**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental, and psychosocial needs for 3 of 24 residents reviewed for care plans. (Residents #28, #42, & #87) The facility did not include interventions and goals for Resident #28's hospice care plan. The facility did not have a care plan to address Resident #42's use of Trazadone. The facility did not have a care plan to address that Resident #87 was PASRR positive and refusing services. These failures could place residents at risk of not having their individual needs met and not receiving needed services. Findings included: 1. Record review of a face sheet dated 12/18/24 indicated Resident #28 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included cerebral infarct (stroke). Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #28 had a BIMS score of 14 indicating cognitively intact and indicated she received hospice care. Record review of physician''s orders dated 12/18/24 indicated Resident #28 was admitted to hospice services as of 08/23/24 for diagnoses of cerebral infarct. Record review of Resident #28''s care plans printed 12/18/24 indicated Resident #28 required hospice services but did not include any goals or interventions related to the hospice services. During an observation on 12/16/24 at 09:30 a.m., Resident #28 was lying in bed, she said she was treated well but was unsure if she received hospice services. 2. Record review of a face sheet dated 12/16/24 indicated Resident #42 was a [AGE] year-old male admitted on [DATE]. Her diagnoses included depression (a mental health condition that can affect how a person thinks, feels, and behaves). Record review of the most recent admission MDS assessment dated [DATE] indicated Resident #42 had a BIMS score of 10 indicating moderately impaired of cognition with no mood symptoms in the last 14 days and no behavior symptoms in the last 7 days. Record review of physician''s orders dated 12/18/24 indicated Resident #42 was prescribed trazadone 50 mg at bedtime for depression with a start date of 11/19/24. Record review of Resident #42''s December 2024 MAR indicated she received trazadone 50 mg daily at bedtime for depression with a start date of 11/19/24. Record review of Resident #42's care plans printed 12/17/24 did not indicate Resident #5 received the antidepressant medication trazadone. During an observation 12/17/24 at 09:54 a.m., Resident #42 was lying in bed, he said he was unsure of what medications he received. 3. Record review of a face sheet indicated Resident #87 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs) and major depressive disorder (a serious mental illness that affects how people feel, think, and act). Record review of a PASRR (Preadmission Screening and Resident Review) level 1 Screening dated 3/5/24 indicated Resident #87 was PASRR positive due to a mental illness. Record review of an annual MDS assessment dated [DATE] indicated Resident #87 had a BIMS score of 13 indicating her cognition with intact and she was currently by state level II PASRR process to have serious mental illness. Record review of a quarterly PASRR Comprehensive Service Plan (PCSP) dated 09/05/24 indicated Resident #87 was refusing PASRR services. Record review of a care plan last updated 09/20/24 indicated Resident #87 had no care plan identifying she was PASRR positive and was refusing PASRR services. During an interview on 12/17/24 at 9:57 a.m., Resident #87 said she felt well balanced and good at the facility. She said she was receiving psychiatric services. She said she didn't need other services and had refused services offered in the PASRR meetings. During an interview on 12/18/24 at 10:48 a.m., LVN C said she was providing care for Resident #28 and #42 on 12/18/24. She said Resident #28 received hospice services and should have been care planned for the hospice services with goals and interventions and was not. She said Resident #42 received trazadone daily and should have been care planned for trazadone and was not. LVN C said the Unit Managers were responsible for care plans. During an interview on 12/18/24 at 10:50 a.m., Unit Manager A said she was responsible for care planning Resident #28's hospice goals and interventions. She said the goals and interventions should have been care planned but were not. Unit Manager A said she was responsible for care planning Resident #42's trazadone. She said it should have been care planned but was not. She said they were overlooked. Unit Manager A said she was educated on care plans and was aware to care plan the hospice goals and interventions and the antidepressant medication. She said the resident risk of Resident #28 not care planned for her goals and interventions for hospice and Resident #42's antidepressant medication was the nurses could be unaware of the care and services the resident's received. During an interview on 12/18/24 at 11:08 a.m., MDS Nurse D said she was responsible for writing PASRR care plans. She said Resident #87 qualified for PASRR services but was refusing the services. She said the resident should have a care plan to address that she was PASRR positive, refused PASRR services, and quarterly meetings were being held to offer services and document Resident #87's refusal. She said she just overlooked writing a PASRR care plan because the resident was not receiving PASRR services. She said she had received PASRR training through HHSC, her corporate office, and webinars. She said a possible negative outcome of not having a PASRR care plan was staff would not be aware Resident #87 was PASRR positive, refused services, and the quarterly meetings held. During an interview on 12/18/24 at 11:18 a.m., the DON said she and other nursing administration were responsible for overseeing care plans and nursing administration met quarterly to review care plans for accuracy. She said the nursing staff were educated on accuracy and completeness of care plans. She said the missed care plans were overlooked. The DON said the resident risk of missed care plans was the potential risk of the nurses being unaware of the resident plan of care. She said she expected all care plans to be updated and completed timely. During an interview on 12/18/24 at 11:22 a.m., the Administrator said nursing was responsible for completed care plans. He said the staff were educated on care planning. The Administrator said the resident risk of services or medication not care- planned was potentially the nurses may not know the plan of care. He said he expected all care plans to be completed timely and accurately. Record review of a facility policy titled Care Plans, Comprehensive Person-Centered revised March 2022 indicated . The comprehensive person-centered care plan: a. includes measurable objectives and time frames; B. describes the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASRR recommendations; and (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice and problem areas and conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure LVN A did not verbally abuse Resident #1 when she yelled, screamed, and made intimidating remarks at the resident on 12/05/2023. This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse. Findings included: Record review of Resident #1's face sheet, dated 11/11/2024, indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia (loss of cognitive functioning), transverse myelitis (is a rare, acquired focal inflammatory disorder often presenting with rapid onset weakness, sensory deficits, and bowel/bladder dysfunction), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), calculus of kidney (kidney stones - hard deposits made of minerals and salts that form inside your kidneys), hypertension (a condition in which the force of the blood against the artery walls is too high), atherosclerotic heart disease of native coronary artery (a condition where the blood vessels become narrowed and hardened due to buildup of fats in the blood vessel wall), and history of falls. Record review of Resident #1's quarterly MDS Assessment, dated 12/06/2023, indicated he was usually able to make himself understood and usually understood others. He had moderate difficulty hearing. He had moderate cognitive impairment, identified with a BIMS score of 8. Record review of Resident #1's care plan, effective on 08/10/2022, indicated the resident was at risk for falls and had a fall 12/05/2023. The interventions included placed call bed/light within easy reach and keep areas free of obstruction to reduce the risk of falls or injuries. The resident had potential risk for injury due to unsafe independent transfer as identified by the nursing/rehab assessment. The interventions include educate patient/responsible party on proper lift/transfer; patient to transfer with assistance of two or more and use of gait belt or stand aid; if staff feels the transfer technique is in appropriate, notify supervisor immediately to determine a safe and appropriate manner of transfer; notify the DON/physician and responsible party of any incident involving transfers; and encourage patient to requested needed assistance in all transfers and keep call light in reach. Record review of Resident #1 progress note dated 12/05/2023 at 5:21 p.m. authored by LVN A indicated Resident #1 sitting on floor at foot of bed, no apparent injury noted or voiced. IV team here to put in IV to left upper arm. Record review of the Incident Self Report, dated 12/05/2023, indicated Resident #1 was verbally abused by LVN A speaking to him in a verbally abusive tone. During the investigation, a witness interview with LVN B corroborated the statement. Assessment of Resident #1 showed no signs of physical injury or emotional distress. Record review of a Facility Investigation Report, dated 12/05/2023, indicated the incident was reported on 12/05/2023 and occurred between 5:00 p.m. and 5:30 p.m. on 12/05/2023. LVN C provided head to toe assessment to Resident #1 on 12/05/2023 indicating no signs of physical injury or emotional distress. The Administrator and DON interviewed Resident #1 individually as part of the facility investigation and he reported feeling safe at the facility. The investigation summary confirmed (and witnessed) verbal abuse. LVN A's employment was terminated effective immediately. Provider action taken post investigation was continued education and in service on prevention of abuse and neglect. The alleged perpetrator (LVN A) was placed on suspension during the investigation and terminated during the investigation process. Facility staff were in-serviced on Abuse Neglect and Resident Rights. During an interview on 11/11/2024 at 1:45 p.m., LVN B said he was working on 12/05/2023 and was requested to assist LVN A to get Resident #1 off the floor after a fall. LVN B said when he entered the room, LVN A was already in the room standing near Resident #1 and he heard LVN A say, he should be restrained to the bed, and he had fallen multiple times today. LVN B said that during the transfer Resident #1 appeared upset with LVN A and he tried to speak calmly to the resident. LVN B said while transferring Resident #1 back to bed that Resident #1 and LVN A made negative statements like don't touch me, you are always grabbing your dick with those hand (s) and pervert, nasty person. LVN B said that during the transfer Resident #1 scratched LVN A and she said, hope I don't get an infection from the scratch from that nasty person. LVN B said that LVN A left the room, and he tried to calm Resident #1. LVN B said that another person (Outside Vendor X) was in the room and witnessed some of the incident. LVN B said Outside Vendor X started talking with Resident #1 and he seemed calmer, and she began providing care, so he (Vendor X) exited the room. LVN B said that he considered the incident as verbal abuse towards Resident #1 because LVN A was using verbal aggressive behaviors while caring for resident. LVN B said he reported the incident to the UM, DON, and the Administrator/AC and that the other person (Outside Vendor X) in the room had already reported the incident as well. During an interview on 11/12/2024 at 11:27 a.m., UM C said she recalled the incident between Resident #1 and LVN A, she said she was notified concurrently by DON and facility staff of the incident. UM C said she immediately returned to the facility and contacted LVN A prior to her arrival to facility and directed her to not provide any care to any residents and complete any unfinished documentation for her shift. UM C said she arrived at the facility in less than 30 minutes, briefly discussed allegation and suspended LVN A, took report, did medication cart count, and directed LVN A to leave the facility and told her she would be contacted during the investigation process. UM C said she took over the responsibilities of CN for LVN A. UM C said she immediately assessed Resident #1 and identified no injuries or distress. UM C said that during the follow-up assessment that Resident #1 was confused which was a preexisting issue, and he was unable to give details of the incident. During an interview on 11/12/2024 at 1:00 p.m., LVN A said she recalled the incident with Resident #1 on 12/05/2023 and said Outside Vendor X had reported to her that Resident #1 was on the floor. LVN A said she requested LVN B to assist her to get him up off the floor. LVN A said, the facility accused me of verbally abusing the resident, but I do not remember saying anything abusive. LVN A said [Resident #1] scratched her during the transfer, but she did not recall her response. LVN A questioned if she assessed resident after fall she said, I am sure I asked him if he was OK, but I don't recall. LVN A said [Resident #1] was known to pleasure himself or play with himself. LVN A said she was contacted by UM C immediately after the incident and was instructed to not perform any additional care on any residents, complete any charting and she would be at the facility shortly. LVN A said UM C arrived at the facility and briefly discussed with her the allegation of abuse and that she would need to leave the facility (suspended) until the investigation was completed. LVN A said the incident with Resident #1 occurred between 5:00 and 5:30 p.m. on 12/05/2024 and the UM C contacted her around 5:45 p.m. regarding the incident/allegation and told her not to provide any patient care and complete her current shift documentation. She said UM C arrived at the facility around 6:00 p.m. they completed report, and cart counts, and she completed her shift documentation and left the facility. LVN A said that she did not provide any care to any resident once she was directed by UM C not too. LVN A said she was contacted by the Administrator later that same day and terminated her for a confirmed allegation of abuse. LVN A said she was provided training by the facility regarding abuse and neglect during orientation and routinely. During an interview on 11/12/2024 at 1:30 p.m., the Administrator stated he was the abuse coordinator and abuse allegation between Resident #1 and LVN A was confirmed and witnessed. The Administrator said Resident #1 was hard of hearing and was unsure if he heard the verbal aggression by LVN A. The Administrator said he interviewed Resident #1 following the incident and he did not exhibit any signs of fear or distress. The Administrator said safe surveys were conducted with other residents on that hall and no other incidents were reported. The Administrator said the facility investigation confirmed verbal abuse and LVN A was suspended during the investigation process and terminated immediately with the confirmation of the allegation. The Administrator said resident abuse was not tolerated at the facility and confirmation of resident abuse was an immediate termination. The Administrator said the facility trained staff on abuse and neglect and management staff made rounds with residents to monitor for abuse. Attempts to interview Outside Vendor X were unsuccessful. Two attempts were made to reach her by telephone on 11/11/2024 at 10:00 a.m., 11/12/2024 at 7:23 a.m., and via email on 11/11/2024 at 7:31 p.m. No return call or email was received prior to exit. Record review of a statement from Outside Vendor X indicated Outside Vendor X said the purpose of this email is to report an incident concerning a patient and a nurse in your facility. I was called in for vascular access placement for [Resident #1]. Upon arrival 12/5/23 around 5:00 p.m. the patient was found on the ground asking for help. I immediately found the nurse [LVN A] and notified her of the patient being on the floor. [LVN A] proceeded to tell me It's the fifth time. We approached the patient's room to assist the patient to the bed. He was sitting on the ground with a wheelchair in front of him. [LVN A] moved the wheelchair as I turned the light on, and the patient screamed. [LVN A] screamed at the patient I did not hit you. (I did not witness if he was hit or not) she also told the patient You're getting on my last nerve. You need to be tied up, if this was the good old days, you'd be tied up already. As she is walking my way towards the door she states, 1'm not touching him with no gloves his hand is always on his dick. She proceeded to grab gloves from her cart and asked another nurse for assistance. As they were assisting the patient up to the bed the patient tried to hold on to the nurse for stability, but she started screaming Don't touch me! Do not touch me! while swinging arm to get loose from him. The patient expressed his anger as well. The patient was assisted on to the mattress. When [LVN A] and [LVN B] stepped out of the room the patient was upset and very apologetic to me about what had happened. He attempted to communicate about the nurse and said the word screaming but I am unaware if he was referring to this instance or a prior instance. His speech was delayed and not very clear but was understandable. I reassured him he had nothing to apologize for. He did not have any apparent injury. I am unaware of the patient's baseline. He complained of pain but was unable to communicate the location of pain. Bed was lowered and call light was given to patient as well as instructed to press call light and not to attempt getting out of bed himself. He was no longer upset when I was leaving at around 5:30 p.m. I notified [LVN A] I was leaving the facility. This incident has been reported to my chain of command as well as Texas Health and Human Services. Record review of employee time records indicated that UM C returned/ clocked in at 6:00 p.m. on 12/05/2023. LVN A clocked in at 12:50 p.m. and clocked out at 7:13 p.m. Record review of LVN A's employee file indicated she received training regarding abuse, neglect, and misappropriation of property during initial orientation on 7/12/2023. LVN A was suspended and terminated on 12/05/2023 for abuse allegation. Record review of the facility's Abuse Prohibition Protocol, dated August 2024, indicated The patient has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required in treating the patient's symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 15 residents (Resident #1 and #2) reviewed for infection control. 1. CNA A failed to wash or sanitize her hands or change gloves while performing incontinent care for Resident #1. 2. CNA D failed to wash or sanitize her hands or change gloves while performing incontinent care for Resident #2. These failures could place residents at risk of exposure to communicable diseases and infections. Findings include: 1. Record review of Resident #1's face sheet, dated 04/10/24, reflected a male who was admitted to the facility on [DATE], he was [AGE] years old, and his diagnoses included paraplegia (impairment in motor or sensory function of the lower extremities), flaccid neuropathic bladder (doesn't contract enough-leads to urinary retention or the inability to fully empty the bladder) and overactive bladder (muscles of the bladder start to tighten on their own even when the amount of urine in the bladder is low). Record review of Resident #1's quarterly MDS assessment, dated 01/23/24, reflected he was able to make himself understood and understood others, was cognitively intact (BIMS score of 13), utilized a wheelchair for mobility, had an indwelling catheter and was always incontinent of bowel. Record review of Resident #1's care plan, dated 08/07/23 reflected Resident #1 was at risk for infection related to indwelling catheter. Interventions included clean around catheter with soap and water or may use wipes as appropriate and report any sign of infection, wash hands before and after procedure. During an observation on 04/02/24 at 5:30 p.m., CNA A assisted by CNA B, performed incontinent care for Resident #1. CNA A and CNA B entered Resident #1's room, washed hands and put on gloves and gown (enhanced barrier precautions). CNA A explained care provided to Resident #1 and performed peri-care/indwelling catheter care by wiping Resident #1's penis and scrotum area with wipes and held the catheter tubing and wiped the catheter tubing. Resident #1 was incontinent of stool and the brief was soiled. CNA A then removed her gloves and put on a pair of new gloves without washing or sanitizing her hands. CNA A and CNA B rolled Resident #1 on his left side. CNA A took a wet wipe and wiped Resident #1's rectal area and removed stool. CNA A removed the used brief from underneath Resident #1 and placed it in the trash. CNA A then took a clean brief placed it under the resident, while wearing the same soiled gloves that were used to wipe the resident's rectal area and removed the old brief. CNA B commented to CNA A she should have changed her gloves. CNA A removed the soiled gloves, sanitized her hands, and placed on a pair of new gloves, then applied Vaseline to Resident #1's coccyx/buttocks area, CNAs A and B positioned Resident #1 on his back and fastened the brief. CNA A and CNA B positioned Resident #1 to a comfortable position. CNA A and CNA B removed their PPE, placed it in the trash and removed the trash from Resident #1's room upon exit. During interview on 04/02/24 at 5:45 p.m., CNA A said she was aware she should have changed her gloves after she wiped the resident's rectum and removed stool. She said the gloves were considered soiled. She said she should have washed or sanitized her hands and applied new clean gloves. During an interview on 04/10/24 at 9:40 a.m., CNA A said she was aware she should have changed her gloves and washed or sanitized her hands when she performed incontinent care for Resident #1. She said she was trained in orientation, on 03/12/24, and after the incident on 04/02/24 on infection control and incontinent care. 2. Record review of Resident #2's face sheet, dated 04/11/24, reflected a female who was admitted to the facility on [DATE], she was [AGE] year old, and her diagnoses included obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow )and dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Record review of Resident #2's quarterly MDS assessment, dated 02/22/24, reflected she was able to make herself understood and understood others, had moderate cognitive impairment (BIMS score of 11), utilized a walker and a wheelchair for mobility, had an indwelling catheter and was always incontinent of bowel. Record review of Resident #2's care plan 09/18/23 reflected Resident #2 was at risk for infection related to an indwelling catheter. Interventions included clean around catheter with soap and water or may use wipes as appropriate and report any sign of infection, wash hands before and after procedure. During an observation on 04/02/24 at 6:00 p.m., CNA D was assisted by CNA C and performed incontinent care for Resident #2. CNA D and CNA C entered Resident #2's room, washed hands and put on gloves and gowns (enhanced barrier precautions). CNA D explained care provided to Resident #2 and performed peri-care by wiping the Resident #2's peri area from top to bottom with wipes. CNA D then removed her gloves and washed/sanitized her hands and applied a new pair of gloves. CNA D used a wet wipe and wiped Resident #2's rectal area, then removed the old brief from underneath Resident #2 and placed it in the trash. CNA D then took a clean brief placed it under Resident #2, applied barrier cream, while wearing the same gloves that were used to remove the old brief. CNA D and CNA C positioned Resident #2 to a comfortable position. CNA D and CNA C removed their PPE, placed it in the trash and removed trash from room upon exit. During interview on 04/02/24 at 6:10 p.m., CNA D said she was aware she should have changed her gloves after she removed Resident #2's old brief. She said the gloves where considered soiled. She should have washed or sanitized her hands and applied new clean gloves. During interview on 04/02/24 at 6:12 p.m., CNA C said CNA D should have changed her gloves after she had removed Resident #2's old brief. During an interview on 04/10/24 at 9:15 a.m., the DON said staff should have changed gloves and performed hand hygiene per the facility's protocol for incontinent care. She said residents could be at risk of an infection if they did not wash or sanitize their hands when changing their gloves. She said staff were trained upon hire in orientation regarding the facility's protocol for incontinent care and as needed. Record review of the facility's, undated, Incontinent Care Skills Checklist reflected .9. Wash from front towards rectum, front to back, using clean stroke, repeat if necessary with a new wipe as all feces must be cleaned off. With a new wipe, cleanse the entire buttock area and surrounding hip area. Turn over surface of wipe to cleanse other side of buttock. 10. Wash and sanitize hands. Apply clean gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviewed, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically transmitted to the CMS System for 1 of 25 residents records reviewed for MDS assessments. (Residents #35) The facility did not ensure the discharge MDS assessment was completed and electronically transmitted as required for Resident #35. This failure could place residents at risk of not having their assessments transmitted timely. Findings included: Record review of Resident #35's admission record dated 10/25/23 indicated she was admitted on [DATE] with a discharge date of 06/26/23. Resident #35's diagnoses included joint replacement surgery. Record review of the MDSs for Resident #35 indicated the discharge MDS assessment was completed on 06/26/23. The discharge MDS assessment was marked current not transmitted or accepted. Record review of the nurse's notes from 06/16/23 to 06/26/23 indicated Resident #35 was discharged home on [DATE]. During an interview on 10/25/23 at 9:30 a.m., LVN C said she did not transmit Resident #35 discharge MDS assessment. She said she had received training on completing, preparing, signing and transmitting the MDS assessment to CMS. LVN C said Resident #35's MDS should have been sent so the resident records would be complete. During an interview on 10/25/23 at 9:45 a.m., the DON said when Resident #35 was discharged home, there should have been a discharge MDS completed and submitted. She said LVN C was responsible for transmitting and the used the RAI manual for the policy. During an interview on 10/25/23 at 10:00 a.m., the Administrator said he expected the discharge MDS assessments to be completed and transmitted. Review of the CMS's RAI Version 3.0 Manual obtained on 10/25/23 from the CMS website, https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_October_2023.pdf indicated the following: CMS's RAI Version 3.0 Manual indicated . Discharge Assessment refers to an assessment required on resident discharge from the facility, or when a resident's Medicare Part A stay ends, but the resident remains in the facility (unless it is an instance of an interrupted stay, as defined below). This assessment includes clinical items for quality monitoring as well as discharge tracking information. RAI OBRA-required Assessment Summary .Discharge Assessment - return not anticipated (Non-Comprehensive) A0310F = 10 discharge date + 14 calendar days .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 24 residents reviewed for indwelling catheters. (Resident #63) The facility failed to prevent Resident #63's urinary catheter drainage bag from touching the floor. This failure could place residents at risk for urinary tract infections. Findings included: Record review of physician orders dated 10/25/23 indicated Resident #63, admitted [DATE], was a [AGE] year-old male with a diagnosis of disorder of the urinary system. The resident had an indwelling urinary catheter (a catheter which is inserted into the bladder to drain urine). The resident had a history of urinary tract infections and was ordered a prophylactic antibiotic Macrobid 100 mg 1 tablet every day. Record review of the most recent MDS dated [DATE] indicated the resident had a urinary catheter in place. The assessment did not indicate Resident #63 had a urinary tract infection in the last 30 days but did indicate the resident had a diagnosis of obstructive uropathy (a disorder of the urinary tract that occurs due to obstructive flow). Record review of a care plan dated 06/07/21 to present indicated Resident #63 had an indwelling urinary catheter and was at risk for increased urinary tract infections. Hospice prophylactic antibiotic order: Macrobid 100 mg one tablet one time a day. The goal was Foley catheter will remain patent and [Resident #63] will not develop increased incidents of UTI's over the next 90 days. The interventions included catheter care, encourage fluids, change catheter per order and did not indicate to keep the urinary catheter bag or tubing off the floor. During the following observations, Resident #63's urinary catheter bag was secured to the left side of the bed and the bag was touching the floor mat beside the resident's bed: *10/23/23 at 10:17 a.m., *10/24/23 at 9:40 a.m., and *10/25/23 at 9:59 a.m. During observation and interview on 10/25/23 at 9:59 a.m., CNA A entered Resident #63's room to perform indwelling catheter care. The resident's catheter bag was touching the floor mat upon entrance. CNA A said Resident #63's catheter bag should not be touching the floor or the floor mat. She said germs could get into the catheter. She said she was responsible for making sure the bag was not touching the floor, but she did not notice the catheter bag was on the floor. During observation and interview on 10/25/23 10:02 a.m., LVN B said the indwelling catheter bag was touching the floor mat and should not be. She said all direct care staff were responsible for ensuring the urinary catheters were not touching the floor or floor mat. She said germs could travel up the catheter and cause infection. During an interview on 10/25/23 at 10:05 a.m., the DON said the indwelling urinary catheter bag should not be touching the floor or floor mat. She said the resident could be at increased risk of infection. She said her expectations were for the catheter bags to be kept off the floor. A Catheter Care policy updated March 2019 indicated: Responsibility: Licensed nurse and nursing assistant. Purpose: to prevent infection and prevent irritation. The policy did not indicate the indwelling catheter should be kept off the floor.

Based on record review and interview, the facility failed to ensure the arbitration agreement contained all the required elements for 1 of 1 facility reviewed for Arbitration Agreements. The facility did not ensure the arbitration agreement contained the required element of informing residents of their right to rescind in 30 calendar days of signing the agreement. This failure could place the residents or the residents' responsible parties in binding agreements not fully understood, cause a loss of their legal rights, and cause negative psychological issues. Findings included: During an interview and record review during the entrance conference on 10/23/23 at 8:30 a.m., the Administrator provided a copy of the facility's admission packet, and the binding Arbitration Agreement was included in the admission packet. The Arbitration Agreement did not include information on the right to rescind the agreement within 30 days of signing. During an interview on 10/24/23 at 4:00 p.m., the Administrator said the arbitration agreement in the admission packet did not include the information on the right to rescind the agreement within 30 calendar days of signing. The Administrator said the right to rescind the agreement within 30 calendar days of signing was to protect the resident's rights. He said the facility had 40 to 50 admissions in the last 30 days. Record review of undated admission Agreement, undated included: .page 23 ARBITRATION AGREEMENT In accordance with the provisions of the Federal Arbitration Act 9 . and in further consideration of the duties and obligations contracted for in the admission and financial Agreement, . the parties to the admission Agreement hereby understand and agree that any dispute, controversary or claims arising out of or relating to the admission Agreement, or the services performed thereunder, the breach thereof or any dispute in tort or in medical malpractice . shall be resolved through arbitration . By signing the admission Agreement, it is understood and agreed by the parties that the right to a jury or court trial . is waived.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed facility coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort for 1 of 3 residents (Resident #153) reviewed for PASRR. The facility failed to refer Resident #153 for PASRR Level II assessments after their PASARR listed them as having evidence or an indicator of Mental Illness. This failure could place all residents who had a mental illness at risk for not receiving needed assessment, care, and specialized services to meet their needs. Findings included: Record review of face sheet dated August 2022 indicated Resident #153, was admitted to the facility on [DATE] and was a [AGE] year-old female with diagnoses of schizophrenia (thoughts or experiences interpret reality abnormally) and Cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture). Record review of an admission MDS dated [DATE] indicated Resident #153 was currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition and Level II Preadmission Screening and Resident Review (PASRR Conditions of A. Serious mental illness; B. Intellectual Disability. Resident #153 had a BIMS of 1 out of 15 indicating severely impaired cognition and decision making and active diagnosis section indicated Neurological Cerebral Palsy and psychiatric/mood disorders of schizophrenia. Record review of a PASRR Level 1 (PL 1) screening dated 8/16/22 completed by MDS Nurse indicated Resident #153 did not have mental illness or developmental disability and was positive intellectual disability. During an interview on 8/23/22 at 12:10 p.m., the MDS Nurse indicated she was responsible for ensuring the PASRR Level 1 was completed accurately for Resident #153. She stated if a hospital incorrectly completed the PASRR 1 and a resident had a qualifying diagnosis, the admitting facility should submit a PL 1 correction so the resident could be evaluated for services. The MDS Nurse stated she was very familiar with the PASRR process as she had been trained on PASRR a year or two ago. She stated when someone was admitted from another nursing facility or hospital, she would input the PASRR information they provided. The MDS Nurse indicated she would call the local authority today, to seek further guidance and would be doing Form 1012 to correct the PASRR to include Resident #153's mental illness diagnosis of schizophrenia. The MDS Nurse said if a PL 1 was inaccurate the resident would need a correction form completed. After reviewing Resident #153's diagnosis the MDS Nurse stated Resident #153's was not screened correctly for PASRR 1, and she would re-screen the resident. The MDS Nurse said possible negative outcomes for inaccurate PASRR Level 1 could be that residents would not receive the specialized services they qualified for through PASRR if the PL 1 was not completed correctly. She said the DON was her supervisor who monitored the PASRRs for accuracy. During an interview on 8/23/22 at 12:53 p.m. the DON said her expectation was for all PL1's to be completed by policy, accurately and timely on all residents. She acknowledged Resident #153's PL 1 did not indicate a diagnosis of mental illness and should have. She said the MDS Nurse was responsible for completing all things PASRR the PL 1 correctly and uploading it into the portal on all residents and would use any clinical documentation of diagnosis to review for mental illness in completing the PL 1 assessment. The DON said she was educated on PASRR and had not been monitoring the admission PASRR process but would put a plan in place to start monitoring for accuracy. The DON said the risk of a resident not having a correct PL 1 completed would possibly be not receiving needed and deserved services. The DON stated facility had no policy on PASRR and the facility used HHSC guidelines on completing PL 1. Record review of an undated and untitled bulleted list included in part: PASRR is required of each state's Medicaid program to ensure that those with Mental Illness (MI0/Intellectual or Developmental Disability (IDD) are cared for properly .review PL1 for potential MI, DD or ID and if positive the Local Authority completes PL2 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 23 residents reviewed for care plans. (Resident #15) The facility did not care plan Resident #15 for diabetes (a high level of sugar in the blood) and insulin (a medication used to treat diabetes). This failure could place the residents at risk of not receiving care and services to maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included: Record review of physician orders dated August 2022 indicated Resident #15, admitted [DATE], was [AGE] years old with a diagnosis of diabetes. The orders indicated he was to receive Novolog insulin 100 units/ml two times a day per sliding scale (a scale amount of insulin administered that varies in accordance with the blood glucose reading [the main sugar found in your blood]) with a start date of 02/26/2022 and was to receive a diabetic snack every evening with a start date of 04/12/2022. Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #15 had a BIMS of 10 (mental status moderately impaired), had impaired vision (can see large print only), required extensive assistance for personal hygiene and had a diagnosis of diabetes. Record review of care plans dated 08/24/22 indicated Resident #15 did not have a care plan for diabetes and/or insulin. During an interview on 08/22/22 at 09:26 a.m., Resident #15 said he was diabetic and took insulin per sliding scale, when he needed it. He said recently his blood sugar levels had been good and he did not have to take insulin. During an interview on 08/24/22 at 1:32 p.m., the DON said Resident #15 did not have a care plan for insulin or diabetes and should have. She said her expectations were for the resident to be care planned for insulin and diabetes. She said the negative outcome of not having a care plan could be the staff would not know how to take care of the patient. She said the LVN unit manager (unit manager B) was responsible for making sure the care plans were completed. During an interview on 08/24/22 at 1:38 p.m., Unit manager B said Resident #15 had been a diabetic since he came from their sister facility years ago. She said it was her responsibility to complete the care plan for the resident, she had not completed the care plan for the resident's diabetes and insulin, however, she had gone into the system just a minute ago and put the care plan in his chart after surveyor intervention. She said he did need to be care planned for diabetes and insulin and the possible negative outcome could be the staff would not know he was on insulin or to monitor it. Review of the Patient Care Management System policy, titled Assessments, dated November 2017 indicated . 3. Upon admission each patient/resident's diagnoses must be reviewed with the physician to develop individualized care plan interventions, including the touchscreen daily care guide. The facility will use patient/resident observation, communication, family input and clinical history . 12. The monthly Quality Assurance and Performance Improvement Meeting must include a review of the timely completion and updating of care plans, timely completion of nursing assessment,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review, the facility failed to provide a therapeutic diet when ordered by the physician to maintain adequate nutritional status, to the extent possible to maintain acceptable parameters of nutritional status for 1 of 23 residents reviewed for weight loss. (Resident # 204) The facility did not ensure Resident #204 received a health shake three times a day as ordered by the physician. This failure could place the residents at risk for not receiving care and services to maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included: Record review of physician orders dated August 2022 indicated Resident #204, admitted [DATE], was [AGE] years old with a diagnosis of protein calorie malnutrition. The resident had an order for health shakes with meals one time a day, which the physician discontinued on 08/3/22 and there was a new order dated 08/3/22 for the resident to receive a health shake with meals three times a day. Record review of the admission MDS assessment dated [DATE] indicated Resident #204 had a BIMS score of 8 out of 15 (mental status moderately impaired), required supervision (encouragement or cueing) for eating, had a diagnosis of protein calorie malnutrition and was on a therapeutic diet. Record review of the care plan dated 08/24/22 indicated Resident #204 received a therapeutic diet. The goal was for the resident to have adequate nutrition and fluid intake over the next 90 days. Interventions indicated to serve diet as ordered and monitor intake. Record review of Resident #204's weight worksheet indicated the resident refused to be weighed on the admission date of 7/6/22. The resident weighed 95.8 lbs. on 07/12/22 and 92.2 lbs. on 08/15/22. Record review of Resident #204's breakfast meal ticket dated 08/24/22 indicated there was no documentation the resident had house shakes ordered. During an interview on 08/22/22 at 11:23 a.m., Resident #204 said she was admitted to the facility because she had weight loss. She said she just kept losing weight During observations of Resident #204's meal service, there was not a health shake on the resident's meal tray for the following dates/times: * 08/22/22 at 12:48 p.m. * 08/23/22 at 8:58 a.m.; and * 08/24/22 at 8:26 a.m. During an interview on 08/22/22 at 12:50 p.m. with LVN C when asked if Resident #204 was on supplements for weight loss, LVN C said the resident was on supplement pass three times a day, which was administered during medication pass. He said the resident had lost weight from 95 lbs to 92 lbs since admission. During observation and interview on 8/24/22 at 8:27 a.m., after observation of Resident #204's meal tray, LVN D said the resident did not have a house shake on her meal tray. She said the orders did indicate the resident was supposed to receive a health shake three times a day with meals. LVN D said the resident could continue to lose weight if she did not receive the health shakes as ordered. During an interview on 08/24/22 at 8:30 a.m. the ADON said Resident #204 should have received the health shakes three times a day as ordered. She said the negative outcome would be she could continue to lose weight if she did not receive the shakes. She said LVN D was the staff who wrote the order. She said at the time the order was written, Resident #204 was on Hall 300 where LVN D worked. She said if LVN D wrote the order, she would be the one who was responsible for delivering the order to the kitchen. She said her expectations were for the residents to receive their diet as ordered. During an interview and record review on 08/24/22 at 8:33 a.m., the DM said the house shakes do go to the residents from the kitchen. She said the nurse who writes the order brings the order to her and she puts the order in the computer so it can be implemented. After record review of Resident #204's meal ticket, she said the house shakes were not on the resident's ticket. The DM presented the resident's dietary order to the surveyor and said the resident did not have dietary orders for house shakes. She said the negative outcome of Resident #204 not receiving the house shakes as ordered would be the resident could possibly lose weight. During an interview on 08/24/22 at 8:54 a.m., LVN D said Resident #204 did have orders for health shakes three times a day. She said she did not remember if she had printed Resident #204's dietary order for the health shakes and/or sent them to the kitchen or not. She said once a dietary order was written it was supposed to be hand carried to the kitchen so they could add the new order to the resident's diet; it could not be sent electronically. She said the resident did not eat or drink well, so she got an order for health shakes. She said the negative outcome was the resident could continue to lose weight. During an interview on 08/24/22 at 8:57 a.m., the DON said when the orders were received for meals or health shakes, the order was supposed to be printed and walked to the kitchen. She said the nurse that took the order was responsible for writing the order and bringing it to the kitchen. She said her expectations were for the health shakes to be served to Resident #204 as ordered. She said the possible negative outcome would be the resident would lose weight. During an interview on 08/24/22 at 2:23 p.m., the corporate nurse said the facility did not have a specific policy related to following physician orders for nutrition/diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments for 1 of 23 residents (Resident #1) and permitted only authorized personnel reviewed for storage of medications. -The facility failed to ensure Resident #1 did not have medication, melatonin 10mg bottle at the bedside. This failure could place residents at risk for consuming unsafe medications and having access to unauthorized medication that could cause a decline in health status and possible drug diversion. The findings included: Record review of Resident #1's face sheet dated August 2022 indicated Resident #1, admitted [DATE], was a [AGE] year old male with diagnoses that included: gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach/esophagus), heart disease, hypertension (high blood pressure) and insomnia (a common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep). Record review of admission MDS ARD dated 8/16/22 indicated Resident #1 had clear speech, ability to understand and be understood by others, BIMS 9 of 15 indicating he had moderately impaired cognition. Record review of Resident #1's electronic record revealed there was no Care Plan addressing to keep medications at bedside and no care plan to self-administer medications. Further review of the electronic record inticated Resident #1 did not have a Self-Administration Medication Assessment initiated or completed for August 2022 Record review of resident #1's August 2022 physician orders indicated no orders for medication self-administration, Melatonin 10mg or to keep medications at bedside. Observation during initial tour, on 8/22/22 at 9:30 A.M. revealed Resident #1 was very hard of hearing, watching TV, sitting on a wheelchair in his room and the door was open. On his bedside table was an open and used bottle of Melatonin 10 mg tablets, with no pharmacy label. Observation on 8/22/22 at 11:30 A.M. revealed Resident #1 was watching TV, sitting on a wheelchair in his room and the door was open. On his bedside table remained the opened and used bottle of Melatonin 10 mg tablets, with no pharmacy label. In an interview and observation on 8/22/22 at 11:33 A.m. Resident #1 stated the Melatonin was his and he took 1 pill when he needed it to get to sleep. Resident #1 said he did not remember the last time he took it but believed it was some time last week. Resident stated he leaves the medication on his table in his room and he thought the nurses should be aware he had the medication because it was in plain eyesight on the bedside table and could be seen every time they walk in the room. He further stated he takes the Melatonin one-tablet at night for sleep but only when need it. Resident #1 stated his family member bought the medication for him, but he could not remember when or when was the last time he took it. Resident #1 said he did not need a doctor's order to take the medication because it was OTC over the counter and no doctor's prescription was necessary for it. On his bedside table was a Melatonin 10 mg bottle, opened and used with no pharmacy label. Observation and interview on 8/22/22 at 12:58 P.M. with LVN C indicated on Resident #1's bedside table was a Melatonin 10 mg bottle, opened and used with no pharmacy label. LVN C stated he did not know when the medication bottle came or who may have brought it in to Resident #1. LVN C said he was the staff person assigned to Resident #1 for medication administration and while looking at the electronic record for Resident #1 LVN stated he did not see an order for Melatonin or any other sleep aide. LVN C said he makes observations on things like safety, cleanliness, and odors every day on his assigned hall and had not seen any medication at the bedside. LVN C said he would have removed the Melatonin bottle, because medication at the bedside that was not locked up can be dangerous if residents use it the wrong way. LVN C left the room with the Melatonin 10 mg tablets remaining on Resident #1's bedside table. Observation and interview with the DON on 8/22/22 at 1:30 P.M. revealed on Resident #1's bedside table was medication Melatonin 10 mg. The DON stated the resident did not have any sleeping problems that she was aware of or being treated with any sleep aid medication. The DON said she teaches staff on orientation and as needed that medications could not be left out unattended at the resident's bedside and staff assigned to resident were to look for medications and remove them . The DON said her expectation was for nursing staff to follow facility policy and procedure and not leave medications at the bedside. The DON said residents would need a doctor's order and medication self-administration assessment completed before they could be able to keep meds at the bed side and administer themselves but none of the residents had any because it was not allowed in the facility. The DON revealed Resident #1 did not have an order for mediation Melatonin 10 mg or to leave medications at bedside and no self-administer medication assessment had been done for Resident #1. The DON said leaving medications at the bedside puts residents at risk of not taking properly or giving it to someone else to take. The DON stated she would make sure the medication was removed and the doctors called to see about getting an order to administer the Melatonin. Record review of facility policy Storage of Medications for patient that Self-Administer, dated March 2016 read in part: . Policy . Storage of medications for self-administration remains the responsibility of nursing staff. In accordance with state and federal laws, the facility must store all drugs in locked storage area and permit only authorized individuals to have access to the keys. Procedure: All medications for self-administration will be stored in the Facility's locked medication carts or other locked storage areas. Record review of facility policy Self-Administration of Medications dated March 2016 read in part: . Procedure: An Assessment for Self-Administration of Medications (see [NAME] Form CFS 1-14HH) must be completed on each Patient requesting to self-administer medications and quarterly thereafter. An Assessment for Self-Administration of Medications is kept with the Patient's medical record under the Assessment tab. If it has been determined the Patient is capable of self-administering his/her medications, a physician order must be obtained, a care plan formulated, and staff in-serviced .

Based on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure kitchen equipment was clean and staff used sanitary measures while preparing food. This failure could place the residents at risk of food borne illnesses. Findings included: During initial observations of the kitchen on 08/22/22 at 8:38 a.m., the following were noted: *There was a brown splattered substance on the surface area surrounding the coffee dispenser spigots; and *There was a buildup of black substance to the surrounding surface area of the juice dispenser spigots. During observation and interview on 08/22/22 at 8:40 a.m., the DM said the coffee and juice machines were not clean and she began wiping the surrounding area of the juice machine spigots off with a white towel she had in her hand. After wiping the juice machine, the white towel had a black substance smeared on it. The DM said the coffee and juice machines were dirty and should be kept clean. She said the possible negative outcome would be contamination. During an observation on 08/22/22 at 8:49 a.m., there were multiple wet, beige, and brown particles on the top front left of the dish machine down to the top back of the dish machine. The particles in the back under the electrical wiring were stuck to the top of the dish machine. During an interview on 8/23/22 at 8:52 a.m., the DM said the food from the dish machine splashed up on top of the dish machine when it was in use, and it needed to be cleaned. She said the staff dishwasher was responsible for making sure the dish machine was clean, but she was on vacation. She said it should be cleaned even when the staff dishwasher was out on leave. She said the staff persons who were responsible for keeping the coffee and juice machines clean were also out on either sick or on vacation at this time. She said the kitchen equipment should be kept clean according to the cleaning schedule to prevent contamination. During observation of the steam table preparation for the noon meal on 08/23/22 at 12:01 p.m., [NAME] A, without washing her hands, walked from the steam table, retrieved her personal thermal cup from a prep table, walked over to the facility ice machine and scooped up a cup of ice using her thermal cup, shut the door, and walked off. During an interview on 08/23/22 at 12:02 p.m., [NAME] A said she did not wash her hands and she should not have put her cup in the facility ice machine to retrieve the ice. She said she knew she was supposed to wash her hands and use the scoop to retrieve ice from the machine. When asked if she was trained on kitchen sanitation, she said she had been in food service for years and no one had to teach her that. She said the negative outcome would be cross contamination. During an observation and interview on 08/23/22 at 12:08 p.m., the DM said the cook knew better than to put her cup down in the ice machine. She said she would have to drain the ice machine and then she walked over and unplugged the machine. She said the staff should always wash their hands and use the scoop to retrieve ice and should not use their personal cups. She said the possible negative outcome would be contamination of the ice. She said she expected the staff to always use the scoop and to wash their hands before getting into the ice machine bin. Review of the cleaning schedule dated August 2022 indicated each day Monday through Sunday, there were 2 allotted spaces for kitchen staff to initial the coffee machine, juice machine and dish machine were cleaned. The dish machine column indicated there were no initials in 6 allotted spaces. The juice machine column indicated there were no initials in 7 allotted spaces. The coffee machine column indicated there were no initials in 37 allotted spaces. Review of the General Sanitation of Kitchen policy dated November 3, 2004 indicated: The staff shall maintain the sanitation of the kitchen through compliance with a written comprehensive cleaning schedule.