. A record review of the video provided by Resident #34's representative revealed CNA P and Resident #34 were in a bedroom. Resident #34 was dressed in a button-down shirt and pants and wore a gait belt. Resident #34 was seated in his wheelchair. CNA P positioned Resident #34 by the bed and stood in front of Resident #34 and attempted to grab the gait belt and lift Resident #34 while Resident #34 grabbed the arm rests of the wheelchair and began to loudly complaint and verbalize Owww!. Further review revealed this was attempted three times with the same results to include CNA P's insistence with the transfer by removing the wheelchair armrest adjacent to the bed. With continued insistence Resident was lifted by his gait belt and swung over to his bed by CNA P while he continued to call out Oww!. The recording terminated after the transfer. A record review of the email provided by Resident #34's Representative, dated 11/22/2023 at 12:33 PM sent to the DON and the Administrator, revealed, Sunday 11/19 at 7 pm (Resident #34) Room (***) (Resident #34) and the aide had a very rough time with just a one person transfer where he hit his femur area on his right leg with the wheelchair arm. This was not safe for her either as she was struggling to get (Resident #34) in position to transfer. (Resident #34) has osteoporosis and is susceptible to fractures easily. Please provide two people for his bed transfers for the safety of the aide and for (Resident #34). After she did finally get him in bed she didn't check his diaper. He had been changed at 4:30 pm before supper and was not changed then until 4:30 am. He went 12 hours without a diaper change and was not turned every two hours as he should have been for circulation and hygienic purposes. He didn't receive his breathing treatments as ordered on Sunday as well. He needs to receive his breathing treatments with assistance three times a day during waking hours. Sent from my (name brand cell phone). A record review of the email provided by Resident #34's Representative, dated 11/22/2023 at 12:47 PM sent by the DON and received by Resident #34's Representative and the administrator, revealed, Thanks, (Resident #34's Representative) I will look into these issues and in-service staff. During an interview on 01/24/2024 at 10:26 AM The Physical Therapy Director stated his training was to report allegations of abuse, neglect, and exploitation to the abuse, neglect, and exploitation prevention coordinator who was also the Administrator. The Physical Therapy Director stated he assessed Resident #34 on Sunday 11/19/2023 without any complaints of pain with ambulation in his wheelchair. The Physical Therapy Director stated on Monday 11/20/2023 Resident #34 had pain with transfers and wheelchair ambulation. The Physical Therapy Director stated Resident #34's Representative had reported to him, on the morning of Tuesday 11/21/2023, a review of the in-room camera footage on the evening of Sunday 11/19/2023 revealed an unidentified CNA was rough with Resident #34 while transferring Resident #34 from his wheelchair to his bed. The Physical Therapy Director stated he reported the allegation of mistreatment to the Administrator during the 08:30 AM stand-up meeting on Tuesday 11/21/2023, the Physical Therapy Director stated the meeting included the Social Worker, The DON and the Administrator. The Physical Therapy Director stated he had not documented a grievance report nor reported the allegation to the state agency since he reported the complaint to the Administrator. During an interview on 11/24/2024 at 01:38 PM the DON stated she could not recall the stand-up meeting on 11/21/2023 but could state if an allegation of mistreatment was identified at the meeting it would have been acted upon at a minimum with a documented grievance report with a follow up investigation and report to the state agency. The DON stated she had received a complaint about Resident #34 on 11/22/2023 from Resident #34's representative and documented the complaint on a grievance report. The DON stated she had also provided additional training for the nursing staff regarding transfers and respiratory treatments. The DON stated she had not reported the allegations of neglect and or mistreatment to the state agency. The DON stated the Administrator was aware of the complaint regarding Resident #34. The DON reviewed a still frame of the video and identified CNA P as the CNA who transferred Resident #34 in the video record. The DON stated CNA P was terminated 12/20/2023 for lack of attendance. During an interview on 11/26/2023 at 04:30 PM the Administrator stated he could not recall the stand-up meeting on 11/21/2023 and/ or the complaint from Resident #34's Representative but could state if an allegation of mistreatment was identified it would have been acted upon at a minimum with a documented grievance report with a follow up investigation and report to the state agency. The Administrator was asked if an allegation of a CNA was rough with a Resident during transfers, allegation a Resident did not receive medications, and/or an allegation of neglect to provide incontinent care or hygiene care became known to him would it rise to the level of reporting the allegation to the state agency, the Administrator stated it would depend on the details and circumstances. A record review of the facility's Abuse, Neglect, and Exploitation policy dated 8/15/2022, revealed, it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .'neglect' means failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . reporting response the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, . within required time frames: immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to have evidence that all alleged violations are thoroughly investigated; Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress; and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 1 of 1 Resident (Resident #34) reviewed for an investigation of allegations of abuse and neglect, in that: The facility failed to investigate to the state agency allegations of abuse and neglect received on 11/22/2023 for Resident #34. This failure could place residents at risk for abuse and neglect by not investigating and reporting the results of their investigation. The findings included: A Record review of Resident #34's admission record dated 01/24/2024 revealed an admission date of 12/11/2023 with diagnoses which included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A record review of Resident #34's admission MDS assessment, dated 12/11/2023, revealed Resident #34 was a [AGE] year-old male admitted for long term care and could not be assessed with a BIMS due to cognitive impairment. A record review of Resident #34's care plan dated 1/23/2024, revealed, Problem: (Resident #34) has an ADL self-care performance deficit r/t Impaired balance, impaired vision, behaviors. Known to resist care .TRANSFER: The resident requires total assistance by 2 staff to move between surfaces. May use (brand name) lift when uncooperative .Revision on: 11/17/2023 .Encourage the resident to participate to the fullest extent possible with each interaction . A record review on 01/12/2024 of the Texas Unified License Information Portal website, accessed 01/24/2024, revealed no facility related report for Resident #34's allegations of neglect and/or mistreatment for the allegations made on 11/21/2023 and 11/22/2023. A record review of the facility's in-service record, dated 11/22/2023, revealed 15 nursing staff were in-serviced specifically for resident #34 for Topic: Resident #34; contents or summary of training session: When providing care for Resident #34 we should be mindful. staff should always communicate what they are doing when providing care. there must be two staff members when transferring resident #34 (gate belt or lift transfer). if resident is agitated allow him time to calm down. let the nurse know so she can assist with care if needed. all residents must be turned and repositioned every two hours. incontinent care should be given at this time During a record review and interview on 01/23/24 at 02:48 PM Resident #34's Representative stated on Sunday 11/19/2023 Resident #34 was ambulating in his wheelchair without any complaints of pain. Resident #34's Representative stated on 11/20/2023 Resident #34 was complaining of pain with transfers from bed to wheelchair. Resident #34's Representative stated Resident #34 had a camera in his room. Resident #34's representative stated she reviewed the camera recordings and discovered an unidentified CNA was attending to Resident #34 around 08:45 PM on Sunday 11/19/2023 and was forcing Resident #34 from his wheelchair to his bed while Resident #34 was refusing and calling out in pain. Resident #34's Representative stated she reported the mistreatment to the facility's Physical Therapy Director on Tuesday morning 11/21/2023 and further reported to the Administrator and the DON with an email on 11/22/2023 at 12:33 PM. Resident #34's Representative stated the DON replied with an email, on 11/22/2023 at 12:47 PM, and stated she would look into the issues and in-service the staff. A record review of the video provided by Resident #34's representative revealed CNA P and Resident #34 were in a bedroom. Resident #34 was dressed in a button-down shirt and pants and wore a gait belt. Resident #34 was seated in his wheelchair. CNA P positioned Resident #34 by the bed and stood in front of Resident #34 and attempted to grab the gait belt and lift Resident #34 while Resident #34 grabbed the arm rests of the wheelchair and began to loudly complaint and verbalize Owww!. Further review revealed this was attempted three times with the same results to include CNA P's insistence with the transfer by removing the wheelchair armrest adjacent to the bed. With continued insistence Resident was lifted by his gait belt and swung over to his bed by CNA P while he continued to call out Oww!. The recording terminated after the transfer. A record review of the email provided by Resident #34's Representative, dated 11/22/2023 at 12:33 PM sent to the DON and the Administrator, revealed, Sunday 11/19 at 7 pm (Resident #34) Room (***) (Resident #34) and the aide had a very rough time with just a one person transfer where he hit his femur area on his right leg with the wheelchair arm. This was not safe for her either as she was struggling to get (Resident #34) in position to transfer. (Resident #34) has osteoporosis and is susceptible to fractures easily. Please provide two people for his bed transfers for the safety of the aide and for (Resident #34). After she did finally get him in bed she didn't check his diaper. He had been changed at 4:30 pm before supper and was not changed then until 4:30 am. He went 12 hours without a diaper change and was not turned every two hours as he should have been for circulation and hygienic purposes. He didn't receive his breathing treatments as ordered on Sunday as well. He needs to receive his breathing treatments with assistance three times a day during waking hours. Sent from my (name brand cell phone). A record review of the email provided by Resident #34's Representative, dated 11/22/2023 at 12:47 PM sent by the DON and received by Resident #34's Representative and the administrator, revealed, Thanks, (Resident #34's Representative) I will look into these issues and in-service staff. During an interview on 01/24/2024 at 10:26 AM The Physical Therapy Director stated his training was to report allegations of abuse, neglect, and exploitation to the abuse, neglect, and exploitation prevention coordinator who was also the Administrator. The Physical Therapy Director stated he assessed Resident #34 on Sunday 11/19/2023 without any complaints of pain with ambulation in his wheelchair. The Physical Therapy Director stated on Monday 11/20/2023 Resident #34 had pain with transfers and wheelchair ambulation. The Physical Therapy Director stated Resident #34's Representative had reported to him, on the morning of Tuesday 11/21/2023, a review of the in-room camera footage on the evening of Sunday 11/19/2023 revealed an unidentified CNA was rough with Resident #34 while transferring Resident #34 from his wheelchair to his bed. The Physical Therapy Director stated he reported the allegation of mistreatment to the Administrator during the 08:30 AM stand-up meeting on Tuesday 11/21/2023, the Physical Therapy Director stated the meeting included the Social Worker, The DON and the Administrator. The Physical Therapy Director stated he had not documented a grievance report nor reported the allegation to the state agency since he reported the complaint to the Administrator. During an interview on 11/24/2024 at 01:38 PM the DON stated she could not recall the stand-up meeting on 11/21/2023 but could state if an allegation of mistreatment was identified at the meeting it would have been acted upon at a minimum with a documented grievance report with a follow up investigation and report to the state agency. The DON stated she had received a complaint about Resident #34 on 11/22/2023 from Resident #34's representative and documented the complaint on a grievance report. The DON stated she had also provided additional training for the nursing staff regarding transfers and respiratory treatments. The DON stated she had not reported the allegations of neglect and or mistreatment to the state agency. The DON stated the Administrator was aware of the complaint regarding Resident #34. The DON reviewed a still frame of the video and identified CNA P as the CNA who transferred Resident #34 in the video record. The DON stated CNA P was terminated 12/20/2023 for lack of attendance. During an interview on 11/26/2023 at 04:30 PM the Administrator stated he could not recall the stand-up meeting on 11/21/2023 and/ or the complaint from Resident #34's Representative but could state if an allegation of mistreatment was identified it would have been acted upon at a minimum with a documented grievance report with a follow up investigation and report to the state agency. The Administrator was asked if an allegation of a CNA was rough with a Resident during transfers, allegation a Resident did not receive medications, and/or an allegation of neglect to provide incontinent care or hygiene care became known to him would it rise to the level of reporting the allegation to the state agency, the Administrator stated it would depend on the details and circumstances. A record review of the facility's Abuse, Neglect, and Exploitation policy dated 8/15/2022, revealed, it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .'neglect' means failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . reporting response the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, . within required time frames: immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must include the minimum healthcare information necessary to properly care for a resident for 1 of 8 residents (Resident #269) reviewed for healthcare information necessary to properly care for a Resident, in that: The facility failed to care plan Resident #269's need for a peripherally inserted central catheter (also known as a PICC line - percutaneous indwelling central catheter, is a form of intravenous access that can be used for a prolonged period for administration of intravenous in the vein medications). This failure could place residents at risk for harm by not receiving care for their indwelling intravenous catheters. The findings include: A record review of Resident #269's admission record dated 01/24/2024 revealed an admission date of 01/16/2024 with diagnoses which included sepsis (a life-threatening complication of an infection). A record review of Resident #269's admission MDS assessment, dated 01/16/2024, revealed Resident #269 was an [AGE] year-old male admitted for short term care. A record review of Resident #269's Initial Baseline / Advanced Care Plan, dated 01/16/2024, revealed an admitting diagnosis of severe sepsis with septic shock (Septic shock is a life-threatening condition caused by a severe localized or system-wide infection that requires immediate medical attention) and medications ordered - antibiotics. Further review revealed the question regarding IV Medications / fluids was left unanswered. A record review of Resident #269's physicians orders, dated 01/24/2024, revealed the physician ordered nursing staff to care for Resident #269's PICC line daily and as needed, monitor midline (PICC) site for redness, tenderness, edema, excessive bleeding outside, chest/neck/ear pain, numbness or tingling of affected arm/and. notify MD of abnormal findings every shift . no blood pressure checks or veiny puncture to midline arm 'left arm'. During an observation and interview on 01/23/2024 at 03:10 PM Resident #269 stated demonstrated a PICC line on his left upper arm covered by a clear bandage. The PICC line was accessed by 2 lumens (small tubes covered with screw on/off caps). Resident #269 stated he received the PICC line while at the hospital and the facility nursing staff used the lumens to inject his antibiotic medications. During an interview on 01/24/2024 at 02:23 PM the DON stated Resident #269 was admitted for short term care related to a severe infection, was currently receiving intravenous antibiotics through a PICC midline on Resident #269's left arm. The DON stated she was the RN who signed off on Resident #269's baseline care plan. The DON stated Resident #269 was not care planned supports and interventions for his intravenous antibiotics and/or his midline PICC line. The DON stated she was responsible for ensuring the accuracy of residents care plans and had made a mistake and overlooked Resident #269's midline intravenous access. The DON stated the lack of care plan interventions could have placed resident #269 at risk for not caring for his intravenous access. A record review of the facility's Care Plans- Baseline policy , dated March 2022, revealed, a baseline plan of care to meet the residents' immediate health and safety needs is developed for each resident within 48 hours of admission. the baseline care plan includes instructions needed to provide effective, person centered care of the resident that meet professional standards of quality care and must include the minimum health care information necessary to properly care for the resident including, but not limited to the following: .physicians' orders

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 8 residents (Residents #2 and #49) for care plan revisions, in that: 1. Resident #2's care plan was not revised to reflect fall interventions after a fall on 12/27/2023 and had not been updated to address Resident #2's new respiratory needs. 2. Resident #49's care plan was not revised to reflect smoking interventions identified in an updated smoking assessment on 10/26/2023. This failure could place residents at risk of receiving inappropriate care. The findings were: 1. Record review of Resident #2's face sheet, dated 01/26/2024, revealed an admission date of 10/26/2021 and diagnoses which included: dementia, with other behavioral disturbance, other malaise (general feeling of being unwell), anemia and essential hypertension (high blood pressure that has no clearly identifiable cause). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 03, which indicated severe cognitive impairment. Review revealed in Section J: Health Conditions; resident did not have a history of falls or respiratory conditions. Record review of Resident #2's Care Plan, with last review completed on 12/27/2023, revealed, [Resident] is at risk for falls r/t impaired balance, impaired cognition, wandering with poor safety awareness. Date initiated 11/03/2021. Further review revealed interventions for falls listed were dated 11/03/2021. An additional intervention for start tx for Respiratory infection dated 12/27/2023 was included in problem area. No problem area for Respiratory Care was noted on the care plan. Review of Resident #2's Order Summary Report, Active Orders as of 01/26/2024, revealed an order for Albuterol Sulfate Inhalation Nebulization Solution, every 6 hours as needed for wheezing, with a start date 12/27/2023 and D/C date 01/18/2024. Record review of Resident #2's electronic medical record revealed an MD notification document, dated 12/28/2023 completed by the DON. Notification provided regarding resident's unwitnessed fall with laceration above Rt eye and wheezing. Orders received from MD for Albuterol Neb Q6 hours PRN. Record review of Resident #2's electronic medical record revealed a Nursing Quarterly/PRN Nursing Evaluation, dated 12/29/2023. Review revealed in Section F: Respiratory, Type of respiratory treatments ordered: Nebulizer. Record review of Resident #2's Skilled Administration Record dated 12/1/2023-12/31/2023, revealed Resident #2 received nebulizer treatments on 12/27/2023 and 12/28/2023. 2. Record review of Resident #49's face sheet, dated 01/25/2024, revealed an initial admission date of 08/29/2022 and a most recent admission of 05/12/2023 with diagnoses that included: end stage renal disease, acquired absence of right leg below knee, lack of coordination, and legal blindness. Record review of Resident #49's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 15, which indicated the resident's cognition to be intact. Further review of Section GG: Functional Abilities revealed Resident #49 required anywhere from substantial/maximal to setup assistance for self-care ADL's. Record review of Resident #49's Care Plan, with last review completed on 11/09/2023, revealed, [Resident] is a smoker. Date initiated: 11/09/2023. Review revealed the interventions included to instruct resident on smoking risks, instruct on policy, monitor hygiene, notify charge nurse for violations, and observe clothing and skin for burns. Care plan did not indicate Resident #49's need for smoking apron and one to one supervision. Record review of Resident #49's electronic medical record revealed a Smoking Safety Screen, dated 08/30/2022, that noted Resident #49 as non-smoker. Further review revealed a Smoking Safety Screen, dated 10/26/2023, that indicated Resident #49's adaptive equipment needs were a smoking apron and one-on-one assistance. In an interview with the CMP on 01/26/2024 at 12:43 p.m., the CMP stated Resident #49 was initially not a smoker when admitted to the facility. The CMP revealed that Resident #49's status changed later to smoker and when the assessment was completed, the care plan should have been updated to include all safety interventions. The CMP stated the care plan was very important so that all staff are aware of each resident's specific needs. The CMP further stated she would have been the one to update the care plan and other than human error is unsure how it was overlooked. In an interview with the DON on 01/26/2024 at 12:55 p.m., the DON revealed revisions were to be made as changes occurred and were the responsibility of all disciplines. The DON reviewed Resident #2 care plan and Resident #2 had not had any falls prior to the fall on 12/27/2024 and due to Resident #2 wheezing at the time we thought the respiratory infection was probably the reason for her fall so we put the treatments under fall risk in care plan. The DON added that instead of the respiratory treatment, some other intervention specific for falls should have been to the problem of fall risk and a new respiratory problem added with the nebulizer treatments as an intervention. A policy was requested regarding Care Plan Revisions however a policy was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the Resident for 1 of 8 residents (Resident #56) reviewed for surviving trauma, in that: The facility failed to provide care in a manner to eliminate and/or mitigate triggers for Resident #56's Post Traumatic Stress due to a rape assault. This failure could place residents at risk for triggering re-traumatization. The findings included: A record review of Resident #56's admission record dated 01/26/2024 revealed an admission date of 07/03/2022 with diagnoses which included Post Traumatic Stress Syndrome (PTSD a disorder that develops in some people who have experienced a shocking, scary, or dangerous event) and dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A record review of Resident #56's quarterly MDS assessment, dated 12/30/2023, revealed Resident #56 was an [AGE] year-old female admitted for long term care and assessed with Post traumatic stress syndrome with a BIMS score of 12 out of a possible 15 which indicated moderate cognition impairment. A record review of Resident #56's hospital discharge documents dated 07/02/2022, revealed Resident #56 was diagnosed with Post Traumatic Stress Syndrome as evidenced by a 2002 sexual assault, rape. A record review of Resident #56's care plan, dated 01/25/2024, revealed, Problem: (Resident #56) uses psychotropic medications .for PTSD, .Presents in angry mood at times, hard to re-direct .Revision on: 01/07/2024 .Problem: Discharge planning has been discussed with the resident/RP. Discharge to the community is not expected .Revision on: 07/03/2023 .Interventions: Assist resident with adjusting to the facility . Encourage family to visit as often as possible .Encourage resident to become involved in facility activities of choice, to attend resident council, and to socialize with others .Follow up as needed to see if there are changes to the discharge plan .Monitor resident for difficulty adjusting to the facility During an interview on 01/24/2024 at 04:05 PM Resident #56 stated she did not want to participate in conversations about her past. Resident became silent when asked if she had male care givers and would return to participating in the interview when the conversation turned away from male care givers. Resident #56 stated she was happy with the care, the girls are good to me. During an interview on 01/25/2024 at 02:23 PM the DON stated there were no interventions and or supports in place to eliminate and/or mitigate any potential triggers for Resident #56 diagnosis for PTSD related to a past sexual assault. The DON stated Resident #56 was at risk for being reminded and possibly trigged for negative feelings related to her past rape. A record review of the facility's Trauma Informed Care policy, dated 10/13/2022, revealed, it is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and or re-traumatization, . the facility will use multi pronged approach to identifying residents history of trauma, as well as his or her cultural preferences. this will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the resident assessment instrument, admission assessments, the history of physical, the social history assessments and others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide food that was palatable, attractive, and prepared by methods which conserved the nutritive value, flavor, and appearance for 1 of 1 meal (noon meal) reviewed for food palatability and nutritive value, in that: 1. The facility served Resident #40 a hamburger with a greenish-gray color substance on the bottom bun. 2. The facility failed to follow the recipe for Resident #32's tuna salad sandwich. This failure could place all residents who ate meals prepared from the kitchen at risk of food borne illness, possible weight loss, altered nutritional status, and diminished quality of life. The findings were: 1. Record review of Resident #40's face sheet, dated 01/26/2024, revealed an initial admission date of 03/02/2020 with a most recent admission of 08/06/2020 and diagnoses which included: chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately or following directions), hypothyroidism (underactive thyroid, thyroid gland doesn't make enough thyroid hormones to meet the body s needs which control how the body uses energy. Affects breathing, heart rate, weight, digestion, and moods) and hypokalemia (low levels of potassium in the blood). Record review of Resident #40's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 10 (out of 15) indicative of moderate cognitive impairment and he required supervision and set up with meals. During an observation of the noon meal on 01/23/2024 at 12:17 p.m., Resident #40 motioned this surveyor to his table. Resident #40 had been served a hamburger and fries which was the alternate meal for the day. Resident #40 had pulled a small piece of the hamburger bun off and placed it on his table pointing at the greenish-gray color substance on the bun. Resident #40 asked, is that pepper or something else? LVN F walked to Resident #40's table and stated, oh, that's mold! Resident #40 was holding the remaining two-thirds of his hamburger down near his lap and as he picked up the hamburger, this surveyor and LVN F saw the bottom of the hamburger bun was covered in the greenish-gray colored substance. During an interview with the LVN F on 01/23/2024 at 12:43 p.m., LVN F revealed the floor nurses had identified a total of 7 potential residents served hamburger buns. LVN F stated she had checked allergies for those residents and that none of the residents served hamburger buns were allergic to penicillin. During an interview with the DON on 01/23/2024 at 12:47 p.m., the DON revealed all the resident's physicians would be notified and the residents monitored closely for any symptoms. During an interview with the RD and Administrator on 01/23/2024 at 3:00 p.m., the RD stated the hamburger bun with the greenish-gray area should not have been served as it would pose a risk for food borne illnesses to residents. During an interview with the FSS on 01/23/2024 at 3:23 p.m., the FSS revealed the hamburger buns used for today's meal were the last bag in the box. The FSS stated she had not checked the expiration date prior to serving however does routine storage checks to determine if food is within expiration dates. 2. A record review of Resident #32's admission record, dated 01/24/2024, revealed an admission date of 05/20/2016 with diagnoses which included muscle wasting and atrophy (a reduction of muscle mass) and vitamin deficiency. A record review of Resident #32's quarterly MDS assessment, dated 12/13/2023, revealed Resident #32 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 15 out of a possible 15 which indicated no cognitive impairment. A record review of Resident #32's physicians orders, dated 01/24/2025, revealed Resident #32 was prescribed fish oil capsules daily for vitamin deficiency. A record review of Resident #32's care plan, dated 01/24/2024, revealed, (Resident #32) has anemia (a common cause of anemia worldwide is iron deficiency. Iron is needed to form hemoglobin, part of red blood cells that carry oxygen and remove carbon dioxide (a waste product) from the body) . The resident will remain free of s/symptoms (signs and or symptoms) or complications related to anemia through review date .Encourage intake of foods high in iron, vitamin C .(Resident #32's) has a potential for nutritional problems as evidenced by weight variances r/t (related to) obesity and vitamin deficiency, hx (history) of constipation, Hypernatremia (too much salt in the blood), Dysphagia (difficulty swallowing foods and or drinks) with coughing during meals. Diet: Regular, mechanical soft texture, Nectar liquids. HS (hour of sleep) snack x30 days .Provide and serve diet as ordered .Provide and serve supplements as ordered A record review of the facility's Quantified Recipe 1418, dated 03/14/2023, revealed, tuna salad sandwich on wheat 3 ounces .serving utensil: #8 scoop / spatula .assemble filling and bread using a #8 scoop .3 ounces .sandwich . is equal to #8 scoop . During an observation and interview on 01/23/2024 at 12:10 PM revealed Resident #32 was served his meal which included a tuna salad sandwich on wheat bread. Resident #32 called out to surveyor and demonstrated the sandwich by spreading apart the slices of bread to reveal a scant, difficult to recognize, smear of tuna salad. Resident #32 stated is there any tuna in this sandwich? Resident #32 gave the Surveyor permission to collected photographic evidence of the sandwich. During an interview on 01/24/2023 at 2:01 PM the dietician viewed the photo of the tuna salad sandwich and stated it was difficult to see the tuna salad in the sandwich from the photo shown. The dietician stated the expectation for the kitchen was to follow recipes for all foods prepared including a tuna salad sandwich. The dietician stated the risk to residents who received foods prepared without following recipes could be residents not receiving the calories needs and recommended. During an interview on 01/25/2024 the Food Service Supervisor stated she was unsure if there was a recipe for tuna salad sandwiches and stated usually the staff prepared the tuna salad sandwich with a knife and not a scoop. A record review of the facility's Tray Service policy, dated 10/2018, revealed, the facility believes that accurate trade service and act adequate portion sizes are essential to the resident's well-being and safe. the facility will ensure that diets are served accurately and in the correct portions and that residents' preferences are met . for trade line service, nutrition and food service staff will check each residence tray card prior to service to ensure that preferences and dislikes are honored, the correct diet is served, portion sizes are accurate A record review of the facility's Portion Control policy, dated 10/2018, revealed, the facility will use standard portion control procedures and utensils to ensure that adequate portions are served to residents . standardize recipes should be used to prevent overproduction . for each food item should follow the specific portion sizes listed on the menus food items should be served using standard sized ladles, scoops, spoondles, and spoons. standard scoop and ladle sizes are listed in the following tables: . scoop #8 half cup 4 ounces .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to ensure residents' rights to voice grievances to the facility or other agencies or entities that heard grievances without discrimination or reprisal and without fear of discrimination or reprisal for 2 of 8 residents (Resident #34, and #56) reviewed for grievances, in that; 1. The facility failed to ensure the Physical Therapy Director initiated a grievance report on behalf of Resident #34's grievance on 11/21/2023. 2. The facility failed to ensure the Physical Therapy Director, The DON, and the Administrator initiated a grievance report on behalf of Resident #56's grievance on 11/17/2023. This failure could place residents at risk by denying their right to make and have grievances heard and contributed to ill feelings of not being heard and unresolved issues. The findings included: 1. Record review of Resident #34's admission record dated 01/24/2024 revealed an admission date of 12/11/2023 with diagnoses which included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A record review of Resident #34's admission MDS assessment, dated 12/11/2023, revealed Resident #34 was a [AGE] year-old male admitted for long term care and could not be assessed with a BIMS due to cognitive impairment. A record review of Resident #34's care plan dated 1/23/2024, revealed, Problem: (Resident #34) has an ADL self-care performance deficit r/t Impaired balance, impaired vision, behaviors. Known to resist care .TRANSFER: The resident requires total assistance by 2 staff to move between surfaces. May use (brand name) lift when uncooperative .Revision on: 11/17/2023 .Encourage the resident to participate to the fullest extent possible with each interaction . During an interview on 01/23/24 at 02:48 PM Resident #34's representative stated on Sunday 11/19/2023 Resident #34 was ambulating in his wheelchair without any complaints of pain. Resident #34's representative stated on 11/20/2023 Resident #34 was complaining of pain with transfers from bed to wheelchair. Resident #34's representative stated Resident #34 has a camera in his room. Resident #34's representative stated she reviewed the camera recordings and discovered an unidentified CNA was attending to Resident #34 around 08:45 PM on 11/19/2023 and was forcing Resident #34 from his wheelchair to his bed while Resident #34 was refusing and calling out in pain. Resident #34's representative stated she reported the mistreatment to the facility's Physical Therapy Director on Tuesday morning of 11/21/2023. During an interview on 01/24/2024 at 10:26 AM The Physical Therapy Director stated his training was to report complaints to the abuse, neglect, and exploitation prevention coordinator who was also the Administrator. The Physical Therapy Director stated he assessed Resident #34 on Sunday 11/19/2023 without any complaints of pain with ambulation in his wheelchair. The Physical Therapy Director stated on Monday 11/20/2023 Resident #34 had pain with transfers and wheelchair ambulation. The Physical Therapy Director stated Resident #34's representative had reported to him, on the morning of 11/21/2023, a review of the in-room camera footage on the evening of 11/19/2023 revealed an unidentified CNA was rough with Resident #34 while transferring Resident #34 from his wheelchair to his bed. The Physical Therapy Director stated he reported the allegation of mistreatment to the Administrator during the 08:30 AM stand-up meeting on 11/21/2023, the meeting included the Social Worker, The DON and the Administrator at a minimum. The Physical Therapy Director stated he had not documented a grievance report since he reported the complaint to the Administrator. During an interview on 11/24/2023 at 11:20 AM the ADON stated she could not recall the stand-up meeting on 11/21/2023 but could state if an allegation of mistreatment was identified at the meeting it would have been acted upon at a minimum with a documented grievance report with a follow up investigation. During an interview on 11/24/2023 at 01:38 PM the DON stated she could not recall the stand-up meeting on 11/21/2023 but could state if an allegation of mistreatment was identified at the meeting it would have been acted upon at a minimum with a documented grievance report with a follow up investigation. During an interview on 11/24/2023 at 01:50 PM the Administrator stated she could not recall the stand-up meeting on 11/21/2023 but could state if an allegation of mistreatment was identified at the meeting it would have been acted upon at a minimum with a documented grievance report with a follow up investigation. A record review on 01/12/2024 of the facility's November 2023, December 2023, and January 2024's grievance records revealed no grievance report for Resident #34. 2. Record review of Resident #56's admission record dated 01/26/2024 revealed an admission date of 07/03/2022 with diagnoses which included Post Traumatic Stress Syndrome (PTSD a disorder that develops in some people who have experienced a shocking, scary, or dangerous event) and dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A record review of Resident #56's quarterly MDS assessment, dated 12/30/2023, revealed Resident #56 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 12 out of a possible 15 which indicated moderate cognition impairment. A record review of Resident #56's care plan, dated 01/25/2024, revealed, Problem: (Resident #56) uses psychotropic medications .for PTSD, .Presents in angry mood at times, hard to re-direct .Revision on: 01/07/2024 .Problem: Discharge planning has been discussed with the resident/RP. Discharge to the community is not expected .Revision on: 07/03/2023 .Interventions: Assist resident with adjusting to the facility . Encourage family to visit as often as possible .Encourage resident to become involved in facility activities of choice, to attend resident council, and to socialize with others .Follow up as needed to see if there are changes to the discharge plan .Monitor resident for difficulty adjusting to the facility During a record review and interview on 01/24/2024 at 10:26 AM The Physical Therapy Director stated his training was to report complaints to the abuse, neglect, and exploitation prevention coordinator who was also the Administrator. The Physical Therapy director stated on 11/17/2023 he began to report Residents' grievances by sending group text messages to the facility's Social Worker, the DON, and the Administrator because he felt the verbal reports were not addressed. The Physical Therapy Director stated residents would voice their grievances to him when he rounded on residents in the mornings. The Physical Therapy Director demonstrated his cell phone with the group text message on 11/17/2023 at 07:55 AM. The Physical Therapy Director stated Resident #56 had complained to him on Friday 11/17/2023 that she was upset at the care she received from a CNA and wanted to go home. The Physical Therapy Director stated no one responded to the group text message. Physical Therapy Director stated he did not document a grievance for Resident #56 because he believed he had met the requirement for reporting complaints by alerting the Administrator, the DON, and the Social Worker. During an interview on 11/24/2023 at 11:20 AM the ADON stated for a period in November and December 2023 the Physical Therapy Director had reported grievances on behalf of residents on group text messages to which she was included. The ADON could not recall the group text message on behalf of Resident #56 on 11/17/2023. The ADON stated she could not recall if she had documented a grievance report for Resident #56 complaint from 11/17/2023 and stated, if I didn't then I believed (Physical Therapy Director) would have. During an interview on 11/24/2023 at 01:38 PM the DON stated for a period in November and December 2023 the Physical Therapy Director had reported grievances on behalf of residents on group text messages to which she was included. The DON could not recall the group text message on behalf of Resident #56 on 11/17/2023. The DON stated she could not recall if she had documented a grievance report for Resident #56 complaint from 11/17/2023 and stated, I could have documented a grievance report for Resident #56 when I received the text message from (the Physical Therapy Director) .but I though he already had and was just alerting us (the group) of the complaint. The DON stated the risk for harm to residents who have not had their grievances heard and resolved could be diminished self-esteem. During an interview on 11/24/2023 at 01:50 PM the Administrator stated he had been receiving group text messages from the Physical Therapy Director in November and December 2023 as well as January 2024. The Administrator stated the Physical Therapy Director had received instructions to document grievance reports on behalf of residents when he received a complaint. The Administrator stated he believed the Physical Therapy Director was documenting grievance reports for all reported complains on the group text messages. The Administrator stated he was responsible for reviewing the grievance reports and had not recognized the Physical Therapy Director had not documented the grievance for Resident #56 complaint on 11/17/2023. The Administrator stated the grievance reports should be documented by the staff who received the grievance. A record review on 01/12/2024 of the facility's November 2023's grievance records revealed no grievance report for Resident #56's complaint on 11/17/2023. A record review of the facility's Resident and Family Grievances policy dated August 2022, revealed, It is the policy of this facility to support each resident and family members right to voice grievances without fear of discrimination or reprisal. Definition: prompt efforts to resolve. include facility acknowledgement of a complaint and or grievance and actively working towards resolution of that complaint and or grievance . Administrator has been designated as the grievance official . the grievance official is responsible for overseeing the grievance process; receiving tracking grievances through their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the Resident; and coordinating with state and federal agencies as necessary in light of specific allegations .grievances may be voiced in the following forms: verbal complaint to a staff member or grievance official . the staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form . forward the grievance form to the grievance official as soon as practicable. the grievance official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form . all staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the grievance official. prompt efforts include acknowledgement of complaint and or grievances and actively working towards a resolution of that compliance and or grievance . the grievance official or designee will keep the resident appropriately apprised of progress towards the resolution of the grievances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property and establish policies and procedures to investigate any such allegations for 1 of 1 resident (Resident #34) reviewed for reporting and investigations of alleged abuse, neglect, exploitation, and mistreatment and 14 of 19 staff (RN C, RN D, RN E, LVN G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, CNA N, CNA O, the FSS and the AD) reviewed for employee misconduct registry screenings, in that: 1. The facility failed to screen, through the employee misconduct registry, 14 staff, which included; RN C, RN D, RN E, LVN G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, CNA N, CNA O, the FSS and the AD. 2. The Administrator, the DON and the Physical Therapy Director did not report to the state agency and or investigate Resident #34's Representative's allegations of mistreatment on 11/22/2023. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The findings were: Record review of the staff roster provided on 01/23/2024 by the facility for RN C revealed a hire date of 01/09/2023. Record review of the personnel file for RN C revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/24/2024 after staff records were requested by surveyor on 01/24/2024. Record review of the staff roster provided on 01/23/2024 by the facility for RN D revealed a hire date of 12/19/2022. Record review of the personnel file for RN D revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/24/2024 after staff records were requested by surveyor on 01/24/2024. Record review of the staff roster provided on 01/23/2024 by the facility for RN E revealed a hire date of 04/05/2022. Record review of the personnel file for RN E revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/09/2023. Record review of the staff roster provided on 01/23/2024 by the facility for LVN G revealed a hire date of 10/29/2013. Record review of the personnel file for LVN G revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/09/2023. Record review of the staff roster provided on 01/23/2024 by the facility for CNA H revealed a hire date of 12/29/2017. Record review of the personnel file for CNA H revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/24/2024 after staff records were requested by surveyor on 01/24/2024. Record review of the staff roster provided on 01/23/2024 by the facility for CNA I revealed a hire date of 09/09/2022. Record review of the personnel file for CNA I revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/24/2024 after staff records were requested by surveyor on 01/24/2024. Record review of the staff roster provided on 01/23/2024 by the facility for CNA J revealed a hire date of 03/30/2016. Record review of the personnel file for CNA J revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/24/2024 after staff records were requested by surveyor on 01/24/2024. Record review of the staff roster provided on 01/23/2024 by the facility for CNA K revealed a hire date of 03/17/2022. Record review of the personnel file for CNA K revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/24/2024 after staff records were requested by surveyor on 01/24/2024. Record review of the staff roster provided on 01/23/2024 by the facility for CNA L revealed a hire date of 08/01/2003. Record review of the personnel file for CNA L revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/24/2024 after staff records were requested by surveyor on 01/24/2024. Record review of the staff roster provided on 01/23/2024 by the facility for CNA M revealed a hire date of 11/03/2022. Record review of the personnel file for CNA M revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/09/2023. Record review of the staff roster provided on 01/23/2024 by the facility for CNA N revealed a hire date of 11/29/2021. Record review of the personnel file for CNA N revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/09/2023. Record review of the staff roster provided on 01/23/2024 by the facility for CNA O revealed a hire date of 10/28/2022. Record review of the personnel file for CNA O revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/09/2023. Record review of the staff roster provided on 01/23/2024 by the facility for the FSS revealed a hire date of 07/22/2008. Record review of the personnel file for the FSS revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/09/2023. Record review of the staff roster provided on 01/23/2024 by the facility for the AD revealed a hire date of 05/30/1989. Record review of the personnel file for the AD revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/09/2023. In an interview with the HRC on 01/25/2024 at 6:05 p.m., the HRC revealed she checked annual EMRs for all facility staff every January. The HRC stated she had been out the previous week and had not had a chance to finish. The HRC confirmed she had performed EMR checks for 7 of the 14 staff whose records were requested on 01/24/2024. In an interview with the Administrator on 01/26/2024 at 4:15 p.m., the Administrator confirmed all EMRs are checked on hire and annually to protect the residents. Record review of the facility's policy titled, Abuse, Neglect and Exploitation Policy, revised December 2017, revealed, Abuse Prevention: Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting or mistreating individuals. 2. Record review of Resident #34's admission record dated 01/24/2024 revealed an admission date of 12/11/2023 with diagnoses which included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A record review of Resident #34's admission MDS assessment, dated 12/11/2023, revealed Resident #34 was a [AGE] year-old male admitted for long term care and could not be assessed with a BIMS due to cognitive impairment. A record review of Resident #34's care plan dated 1/23/2024, revealed, Problem: (Resident #34) has an ADL self-care performance deficit r/t Impaired balance, impaired vision, behaviors. Known to resist care .TRANSFER: The resident requires total assistance by 2 staff to move between surfaces. May use (brand name) lift when uncooperative .Revision on: 11/17/2023 .Encourage the resident to participate to the fullest extent possible with each interaction . A record review on 01/12/2024 of the Texas Unified License Information Portal website, accessed 01/24/2024, revealed no facility related report for Resident #34's allegations of neglect and/or mistreatment for the allegations made on 11/21/2023 and 11/22/2023. a record review of the facility's in-service record, dated 11/22/2023, revealed 15 nursing staff were in-serviced specifically for resident #34 for Topic: Resident #34; contents or summary of training session: When providing care for Resident #34 we should be mindful. staff should always communicate what they are doing when providing care. there must be two staff members when transferring resident #34 (gate belt or lift transfer). if resident is agitated allow him time to calm down. let the nurse know so she can assist with care if needed. all residents must be turned and repositioned every two hours. incontinent care should be given at this time During an interview on 01/23/24 at 02:48 PM Resident #34's Representative stated on Sunday 11/19/2023 Resident #34 was ambulating in his wheelchair without any complaints of pain. Resident #34's Representative stated on 11/20/2023 Resident #34 was complaining of pain with transfers from bed to wheelchair. Resident #34's Representative stated Resident #34 had a camera in his room. Resident #34's representative stated she reviewed the camera recordings and discovered an unidentified CNA was attending to Resident #34 around 08:45 PM on Sunday 11/19/2023 and was forcing Resident #34 from his wheelchair to his bed while Resident #34 was refusing and calling out in pain. Resident #34's Representative stated she reported the mistreatment to the facility's Physical Therapy Director on Tuesday morning 11/21/2023 and further reported to the Administrator and the DON with an email on 11/22/2023 at 12:33 PM. Resident #34's Representative stated the DON replied with an email, on 11/22/2023 at 12:47 PM, and stated she would look into the issues and in-service the staff. A record review of the email provided by Resident #34's Representative, dated 11/22/2023 at 12:33 PM sent to the DON and the Administrator, revealed, Sunday 11/19 at 7 pm (Resident #34) Room (***) (Resident #34) and the aide had a very rough time with just a one person transfer where he hit his femur area on his right leg with the wheelchair arm. This was not safe for her either as she was struggling to get (Resident #34) in position to transfer. (Resident #34) has osteoporosis and is susceptible to fractures easily. Please provide two people for his bed transfers for the safety of the aide and for (Resident #34). After she did finally get him in bed she didn't check his diaper. He had been changed at 4:30 pm before supper and was not changed then until 4:30 am. He went 12 hours without a diaper change and was not turned every two hours as he should have been for circulation and hygienic purposes. He didn't receive his breathing treatments as ordered on Sunday as well. He needs to receive his breathing treatments with assistance three times a day during waking hours. Sent from my (name brand cell phone). A record review of the email provided by Resident #34's Representative, dated 11/22/2023 at 12:47 PM sent by the DON and received by Resident #34's Representative and the administrator, revealed, Thanks, (Resident #34's Representative) I will look into these issues and in-service staff. During an interview on 01/24/2024 at 10:26 AM The Physical Therapy Director stated his training was to report allegations of abuse, neglect, and exploitation to the abuse, neglect, and exploitation prevention coordinator who was also the Administrator. The Physical Therapy Director stated he assessed Resident #34 on Sunday 11/19/2023 without any complaints of pain with ambulation in his wheelchair. The Physical Therapy Director stated on Monday 11/20/2023 Resident #34 had pain with transfers and wheelchair ambulation. The Physical Therapy Director stated Resident #34's Representative had reported to him, on the morning of Tuesday 11/21/2023, a review of the in-room camera footage on the evening of Sunday 11/19/2023 revealed an unidentified CNA was rough with Resident #34 while transferring Resident #34 from his wheelchair to his bed. The Physical Therapy Director stated he reported the allegation of mistreatment to the Administrator during the 08:30 AM stand-up meeting on Tuesday 11/21/2023, the Physical Therapy Director stated the meeting included the Social Worker, The DON and the Administrator. The Physical Therapy Director stated he had not documented a grievance report nor reported the allegation to the state agency since he reported the complaint to the Administrator. During an interview on 11/24/2024 at 01:38 PM the DON stated she could not recall the stand-up meeting on 11/21/2023 but could state if an allegation of mistreatment was identified at the meeting it would have been acted upon at a minimum with a documented grievance report with a follow up investigation and report to the state agency. The DON stated she had received a complaint about Resident #34 on 11/22/2023 from Resident #34's representative and documented the complaint on a grievance report. The DON stated she had also provided additional training for the nursing staff regarding transfers and respiratory treatments. The DON stated she had not reported the allegations of neglect and or mistreatment to the state agency. The DON stated the Administrator was aware of the complaint regarding Resident #34. During an interview on 11/26/2023 at 04:30 PM the Administrator stated he could not recall the stand-up meeting on 11/21/2023 and/ or the complaint from Resident #34's Representative but could state if an allegation of mistreatment was identified it would have been acted upon at a minimum with a documented grievance report with a follow up investigation and report to the state agency. The Administrator was asked if an allegation of a CNA was rough with a Resident during transfers, allegation a Resident did not receive medications, and/or an allegation of neglect to provide incontinent care or hygiene care became known to him would it rise to the level of reporting the allegation to the state agency, the Administrator stated it would depend on the details and circumstances. A record review of the facility's Abuse, Neglect, and Exploitation policy dated 8/15/2022, revealed, it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .'neglect' means failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . reporting response the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, . within required time frames: immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency, for 4 of 10 residents (Residents #1, #7, #10, #34) reviewed for allegations of abuse, neglect, exploitation, and mistreatment, in that: 1. The Administrator, the DON and the Physical Therapy Director did not report to the state agency and or investigate Resident #34's Representative's allegations of mistreatment on 11/22/2023. 2. The Administrator and the DON did not report to the state agency and or investigate Resident #10's allegation of mistreatment on 12/05/2023. 3. The Administrator and the DON did not report to the state agency and or investigate Resident #1's allegation of neglect on 12/13/2023. 4. The Administrator and the DON did not report to the state agency and or investigate Resident #7's allegation of neglect on 12/18/2023. These failures could place residents at risk for abuse, neglect, exploitation, and/ or mistreatment. The findings included: 1. Record review of Resident #34's admission record dated 01/24/2024 revealed an admission date of 12/11/2023 with diagnoses which included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A record review of Resident #34's admission MDS assessment, dated 12/11/2023, revealed Resident #34 was a [AGE] year-old male admitted for long term care and could not be assessed with a BIMS due to cognitive impairment. A record review of Resident #34's care plan dated 1/23/2024, revealed, Problem: (Resident #34) has an ADL self-care performance deficit r/t Impaired balance, impaired vision, behaviors. Known to resist care .TRANSFER: The resident requires total assistance by 2 staff to move between surfaces. May use (brand name) lift when uncooperative .Revision on: 11/17/2023 .Encourage the resident to participate to the fullest extent possible with each interaction . A record review on 01/12/2024 of the Texas Unified License Information Portal website, accessed 01/24/2024, revealed no facility related report for Resident #34's allegations of neglect and/or mistreatment for the allegations made on 11/21/2023 and 11/22/2023. A record review of the facility's in-service record, dated 11/22/2023, revealed 15 nursing staff were inserviced specifically for resident #34 for Topic: Resident #34; contents or summary of training session: When providing care for Resident #34 we should be mindful. staff should always communicate what they are doing when providing care. there must be two staff members when transferring resident #34 (gate belt or lift transfer). if resident is agitated allow him time to calm down. let the nurse know so she can assist with care if needed. all residents must be turned and repositioned every two hours. incontinent care should be given at this time During an interview on 01/23/24 at 02:48 PM Resident #34's Representative stated on Sunday 11/19/2023 Resident #34 was ambulating in his wheelchair without any complaints of pain. Resident #34's Representative stated on 11/20/2023 Resident #34 was complaining of pain with transfers from bed to wheelchair. Resident #34's Representative stated Resident #34 had a camera in his room. Resident #34's representative stated she reviewed the camera recordings and discovered an unidentified CNA was attending to Resident #34 around 08:45 PM on Sunday 11/19/2023 and was forcing Resident #34 from his wheelchair to his bed while Resident #34 was refusing and calling out in pain. Resident #34's Representative stated she reported the mistreatment to the facility's Physical Therapy Director on Tuesday morning 11/21/2023 and further reported to the Administrator and the DON with an email on 11/22/2023 at 12:33 PM. Resident #34's Representative stated the DON replied with an email, on 11/22/2023 at 12:47 PM, and stated she would look into the issues and in-service the staff. A record review of the email provided by Resident #34's Representative, dated 11/22/2023 at 12:33 PM sent to the DON and the Administrator, revealed, Sunday 11/19 at 7 pm (Resident #34) Room (***) (Resident #34) and the aide had a very rough time with just a one person transfer where he hit his femur area on his right leg with the wheelchair arm. This was not safe for her either as she was struggling to get (Resident #34) in position to transfer. (Resident #34) has osteoporosis and is susceptible to fractures easily. Please provide two people for his bed transfers for the safety of the aide and for (Resident #34). After she did finally get him in bed she didn't check his diaper. He had been changed at 4:30 pm before supper and was not changed then until 4:30 am. He went 12 hours without a diaper change and was not turned every two hours as he should have been for circulation and hygienic purposes. He didn't receive his breathing treatments as ordered on Sunday as well. He needs to receive his breathing treatments with assistance three times a day during waking hours. Sent from my (name brand cell phone). A record review of the email provided by Resident #34's Representative, dated 11/22/2023 at 12:47 PM sent by the DON and received by Resident #34's Representative and the administrator, revealed, Thanks, (Resident #34's Representative) I will look into these issues and inservice staff. During an interview on 01/24/2024 at 10:26 AM The Physical Therapy Director stated his training was to report allegations of abuse, neglect, and exploitation to the abuse, neglect, and exploitation prevention coordinator who was also the Administrator. The Physical Therapy Director stated he assessed Resident #34 on Sunday 11/19/2023 without any complaints of pain with ambulation in his wheelchair. The Physical Therapy Director stated on Monday 11/20/2023 Resident #34 had pain with transfers and wheelchair ambulation. The Physical Therapy Director stated Resident #34's Representative had reported to him, on the morning of Tuesday 11/21/2023, a review of the in-room camera footage on the evening of Sunday 11/19/2023 revealed an unidentified CNA was rough with Resident #34 while transferring Resident #34 from his wheelchair to his bed. The Physical Therapy Director stated he reported the allegation of mistreatment to the Administrator during the 08:30 AM stand-up meeting on Tuesday 11/21/2023, the Physical Therapy Director stated the meeting included the Social Worker, The DON and the Administrator. The Physical Therapy Director stated he had not documented a grievance report nor reported the allegation to the state agency since he reported the complaint to the Administrator. During an interview on 11/24/2024 at 01:38 PM the DON stated she could not recall the stand-up meeting on 11/21/2023 but could state if an allegation of mistreatment was identified at the meeting it would have been acted upon at a minimum with a documented grievance report with a follow up investigation and report to the state agency. The DON stated she had received a complaint about Resident #34 on 11/22/2023 from Resident #34's representative and documented the complaint on a grievance report. The DON stated she had also provided additional training for the nursing staff regarding transfers and respiratory treatments. The DON stated she had not reported the allegations of neglect and or mistreatment to the state agency. The DON stated the Administrator was aware of the complaint regarding Resident #34. During an interview on 11/26/2023 at 04:30 PM the Administrator stated he could not recall the stand-up meeting on 11/21/2023 and/ or the complaint from Resident #34's Representative but could state if an allegation of mistreatment was identified it would have been acted upon at a minimum with a documented grievance report with a follow up investigation and report to the state agency. The Administrator was asked if an allegation of a CNA was rough with a Resident during transfers, allegation a Resident did not receive medications, and/or an allegation of neglect to provide incontinent care or hygiene care became known to him would it rise to the level of reporting the allegation to the state agency, the Administrator stated it would depend on the details and circumstances. 2. Record review of Resident #10's admission record dated 01/24/2024 revealed an admission date of 11/20/2023 with diagnoses which included hypokalemia (a lower than normal potassium level in your bloodstream) and Gastro-esophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). A record review of Resident #10's admission MDS assessment, dated 11/20/2023, revealed Resident #10 was a [AGE] year-old female admitted for long term care and was assessed with a BIMS score of 15 out of a possible 15 which indicated no cognition impairment. A record review of Resident #10's care plan dated 1/23/2024, revealed, Problem: (Resident #10) has a potential nutritional problem r/t new admission, recent hospital stay, Obesity, vascular disorder of intestine. Diet: Low Fat - Reg with no fried food and gravies diet Regular texture, Regular Liquids consistency, NAS---large protein portions at all meal Snacks BID (twice a day) .Revision on: 12/06/2023 .The resident will maintain adequate nutritional status as evidenced by maintaining weight, no s/sx of malnutrition, and consuming meals daily through review date A record review of Resident #10's grievance report dated 12/10/2023 revealed, (Resident #10) .12/05/2023 .name of person contacted: DON .nature of complaint: Staff concerned because CNA's slid a residents snack down the hall on the floor .date resolved .spoke to CNA involved - stated this will not happen again .signature of person resolving concern/grievance DON Further review revealed the Administrator signed the grievance form on 12/15/2023. A record review on 01/12/2024 of the Texas Unified License Information Portal website, accessed 01/24/2024, revealed no facility related report for Resident #10's allegations of abuse and/or mistreatment for the allegations made on Resident #10's grievance report dated 12/10/2023. 3. Record review of Resident #1's admission record dated 01/26/2024 revealed an admission date of 08/23/2023 with diagnoses which included Gastro-esophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). A record review of Resident #1's quarterly MDS assessment, dated 12/18/2023, revealed Resident #1 was a [AGE] year-old male admitted for long term care and was assessed with a BIMS score of 10 out of a possible 15 which indicated mild cognition impairment. A record review of Resident #1's care plan dated 1/23/2024, revealed, Problem: (Resident #1) has a potential for dehydration related to episodes of nausea and vomiting A record review of Resident #1's grievance report dated 12/13/2023 revealed, (Resident #1) .12/13/2023 .name of person contacted: DON .nature of complaint: it was reported to the social worker that the Resident threw up and it remained in his room for several hours before being cleaned up .date resolved 12/15/2023 .spoke to spoke to the nurse regarding this and how she should have taken care of this and how to deal with this in the future .signature of person resolving concern/grievance DON Further review revealed the Administrator signed the grievance form on 12/15/2023. A record review on 01/12/2024 of the Texas Unified License Information Portal website, accessed 01/24/2024, revealed no facility related report for Resident #1's allegations of neglect for the allegations made on Resident #1's grievance report dated 12/13/2023.4 . Record review of Resident #7's admission record dated 01/24/2024 revealed an admission date of 11/18/2023 with diagnoses which included dysphagia (Difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage) and Gastro-esophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). 4. A record review of Resident #7's admission MDS assessment, dated 11/20/2023, revealed Resident #7 was a [AGE] year-old female admitted for long term care and was assessed with a BIMS score of 03 out of a possible 15 which indicated severe cognition impairment. A record review of Resident #7's care plan dated 1/23/2024, revealed, Problem: (Resident #7) is at risk for complications due to GERD and hx (history) of Gastrointestinal hemorrhage .The resident will remain free from discomfort, complications or s/symptoms (signs and symptoms) related to dx (diagnosis) of GERD through review date .Avoid lying down for at least 1 hour after eating. Keep HOB elevated. Encourage to stand/sit upright after meals A record review of Resident #7's grievance report dated 12/18/2023 revealed, (Resident #7) .12/18/2023 .name of person contacted: DON .nature of complaint: Resident was not up for breakfast per ST (Speech Therapist) .date resolved 12/19/2023 . this was discussed with (the physical therapist regional supervisor) plan was to have therapy assist with out of bed transfer if short handed .signature of person resolving concern/grievance DON Further review revealed the Administrator signed the grievance form on 12/19/2023. A record review on 01/12/2024 of the Texas Unified License Information Portal website, accessed 01/24/2024, revealed no facility related report for Resident #7's allegations of neglect and/or mistreatment for the allegations made on Resident #7's grievance report dated 12/18/2023. A record review of the facility's Abuse, Neglect, and Exploitation policy dated 8/15/2022, revealed, it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .'neglect' means failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . reporting response the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, . within required time frames: immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury .

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, in that: 1. There was a paper bag containing personal food items from an unapproved source on a cart in the kitchen. 2. [NAME] A had facial hair and was not wearing a facial hair restraint while engaged in food preparation and service in the kitchen. 3. [NAME] B wore jewelry on her right wrist while engaged in food preparation and service in the kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 01/23/2023 at 11:20 AM in the kitchen next to the steam table revealed a white paper bag on a rolling cart. The bag was open and inside were a container of French fries and a wrapped sandwich. Next to the paper bag was a closed disposable cup filled with a beverage. During an interview on 01/23/2023 at 11:21 AM with [NAME] A he stated the bag containing the French fries and sandwich and disposable cup with the beverage were his personal food items and did not come from the facility's food supplier. [NAME] A further stated he forgot to store the bag in the proper place and it should not have been on a cart in the middle of the kitchen. Interview on 01/23/2023 at 11:22 AM with the DM revealed [NAME] A should not have had his personal food items in the kitchen. 2. Observation on 01/23/2023 at 11:22 AM in the kitchen revealed [NAME] A stood in front of the steam table using serving utensils to place food onto plates for the residents' noon meal. [NAME] A had facial hair on his upper lip approximately 1 in length and hair on is chin that was approximately 1 in length. [NAME] A was not wearing a facial hair restraint. During an interview on 01/23/2023 at 11:23 AM with [NAME] A he stated he knew he should have worn a facial hair restraint over his mustache and beard but, They didn't have any. During an interview on 01/23/2023 at 11:23 AM with the DM she stated [NAME] A could have used the type of hair net used to cover hair on one's head for his facial hair. The DM further stated that [NAME] A received training on employee sanitation upon his hire and she and the consultant RD conducted training on a monthly basis. 3. Observation on 01/23/2023 at 11:54 AM in the kitchen revealed [NAME] B wore a bracelet made of colored strings and beads on her right wrist. [NAME] B was standing in front of the steam table where food was being plated for the residents' noon meal. During an interview on 01/23/2023 at 11:54 AM with [NAME] B she stated the consultant RD told her it was okay to wear the bracelet in the kitchen. During an interview on 01/23/2023 at 1:05 PM with the consultant RD, he stated he never told [NAME] B she could wear a bracelet in the kitchen. The consultant RD further stated he conducted inservices frequently with the staff in the dietary department on employee hygiene. Record review of facility policy 03.002 Food Deliveries approved 10/01/2018 revealed, 1. All foods delivered will be from an approved source, which includes commercial vendors and grocery stores. Record review of facility policy 04.001 Employee Sanitation approved 10/01/2018 revealed, b. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. f. No jewelry can be worn on the arms and hands while preparing food except for a single plain ring such as a wedding band. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 2-401.11, revealed, Eating, Drinking or Using Tobacco Products. (A) Except as specified in (B) of this section, an employee shall eat, drink, or use any form of tobacco products only in designated areas where the contamination of exposed food; clean equipment, utensils, and linens; unwrapped single-service and single-use articles; or other items needing protection cannot result. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 2-402.11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-303.11 Jewelry Prohibition. Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 3 residents (Resident #1) reviewed for infection control, in that: CNA A did not wash or sanitize her hands between change of gloves during incontinent care for Resident #1. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 1 .Record review of Resident 1's face sheet, dated 11/28/2023, revealed an admission date of 11/26/2016 and, a readmission date of 08/21/2023, with diagnoses which included: Dementia (decline in cognitive abilities), Anemia (Blood disorder in which the blood has a reduced ability to carry oxygen), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Hypertension (High blood pressure) and, Bipolar disorder (Mental disorder characterized by periods of depression and periods of abnormally elevated mood). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 99, she was coded as having severe impairment and memory problems. Resident #1 required extensive assistance and was always incontinent of bowel and bladder. Review of Resident #1's care plan dated 08/19/2021 revealed a problem of Resident #1 has FUNCTIONAL bladder incontinence r/t (related to) impaired cognition and impaired mobility with an intervention of Monitor/document for s/sx (signs and symptoms)UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 11/30.2023 at 1:15 p.m. revealed, while providing incontinent care for Resident #1, CNA A, after cleaning the genital area and front of Resident #1, changed her gloves but did not sanitize or wash her hands before putting new gloves on. CNA A changed her gloves after she finished cleaning the resident's buttocks but did not sanitize or wash her hands. During an interview with CNA A on 11/30/2023 at 1:30 p.m., CNA A verbally confirmed she should have washed or sanitized her hands between change of gloves but forgot. She confirmed the staff received infection control training. Review of CNA A's CNA orientation skills checklist, dated 01/11/2023, revealed she met proficiency in infection control and incontinent care. During an interview with the DON on 11/30/2023 at 5:30 p.m., the DON confirmed the staff should have washed or sanitized her hands between change of gloves. The DON confirmed the staff received training on infection control. The facility did annual skill checklists with the staff. The ADON did spot checks on different staff to check their knowledge and skills. Review of the facility policy titled, Perineal care, dated 10/24/2022, revealed 16. Remove gloves and discard. Perform hand hygiene. Review of the facility's Incontinent care proficiency checklist, undated, revealed Use hand gel between glove changes. If heavily soiled, wash hands with soap and water.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system that relayed the call directly to a staff member or a centralized staff work area for 1 of 24 resident (Resident # 61) reviewed for resident call systems, in that: The facility failed to ensure (Resident #61) had a call light within reach This failure could have placed residents at risk of being unable to obtain assistance when needed. The findings were: A record review of Resident #61's face sheet, dated 11/08/22, revealed an admission date of 11/02/2021, with a diagnosis that consists of Schizophrenia- which is a chronic, severe mental disorder that affects the way a person thinks, acts, and expresses emotions, perceives reality, and relates to others. Bipolar disorder- is a mental health condition that causes extreme mood swings that include emotional highs and lows, and Muscular atrophy- is the decrease in size and wasting of muscle tissue. Review of Resident #61''s baseline care plan dated 11/08/2022 revealed, Be sure the resident's call light is within reach. Record review of resident #61's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 02, which indicates the resident has Severe cognitive impact. Observation and interview on 11/08/2022 at 09:35 am revealed a call light on the floor, not at arm's length, while the patient was in her bed. LVN A confirmed she was the assigned nurse and that the call light was not within reach of the resident. She stated she did not know why the call light was not within reach of the resident but that the patient could have fallen or could have needed something and did not have a way to ask for assistance. Interview with ADON on 11/08/22 at 11:45 am confirmed that the call light for resident # 61 was not at arm's length. She stated resident risked needing something and did not have the means to ask for assistance. Interview with DON on 11/08/2022 at 1: 35 PM, she stated call light should always be within the patient's reach. She stated the resident suffered no harm by not having a call light within reach but risked needing assistance and not having means of letting anyone know. Interview with the resident on 11/08/2022 at 1:40 PM resident # 61 stated, I don't know why they leave my call light so far from me; what if I need to call for help. Record review of the facility's policy titled Call Lights: Accessibility, Implemented 10/13/2022, revealed, Staff will ensure the call light is within reach of resident and secured as needed.

Based on observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food service safety, in that: 1. A one-gallon jar of dill pickle relish in the walk-in cooler was undated. 2. A 5 lb container of tuna in the walk-in cooler was undated. 3. A 5 lb container of chicken salad in the walk-in cooler was undated. 4. A 2 x 3 foot vent unit in the food storage unit was covered with dust and dirt particles 5. Two vents measuring 2 x 3 feet in the main dining room next to the kitchen entry door were covered with dust and dirt particles. These deficient practices could place residents at risk of consuming spoiled food and maintained an unsafe food sanitation environment. Findings included: Observation in the kitchen on 11/08/22 from 8:40 a.m. through 9:15 a.m. revealed a one- gallon jar of dill pickle relish, a 5 lb container of tuna, and a 5 lb container of chicken salad in the walk-in cooler which were undated; the 2 x3 foot wall vent in the kitchen food storage unit was covered with dust and dirt particles; the two wall vents measuring 2x3 feet in the main ding room next to the kitchen entry door were covered with dust and dirt particles. Interviews in the kitchen on 11/8/22 from 8:40 a.m. through 9:15 a.m. revealed the DM stated the one gallon jar of dill pickle relish, the 5 lb container of tuna, and the 5 lb container of chicken salad in the walk-in cooler should have been dated. She stated that containers that do not have a use-by date do not allow staff to determine if the food is still fresh to be served and that the containers would be immediately removed. The DM stated that the 2 x 3 foot wall vent in the food storage room was dirty and could allow dust to come into the food storage room. She stated that the two 2 x 3 foot wall vents in the dining room next to the kitchen door were dirty and could allow dust to come into the dining room. She stated that she would notify the MS immediately to clean the vents. Interview in the kitchen on 11/8/22 from 12:00 p.m. through 12:15 p.m. with the MS and the Regional MS. They stated that the 2 x3 foot wall vent in the kitchen food storage room was dirty and needed to be cleaned which was already done; they stated that the two 2 x 3 foot wall vents in the dining room next to the kitchen door were also dirty and needed to be cleaned and this cleaning process was underway. They stated that the kitchen vent cleaning is the responsibility of the maintenance dept. and the facility used the TELS electronic work order system (an electronic computer system that be used to reqest work repairs ) to notify the maintenance dept of needed repairs. Record review of Nutrition and Food Service Policies and Procedures Manual approved in 2018 stated in section 3-4 that all refrigerated foods are to be dated and labeled; it stated in section 4-5 that non-food-contact services of equipment are to be cleaned as necessary to keep them free of dust and dirt particles. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (A) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Record review of the facility's undated work order request policy stated that staff can submit work order requests for needed repairs.

Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program as set forth at § 483.75. for 18 of 23 staff (Administrator, DON, ADON B, SW, DM, AD, LVN C, LVN D, LVN E, LVN F, CNA G, CNA H, CNA I, CNA J, CNA K, Receptionist L, DA M and CNA M) reviewed for training, in that: The facility failed to ensure that the Administrator, DON, ADON B, SW, DM, AD, LVN C, LVN D, LVN E, LVN F, CNA G, CNA H, CNA I, CNA J, CNA K, Receptionist L, DA M and CNA M had completed QAPI training This deficient practice could place residents at risk for injury or improper care due to lack of training. The findings were: 1. Record review of Staff Roster, undated, revealed the Administrator was hired on 04/25/2019 Record review of the Administrator's training record, undated, revealed no QAPI training. 2. Record review of Staff Roster, undated, revealed the DON was hired on 03/14/1975 Record review of the DON's training record, undated, revealed no QAPI training. 3. Record review of Staff Roster, undated, revealed ADON B was hired on 06/24/1988 Record review staff training record, undated, revealed no QAPI training. 4. Record review of Staff Roster, undated, revealed the SW was hired on 07/26/2021 Record review of SW's training record, undated, revealed no QAPI training. 5. Record review of Staff Roster, undated, revealed DM was hired on 07/22/2008 Record review of DM's training record, undated, revealed no QAPI training. 6. Record review of Staff Roster, undated, revealed the AD was hired on 05/30/1989 Record review of AD's training record, undated, revealed no QAPI training. 7. Record review of Staff Roster, undated, revealed LVN C was hired on 01/29/2019 Record review of LVN C's training record, undated, revealed no QAPI training. 8. Record review of Staff Roster, undated, LVN D was hired on 11/22/1993 Record review of LVN D's training record, undated, revealed no QAPI training. 9. Record review of Staff Roster, undated, revealed LVN E was hired on 11/01/2019 Record review of LVN E's training record, undated, revealed no QAPI training. 10. Record review of Staff Roster, undated, revealed LVN F was hired on 11/30/2011 Record review of LVN F's training record, undated, revealed no QAPI training. 11. Record review of Staff Roster, undated, revealed CNA G was hired on 12/29/2017 Record review of CNA G's training record, undated, revealed no QAPI training. 12. Record review of Staff Roster, undated, revealed CNA H was hired on 06/04/2015 Record review of CNA H's training record, undated, revealed no QAPI training. 13. Record review of Staff Roster, undated, revealed CNA I was hired on 10/14/2021 Record review of CNA I's training record, undated, revealed no QAPI training. 14. Record review of Staff Roster, undated, revealed CNA J was hired on 02/22/2012 Record review of CNA J's training record, undated, revealed no QAPI training. 15. Record review of Staff Roster, undated, revealed CNA K was hired on 08/26/2021 Record review of CNA K's training record, undated, revealed no QAPI training. 16. Record review of Staff Roster, undated, revealed Receptionist L was hired on 09/02/2021 Record review of Receptionist L's training record, undated, revealed no QAPI training. 17. Record review of Staff Roster, undated, revealed DA M was hired on 10/15/2021 Record review of DA M's training record, undated, revealed no QAPI training. 18. Record review of Staff Roster, undated, revealed CNA N was hired on 10/14/2021 Record review of CNA N's training record, undated, revealed no QAPI training. During an interview on 11/11/2022 at 2:39 p.m., HR stated she was not aware it was a requirement for staff to complete QAPI training. She also stated their corporate office was responsible for assigning a staff member's required training in the online training website. HR further stated that staff were only able to complete courses that are selected for that specific staff member to complete in the online training website. HR stated the potential for harm to residents was staff not knowing what to do, procedure wise, for abuse. During an interview on 11/11/2022 at 2:39 p.m., the Administrator stated he was not aware QAPI training was required for staff. He also stated that their corporate office was responsible for adding the correct courses for a specific staff member in the online training website. The Administrator was not aware of a potential harm to residents by staff not having completed this training. Per email sent on 11/15/2022 at 7:44 p.m., the Administrator stated the facility did not have a policy for QAPI training.