Avir At Citizens Trail

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the kitchen. During the initial tour with the Dietary Manager, surveyors observed two bags of frozen zucchini that were unlabeled and undated, three bags of frozen tater tots that were unlabeled, one bag of frozen steak fries that was unlabeled and undated, three frozen dish pie shells that were undated, three frozen chocolate creme pies that were undated, and one frozen pecan pie that was undated. The Dietary Manager identified these items during the observation. Surveyors also observed a brown buildup inside the microwave, brown buildup on the toaster, golden food crumbs on the inside surfaces of the deep fryer, and a thick gooey red substance on the juice machine spigot where juice was dispensed. A staff member's personal cell phone was charging next to the toaster, and a blue vitamin water was stored in the stand-alone refrigerator without a name or date. During interviews, Dietary staff and the Dietary Manager stated that food items should be labeled and dated, kitchen equipment should be cleaned after use or daily as applicable, personal drinks should be labeled and dated when stored in the walk-in cooler, and personal cell phones should be kept away from the work area.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain infection prevention and control practices during blood sugar checks for two residents. During an observation, RN A performed fingerstick blood sugar testing for one resident and placed the glucometer, lancet, test strip, and alcohol wipe on the resident’s dining table without using a barrier. After using the glucometer, RN A returned it to the medication cart without disinfecting it. During a second observation, RN A again placed blood sugar testing supplies on another resident’s dining table, pricked the resident’s finger, changed gloves without cleansing her hands or using hand sanitizer, and continued the blood sugar check. RN A stated she should have performed hand hygiene between glove changes and cleaned the glucometer between residents, and stated the practice was an infection control issue. The facility also failed to keep clean linen carts covered and medication carts clean. An uncovered linen cart on A wing contained sheets, pillowcases, gowns, underpads, blankets, briefs, and washcloths. Staff stated clean linen carts should always be covered when not in use and that all nursing staff were responsible for keeping the front flap down. In separate observations, brown gooey substances were noted in drawers of medication carts on wings C and A where liquid medications were stored. Staff stated nurses and MAs were responsible for keeping the carts cleaned, and that the carts should be cleaned whenever dirt was noticed or every shift. The facility further failed to ensure trash was handled properly and that enhanced barrier precautions were followed for a resident with a feeding tube. CNA F was observed placing clear trash bags from resident rooms into a black trash bag on the hallway floor on A wing, and stated she should not have placed trash bags on the floor. For Resident #3, who had dementia, was dependent for all ADLs, and had a gastrostomy tube, the order summary indicated enhanced barrier precautions were required for high-contact care. During observation, LVN L disconnected the resident’s feeding from the g-tube while wearing gloves but without a gown. LVN L stated she was not aware of the requirement for enhanced barrier precautions when accessing a feeding tube and did not remember receiving training on it.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement an infection prevention and control program that included antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 facility reviewed for antibiotic stewardship. Record review showed the facility's antibiotic tracking log had last been completed in July 2025, and the tracking logs for August 2025 and September 2025 were not completed. During an interview on 09/23/25, the DON stated the infection control logs for August 2025 and September 2025 had not yet been completed and explained that she was responsible for completing them. She stated the delay was related to a transition to a new company and EHR system, along with the ADON leaving two months earlier. The DON stated the ADON usually completed the log and she monitored it weekly by email. During later interviews, the Regional Nurse Consultant stated the DON was responsible for completing the infection control log with applicable tracking and trending, that the log should be completed monthly, and that the facility was between ADONs. The Administrator also stated he expected tracking and trending logs to be completed timely, and the facility policy on Antibiotic Stewardship stated the purpose of the program was to monitor antibiotic use in residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to treat residents with respect and dignity when a staff member did not respond to Resident #30’s request to be taken to the restroom before lunch. Resident #30, a male resident with diagnoses including chronic systolic congestive heart failure, sleep apnea, atrial fibrillation, and high blood pressure, had an admission MDS indicating severe cognitive impairment with a BIMS score of 7 and required moderate assistance with transfers and bed mobility, maximal assistance with toileting and bathing, and setup for eating. On 09/22/25 at 12:20 PM, he was observed in bed with his lunch tray untouched on his bedside table and stated that an unknown staff member brought his tray and said they would return to take him to the restroom. He said he tried to wait but had already had an accident and did not want to eat while covered in urine, and he said he felt unclean. During interview, CNA B stated she was unaware Resident #30 needed to use the restroom because department heads passed trays on the hall daily and no one notified her. She stated that if she had known, she would have taken him because it was his right. The DON stated the unknown staff should have notified nursing when Resident #30 expressed the need to use the restroom so he could be assisted and prevented from urinating on himself. The administrator stated staff were expected to meet resident care needs timely regardless of meal service and to notify the correct staff member so Resident #30 could be taken to the restroom. The facility also failed to provide privacy when RN A administered insulin to two residents in the dining room. Resident #31, a male resident with diabetes mellitus due to underlying condition with diabetic chronic kidney disease, had a quarterly MDS showing he made himself understood and understood others, with a BIMS score of 9. Resident #2, a female resident with type 2 diabetes mellitus with diabetic nephropathy and legal blindness, had a quarterly MDS showing she made herself understood and understood others, with a BIMS score of 12. On 09/22/25, RN A administered 4 units of insulin to Resident #31 and 14 units of insulin to Resident #2 while both were seated at dining tables with multiple residents present and lunch about to be served. Resident #2 later stated she was not aware RN A raised her shirt and administered insulin in the dining room and said she would have said something if she had known. RN A stated it was standard practice to administer insulin in an open area, while the Nurse Consultant, DON, and Administrator stated insulin should be given in a private area to protect residents’ dignity and privacy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement comprehensive person-centered care plans for multiple residents whose assessments and orders identified specific needs. For Resident #3, the record showed dementia, gastrostomy status, dependence on staff for all ADLs, and unhealed pressure ulcers/injuries. Orders were in place for enhanced barrier precautions related to the g-tube and for treatment of an abrasion on the right buttock, a Stage I pressure wound on the right buttock, and an unstageable deep tissue injury to the coccyx, but the care plan reviewed did not address the wounds, wound care, or enhanced barrier precautions. During observation, LVN L did not follow enhanced barrier precautions when disconnecting Resident #3's g-tube from her feeding. The Treatment Nurse entered the room, donned gown and gloves, and prompted LVN L to put on a gown. The Treatment Nurse then provided wound care to the resident's right buttock and coccyx as ordered with assistance from LVN L. The MDS Coordinator stated the wound care and enhanced barrier precautions were not included in the care plan because she had not had time to put them in and did not have access to enter the care plans due to a change in companies. For Resident #17, the record showed a diagnosis of cerebral infarction and gastrostomy, with severe cognitive impairment on the MDS and orders for tube site care, verification of enteral tube placement, and continuous tube feeding via g-tube. The care plan reviewed did not address the g-tube, and the resident was observed receiving Diabetisource 1.2 through the g-tube at 50 ml/hr. The MDS Coordinator stated the g-tube was not included in the care plan because it had not been entered yet. Resident #30's record showed diagnoses including chronic systolic congestive heart failure, sleep apnea, atrial fibrillation, and hypertension, with severe cognitive impairment on the MDS. The care plan did not indicate that he was a smoker. The MDS Nurse stated Resident #30 should have had a smoking care plan but she forgot to add it, and the DON stated the care plan should have been completed on admission. For Resident #5, the record showed vascular dementia, schizophrenia, hypertension, and aphasia, with severe cognitive impairment on the MDS. The EMR showed no care plan implemented on 09/23/25, although a prior care plan existed from a previous stay. The MDS Nurse stated she was responsible for comprehensive care plans and that Resident #5 should have had one in place, while the DON stated the care plan should have been completed within 14 days after the admission MDS.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the resident environment remained free of accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. The report identified multiple unsafe conditions involving resident rooms and equipment, including unsecured personal care items in resident rooms, improper disposal of a lancet, and an uncovered razor in a medication cart. The report also identified a transfer incident in which a resident was moved with a mechanical lift by one CNA without the required second staff member. Resident #2 had diagnoses including schizoaffective disorder depressive type, legal blindness, muscle weakness, and muscle wasting and atrophy. Her MDS indicated severe vision impairment, a BIMS score of 12, dependence on staff for transfers, and need for substantial to maximal assistance with several ADLs. Her care plan identified a potential for injury related to previous falls, unsteady gait, visual deficits, and attempts to stand unassisted, and it directed 2 staff to assist during transfers. On 09/24/2025, CNA K was observed coming out of Resident #2's room with the mechanical lift, and no other staff were present in the room. Resident #2 stated CNA K transferred her from bed to wheelchair and she was not comfortable in the wheelchair. CNA K stated she transferred the resident by herself because the nurse stepped out and she did not wait for help. Staff interviews confirmed that 2 staff were required for mechanical lift transfers. The report also documented unsafe items left accessible in resident rooms. Resident #22, who had Alzheimer's disease, anxiety disorder, high blood pressure, and a BIMS score of 3 indicating severe cognitive impairment, was observed with fingernail clippers on her dresser and hand sanitizer and hair spray on her bedside table. Resident #29, who had dementia, anxiety, high blood pressure, depression, and a BIMS score of 6, was observed with a can of hairspray on her dresser, nail polish remover in her caddy, another can of hairspray on her table by the window, and nail polish remover on her dresser by the television in a caddy; these items remained present on a later observation as well. Resident #51, who had senile degeneration of the brain, impulse disorder, depressive disorder, chronic pain, and a BIMS score of 0, was observed lying in bed with a blue razor in the trash can in her room. In addition, RN A was observed performing a fingerstick blood sugar on Resident #2 and disposed of the used lancet in the trash can on her medication cart instead of the sharps container. A razor was also observed uncovered in the bottom drawer of the wing B nurse's cart.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure safe, appropriate dialysis care and services for three residents who required dialysis. For Resident #58, the record showed end stage renal disease, intact cognition, and a care plan for hemodialysis with dialysis-related interventions. The resident’s family member stated she went to dialysis every Tuesday, Thursday, and Saturday. However, the facility did not have a dialysis contract for the resident’s dialysis clinic, and the Administrator acknowledged this was an oversight and that he was responsible for obtaining the contract. The facility also failed to maintain ongoing communication, coordination, and collaboration with the dialysis clinic for Resident #58, Resident #1, and Resident #8. Staff reported sending dialysis communication forms without receiving them back, and the LVN stated she had not attempted to contact the clinic for treatment information or to follow up on the forms. The dialysis clinic charge nurse stated the facility had not been sending communication forms for the clinic to complete. The DON stated there was no monitoring in place to ensure communication with the dialysis clinic was completed, and the Administrator stated the facility’s communication system with the dialysis clinic should be adhered to and that charge nurses were responsible for maintaining ongoing communication.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Drugs and biologicals were not consistently stored in locked compartments or kept labeled and dated in accordance with facility policy. During observations, several residents had creams or ointments left out in their rooms or on bedside furniture rather than secured in a locked medication area. Resident #24, who had diagnoses including diabetes mellitus, anxiety disorder, dementia, tremors, and high blood pressure and a BIMS score of 3, had a tube of Remedy Prevent ointment on her dresser table during two separate observations. Resident #27, who had Alzheimer’s disease, psychotic disorder, depression, heart failure, and high blood pressure and a BIMS score of 7, had a tube of triple antibiotic ointment in her bedside caddy, although no order for that ointment was listed on her order summary. Resident #28, who had dementia, heart failure, anxiety, and major depression and a BIMS score of 6, had Preparation H rectal ointment and lantiseptic cream left on top of plastic drawers next to her chair during two observations. Her order summary showed an order for Preparation H rectal ointment as needed for hemorrhoids. During the interview, Resident #28 stated she used it when she needed to and described applying it when it hurt. Resident #50, who had anxiety disorder, dementia, hearing loss, and high blood pressure, had an unknown white cream in a specimen cup on his shelf during observation. CNA E stated the white cream had been brought in by the family for his mouth and said medications and creams were not supposed to be left out on the unit. An additional observation found the A-Wing nurse medication cart unlocked and unattended while RN E was responsible for it. RN E stated she did not realize she had left it unlocked and acknowledged that medication carts should be locked at all times because somebody could get into it. The DON and Administrator stated that creams and medications should not have been left out in residents’ rooms and that medication carts should be locked when not in use. The facility policy stated that medications and biologicals are stored in locked compartments and that carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Food and drink were not ensured to be palatable, attractive, and at a safe and appetizing temperature for 16 of 16 confidential residents reviewed for food and nutrition services. On 09/22/2025, a resident's family member stated the food was served cold. On 09/23/2025, a resident stated the food tasted bad. During a lunch tray observation on 09/23/25, the Dietary Manager and surveyors sampled a tray that included a smothered pork chop, green beans, black eyed peas, peach pie, and a roll, and the Dietary Manager stated the pork chop was lukewarm, the green beans were lukewarm/bland, the black-eyed peas were lukewarm/bland, and the pie was tart; the surveyors agreed. During interviews on 09/24/25, CNA U and LVN O stated they had not received complaints about food being cold or bland, but would offer an alternative and report concerns to nursing and dietary staff if complaints were made. The Dietary Manager stated she had not received complaints about food being cold or bland and said she monitored meal service daily by interviewing residents and tray sampling, but reported no issues were found during her tray sampling. The Administrator stated he expected food to be the appropriate temperature and seasoned for palatability, and the facility policy stated each resident is provided with a nourishing, palatable, well-balanced diet that meets daily nutritional needs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure Resident #2 had her call light within reach. Resident #2 was a female admitted with diagnoses including schizoaffective disorder depressive type, legal blindness, muscle weakness, and muscle wasting and atrophy. Her quarterly MDS indicated severe vision impairment, a BIMS score of 12, and dependence on staff for transfers and substantial to maximal assistance with several ADLs. Her care plan identified her as at risk for falls, impulsive when asking for care, and in need of her call light within reach, but during observation she was in her wheelchair at the foot of her bed and her call light was on the bed near the head of the bed. She told staff she was blind and said staff had issues giving her the call light, and the CNA stated she had rushed out and forgotten to give it to her. The facility also failed to ensure Resident #51's call light remained within reach. Resident #51 was a female admitted with diagnoses including senile degeneration of the brain, impulse disorder, depressive disorder, and chronic pain. Her quarterly MDS indicated severe cognitive impairment with a BIMS score of 0 and dependence on staff for all ADLs. Her care plan addressed cognitive loss and provided for a homelike environment. During observation, her call light was found in the dresser drawer next to her bed, and later it was observed on the floor under her bed while she was lying in bed yelling loudly. The DON stated that call lights should always be in reach for all residents and that all staff were responsible for ensuring this. The Administrator also stated call lights should always be in reach and that failure to do so placed a risk for timely care being compromised. The facility policy titled Call System, Residents stated each resident is provided with a means to call staff directly for assistance from the bed, toileting/bathing facilities, and from the floor, and that the resident call system remains functional at all times.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a safe, clean, and comfortable environment for two residents by not maintaining their bedding in a homelike condition. Resident #51, an older female with senile degeneration of the brain, impulse disorder, depressive disorder, chronic pain, and severe cognitive impairment with a BIMS score of 0, was dependent on staff for all ADLs and had a care plan intervention for a homelike environment. During observation, she was lying in bed without a pillowcase on her pillow. An LVN later said she was unsure why the pillowcase was missing but agreed the resident should have had one, and stated the CNAs were responsible for putting it on and replacing it if the resident removed it. Resident #2, an older female with schizoaffective disorder depressive type, legal blindness, muscle weakness, and muscle wasting and atrophy, had moderate cognitive impairment and required substantial to maximal assistance with several ADLs. During observation, her fitted sheet had multiple brown stains and reddish-brownish particles in the bed, and her bed pad had a dried light tan stain. Later observation showed the top sheet and bed pad were clean, but the fitted sheet still had multiple brown stains. A CNA said she changed the top sheet but did not change the fitted sheet because she did not notice it was stained, and stated that CNAs were responsible for ensuring residents had clean linens. Interviews with nursing and administrative staff showed expectations that CNAs should ensure pillowcases and clean linens were in place, with nurses checking that sheets were changed and the DON and Administrator stating residents should have clean linens for sanitation, dignity, comfort, and infection control. The facility policy titled Homelike Environment stated residents are to be provided a safe, clean, comfortable, and homelike environment, including clean, sanitary, orderly surroundings and clean bed and bath linens in good condition.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure transfer and discharge documentation was completed and placed in the medical record for 2 of 4 residents reviewed for discharge. For one resident, the electronic medical record did not contain discharge orders, discharge assessments, progress notes reflecting a change of condition, physician or family notification, or a discharge summary for multiple hospital transfers and readmissions. The resident’s record showed diagnoses including end stage renal disease, heart failure, atrial fibrillation, seizures, peripheral vascular disease, major depressive disorder, and acute respiratory failure with hypoxia, and the resident was cognitively intact with a BIMS score of 15. For the second resident, the electronic medical record did not contain discharge orders, discharge assessments, progress notes reflecting a change of condition or need for hospitalization, physician or family notification, or a discharge summary for the hospital discharge. The resident’s record showed diagnoses including peripheral vascular disease, cervical discitis, urinary retention, hyperlipidemia, osteoarthritis, hypertension, anemia, dementia, and right leg atherosclerosis. The discharge MDS indicated intact short-term memory and cognitive skills for daily decision making, while SLUMS testing indicated dementia. During interviews, an RN stated she would document vital signs, reason for transfer, and the hospital to which the resident was sent, but could not recall whether this was done consistently for all transfers. Medical records staff stated discharge summaries were not available for the residents. The DON stated she expected nursing staff to complete a physical assessment before discharge and document the reason for discharge, notification of the responsible party, physician and DON, vital signs, and SBAR data. The Administrator stated he expected full nursing assessments, notification of appropriate personnel, on-site interventions, and documentation of these tasks, and acknowledged that failure to complete full documentation could place residents at risk for improper discharges.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure services provided, as outlined by the comprehensive care plan, met professional standards of quality for one resident with diabetes mellitus and diabetic nephropathy. The resident’s care plan included diabetes medication as ordered, monitoring and documenting for side effects and effectiveness, and fasting serum blood sugar checks as ordered. The physician order summary reflected an order for Humalog KwikPen, 14 units subcutaneously before meals and at bedtime for diabetes mellitus. During an observation, RN A prepared and administered the resident’s Humalog KwikPen but did not prime the insulin pen with 2 units before turning the dose knob to 14 units. RN A stated priming was not required, while the Pharmacy Consultant, Regional Nurse Consultant, DON, and Administrator all stated insulin pens should be primed with 2 units before administration to ensure the resident received the correct dose. The DON stated RN A’s insulin administration check-off should have been completed earlier in the year, but it had not been completed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #4 was a female admitted and re-admitted to the facility with diagnoses including multiple pelvic fractures and dementia. Her MDS assessment indicated a BIMS score of 4, showing severely impaired cognition, and she required partial/moderate assistance with dressing and personal hygiene, along with setup or clean-up assistance with eating. Her care plan identified an ADL self-care performance deficit related to limited physical mobility and required assistance from 1 staff member for bathing. Record review showed the resident's bathing task record had no signatures indicating bathing was completed on multiple dates in September 2025. During observations, the resident was found in bed with multiple hairs on her chin and upper lip approximately 1-2 cm long, and she stated she had not removed her facial hair but needed to. Staff interviews confirmed CNAs were responsible for removing facial hair, usually on shower days, and that the resident sometimes refused showers but did allow facial hair removal. The LVN, CNA, and DON all acknowledged the resident had facial hair and stated it was important for dignity and self-esteem, while the DON said she was not aware of the resident refusing facial hair removal.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the Treatment Nurse completed a skin assessment after being notified that a resident had newly identified redness under both breasts. The resident had diagnoses including Alzheimer's disease, cerebral palsy, legal blindness, and excoriation skin-picking disorder. Her MDS indicated she was moderately cognitively impaired, highly visually impaired, and required partial to moderate assistance with personal hygiene, bathing, and toileting. Her care plan identified her as at risk for pressure ulcers due to moisture, impaired mobility, and scratching, with interventions to assess for moisture problem areas such as under the breasts. On 09/22/2025, during an observation and interview, the resident stated she had an open area on her breast that bothered her. With CNA assistance, redness and irritation were observed under both breasts, with increased irritation and redness on the left breast. CNA B applied powder and said she would notify the Treatment Nurse. CNA B later stated she charted the redness in the electronic record and verbally notified the Treatment Nurse that day when a new skin condition was identified. During interview, the Treatment Nurse stated CNA B reported the redness under the resident's breasts on Monday, 09/22/2025, but she did not complete a skin assessment because it slipped her mind. She stated that when staff notified her of a skin issue, she should complete a skin assessment to monitor whether the condition was healing or worsening and to report it to the doctor. The DON and Administrator both stated the resident should have been assessed after the abnormal skin finding was reported. The facility policy titled, Prevention of Pressure Injuries, indicated the skin should be inspected daily during personal care or ADLs and potential changes in the skin should be evaluated, reported, and documented.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain acceptable nutritional and hydration status for 2 residents. For Resident #57, who had diagnoses including Alzheimer's dementia, atherosclerotic heart disease, hypertension, hyperlipidemia, SIADH, and diabetes mellitus, the record showed severe cognitive impairment and total dependence for eating and drinking. Observations on multiple days found the resident with a dry oral cavity, cracked or chapped lips, and no fluids or mouth swabs at the bedside during some checks. Although a later observation found a water pitcher with clear liquid and oral swabs on the nightstand, staff interviews showed the CNA did not notice fluids at the bedside and was unable to identify the thickened liquid type, and the LVN stated she was not aware of any diet change for the resident. For Resident #4, who had diagnoses including multiple pelvic fractures and dementia with severe cognitive impairment, the record showed a significant weight loss and an RD note recommending Boost VHC 60 ml four times a day to support nutrition adequacy and replenish lost weight. However, the medication flowsheet showed the resident was receiving Boost VHC 60 ml twice a day, and the care plan did not address nutritional supplements or weight loss. Staff interviews confirmed the resident was still receiving the supplement twice daily, and the RN and DON stated they were not aware of the RD recommendation for four times daily. The report also states that the DON was responsible for making the RD changes and that the Administrator expected the RD recommendations to be followed and addressed appropriately. The facility policy on hydration stated that nurses' aides would provide and encourage intake of bedside, snack, and meal fluids on a daily and routine basis, and that signs of inadequate intake or dehydration would be monitored and incorporated into the care plan. The deficiency was based on the facility's failure to provide fluids for Resident #57 and failure to implement the RD's supplement recommendation for Resident #4.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a resident with a gastrostomy tube received the enteral feeding formula ordered by the physician. Resident #17, a female with diagnoses including cerebral infarction and gastrostomy, had a comprehensive MDS assessment showing severe cognitive impairment and need for assistance with eating. Her care plan directed enteral feeding if she was unable to swallow, and the physician order summary listed Isosource 1.5 at 50 ml/hr via g-tube, with Diabetisource 1.2 permitted only until Isosource arrived. Record review and observations showed the resident was receiving Diabetisource 1.2 at 50 ml/hr via g-tube instead of Isosource 1.5. The MAR did not show the Isosource order, and one shift signature was missing for the temporary Diabetisource order. Staff interviews indicated the formula was changed because Isosource was unavailable during a transition in companies and ordering issues, and the DON stated nurses should have called the doctor to obtain an order for the alternate formula if Isosource was not available. The Administrator stated he expected feeding formulas to be followed per physician orders.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Resident #30, a male with diagnoses including chronic systolic congestive heart failure, sleep apnea, atrial fibrillation, and high blood pressure, was admitted to the facility and assessed as having severe cognitive impairment with a BIMS score of 7. He required moderate assistance with transfers and bed mobility, maximal assistance with toileting and bathing, and setup for eating. His care plan dated 09/23/25 did not indicate oxygen use, and the order summary report did not show an order for changing or cleaning the oxygen tubing, water, or filter. During observation on 09/22/25, Resident #30 was in bed with oxygen at 2L/M, and the oxygen filter in the back of the concentrator was dirty with thick gray fuzzy matter; the oxygen water and tubing had no dates. On 09/23/25, the resident was again observed in bed with oxygen at 2L/M, and although the oxygen water and tubing were dated 9/22/25, the oxygen filter remained dirty with thick gray fuzzy matter. On 09/24/25, the LVN and surveyor observed the dirty filter, and the LVN stated charge nurses were supposed to change the oxygen filters and tubing on Sundays and clean the filters. The DON stated nurses were responsible for cleaning and changing the filters and water weekly, and that Resident #30 should have had an order in place to ensure those tasks were completed. The Administrator stated the concentrators should have been maintained appropriately and that the charge nurses should have been cleaning and changing the filters as ordered.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure pain management was provided for Resident #57, a male resident with diagnoses including Alzheimer's dementia, atherosclerotic heart disease, hypertension, hyperlipidemia, SIADH, and diabetes mellitus. His admissions BIMS assessment showed severe cognitive impairment, and his care plan indicated he was receiving hospice services with a goal of being comfortable with no signs or symptoms of pain or distress. A physician's order dated 9/10/25 required a pain assessment every shift, but the September MAR showed only one recorded pain level of 0 on 09/15/25 during the night shift, with no other pain assessment levels documented. Record review of nursing progress notes from 8/1/25 through 9/10/25 did not reveal documentation that pain assessments were completed every shift. During observations, Resident #57 was noted with non-verbal communications, strained facial expression, nonsensical calling out, groans to verbal stimuli, moaning in response to verbal stimuli, and facial grimacing. The family member stated the resident was not getting enough to drink and wanted staff to check on him more often. An LVN stated she was not aware of the order requiring pain assessment each shift, and the DON and Administrator stated staff were expected to complete ordered assessments, record pain levels, and notify the physician of concerns.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that licensed staff demonstrated the specific competencies and skill sets needed to care for residents. One licensed nurse, RN A, did not have annual skill checkoffs completed for fingerstick blood glucose testing and insulin administration. During an observation, RN A performed hand hygiene, put on gloves, and prepared to obtain a fingerstick blood sugar for a resident who was seated at a dining table. RN A placed the glucometer, lancet, alcohol wipe, and test strip on the table, attempted the fingerstick, changed gloves without cleansing her hands or using hand sanitizer, and then repeated the fingerstick process. RN A also disposed of the used lancet in the trash can on the medication cart and administered Humalog KwikPen insulin without priming the pen first. RN A stated priming was not required and stated it was acceptable to place the testing supplies on the resident's dining table without a barrier. The resident involved was a female with diagnoses including schizoaffective disorder depressive type, legal blindness, muscle weakness, and muscle wasting and atrophy. Her quarterly MDS indicated she was understood and understood others, had severely impaired vision, a BIMS score of 12, and required substantial to maximal assistance with toileting, bathing, and lower body dressing, partial to moderate assistance with personal hygiene and upper body dressing, and was dependent on staff for transfers. The DON stated insulin administration checkoffs should be completed upon hire, annually, and as needed, and that RN A's checkoff should have been completed in April 2025. The DON stated she was responsible for ensuring the competencies were completed in a timely manner. The facility also failed to complete a competency assessment for CNA K on the use of the mechanical lift. The resident's care plan indicated she had a potential for injury related to falls, unsteady gait, visual deficits, and attempting to stand unassisted, and that two staff were to assist with transfers. During observation, CNA K was seen coming out of the resident's room with the mechanical lift, and no other staff were present in the room. The resident stated CNA K transferred her from bed to wheelchair by herself. CNA K said the transfer was done with the mechanical lift by herself and was unsure whether two staff were required. The DON stated the mechanical lift required two staff, that competency checks should be completed upon hire, and that CNA K's competency check had been missed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide pharmaceutical services to ensure accurate dispensing and administration of medications for three residents. For one resident with chronic embolism and thrombosis of the bilateral lower extremities and hypertension, a telephone order dated 09/15/2025 directed Lasix 20 mg daily at 7:00 AM for edema and Potassium 20 mEq daily at 7:00 AM for 5 days, but the medications were not administered until 09/19/2025. The resident’s MAR showed both medications given from 09/19/2025 through 09/23/2025, and the order summary later reflected Lasix with a start date of 09/19/2025 and no potassium order listed. For another resident who was admitted with a right femur fracture and had an intact BIMS score of 15, the physician order report showed daptomycin 500 mg IV every 24 hours starting 04/01/2025. The resident’s baseline care plan indicated she required IV medications/fluids. The pharmacy technician stated the daptomycin was delivered on 04/02/2025 between 3 PM and 5 PM, and RN A stated that if a medication did not arrive, the nurse should call the pharmacy. RN A did not remember whether the missed dose was reported to the pharmacy or NP. For a resident with type 2 diabetes mellitus and diabetic nephropathy, RN A administered Humalog KwikPen insulin during an observed medication pass but did not prime the pen with 2 units before giving the ordered 14-unit dose. RN A stated priming was not required, while the pharmacy consultant, regional nurse consultant, DON, and administrator all stated the pen should be primed before each injection according to manufacturer instructions. The facility’s insulin administration policy stated nursing staff should have access to manufacturer instructions for insulin delivery systems prior to use, and the manufacturer’s guidance stated priming before each injection ensures the pen is working correctly and helps prevent too much or too little insulin from being given.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident with Type 2 diabetes mellitus and diabetic nephropathy was free from a significant medication error during insulin administration. The resident’s record showed an order for Humalog KwikPen, 14 units subcutaneously before meals and at bedtime for diabetes mellitus. During observation, RN A prepared and administered the insulin to the resident’s RLQ but did not prime the Humalog KwikPen before giving the dose. RN A stated priming was not required before administering the insulin. The manufacturer’s instructions for Humalog KwikPen stated to prime before each injection and explained that priming removes air from the needle and cartridge and ensures the pen is working correctly. The Pharmacy Consultant, Regional Nurse Consultant, DON, and Administrator all stated the pen should be primed with 2 units before administration to ensure the resident received the correct dose. The DON also stated RN A’s insulin administration check-off should have been completed in April 2025, and RN A stated she had not been checked off that year.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accommodate Resident #21’s food preference for double meat on the lunch meals served on 09/22/2025 and 09/23/2025. Resident #21 was a male with diagnoses including schizoaffective disorder, bipolar type, and profound intellectual disabilities. His MDS indicated he could make himself understood and understand others, had a BIMS score of 10, was independent with eating, and required a therapeutic diet. His care plan addressed a no added salt, regular texture diet with thin liquids, but did not further address double meat for all meals. Meal tickets for both lunch meals indicated double meat all meals, but observation showed he received only one beef pepper steak on 09/22/2025 and did not receive double meat portions on 09/23/2025. During interview, Resident #21 said he did not know he was supposed to get double meat portions, but it may be so he did not stay hungry. The MDS Coordinator stated he was not served double portions because the second portion was not given until he finished the first portion of meat. The Dietary Manager said the resident received double meats because he requested it, but the cook missed serving them. RN A said she was responsible for checking trays on 09/23/2025 but did not catch that Resident #21 was not served double meat portions. The DON and Administrator stated staff were responsible for checking meal trays and following meal tickets and resident preferences, and the facility policy required accommodating resident preferences and inspecting trays to ensure the correct meal was provided.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure safe and sanitary storage of a resident’s food items by not developing or implementing its personal food policy related to personal refrigerators. Resident #30 was a male admitted with chronic systolic congestive heart failure, sleep apnea, atrial fibrillation, and high blood pressure. His admission MDS indicated he was understood by others and could make himself understood, but also showed a BIMS score of 7, indicating severe cognitive impairment. He required moderate assistance with transfers and bed mobility, maximal assistance with toileting and bathing, and setup for eating. His care plan did not address his ADL care. During observation, his refrigerator had no thermometer and no paper with dates and temperatures. The refrigerator contained 2 cokes, 2 packages of sandwich meat, and one capri sun drink. The resident stated he did not know about the thermometer and said he ate his food when he did not like what the facility served. The Administrator stated the facility did not have a policy for personal refrigerators. The Treatment Nurse stated every resident should have had a thermometer in the refrigerator and a temperature log. The DON stated she expected a thermometer in the room and said she was not aware Resident #30 had a personal refrigerator. The Housekeeping Supervisor stated she kept a log of refrigerator temperatures, but Resident #30 had received his refrigerator about a week earlier and she had not taken its temperature since he had it; she also said the Maintenance Supervisor usually placed thermometers in residents’ refrigerators.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to keep Resident #6’s medical record accurate and consistent with the resident’s signed diet waivers and current meal ticket. Resident #6 was a male with dysphagia, dementia, bipolar disorder, atrial fibrillation, COPD, and hypertension, and his MDS showed severe cognitive impairment. His care plan documented that he signed a waiver refusing nectar-thick liquids and preferred thin liquids while receiving a pureed diet, and the record also contained signed refusal forms to discontinue nectar-thick liquids and puree. However, the physician’s orders and current diet documentation did not consistently match those waivers, with orders changing over time and the dietary manager stating the discrepancy was corrected only after it was identified during the survey. The facility also failed to complete admission and re-admission assessments for Resident #5 within the required timeframe. Resident #5 was a female with vascular dementia, schizophrenia, hypertension, and aphasia, and her MDS showed severe cognitive impairment with assistance needed for toileting, bathing, dressing, and supervision with eating. Review of the EMR showed no admission assessment completed for her admission and no re-admission assessment completed after she returned from a hospital stay, and the paper chart contained only an undated incomplete admission assessment created by an LVN. Staff interviews showed uncertainty about who was responsible for completing the assessments and when they were due. The LVN who worked the overnight shift said she thought she completed the admission assessment but was not sure, another LVN said she did not know the timeframe for admission or re-admission assessments, the MDS nurse said she did not know when each assessment should be completed, and the DON and Administrator stated the assessments should have been completed within 24 hours of admission and that the re-admission assessment should have been completed after the hospital return. The Administrator also stated the charge nurses were responsible for completing the assessments and that the DON was expected to follow up to ensure completion.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow its established smoking policy regarding where smoking materials were to be kept while staff were in the building. During an observation and interview on 09/22/25 at 9:49 a.m., a 1/2 smoked cigarette was observed next to the toaster in the kitchen, and [NAME] Q stated the cigarette belonged to her and should not have been at the workstation next to the toaster. [NAME] Q stated her personal belongings should be stored in her bag and that cigarettes needed to be stored there to prevent a fire. During another observation and interview on 09/22/25 at 10:59 a.m., a cigarette was observed in a filing cabinet in the laundry room, and the Housekeeping Supervisor stated it belonged to a PRN staff member who would no longer return. The Housekeeping Supervisor stated cigarettes should be stored in a cigarette cart in staff personal bags and that she monitored compliance through spot checks. The Dietary Manager later stated cigarettes should be stored in personal bags until staff went to the designated smoking area, and the Administrator stated cigarettes should remain in the cigarette cart while in the building and be stored in an area inaccessible to residents. Record review showed the designated smoking area was outside the main dining room, and the Employee Handbook dated 04/2025 did not address where smoking materials should be kept while not in the designated smoking area.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to promote resident self-determination by not honoring a resident's preference for showers over bed baths. The resident, who has vascular dementia, hypertension, and muscle weakness, expressed a clear preference for showers, which was not respected. Despite being understood and able to communicate his needs, the resident reported not having received a shower in over six weeks, only receiving bed baths instead. This was confirmed by a review of the shower schedule, which showed no record of showers being provided during the specified period. Interviews with the resident and staff, including the Director of Nursing (DON) and the Administrator (ADM), revealed that the responsibility for ensuring adherence to the shower schedule lay with the charge nurses. The DON acknowledged the issue and confirmed that the resident had only received bed baths, despite his preference for showers. The ADM also recognized the responsibility of the nursing staff to follow the shower schedule, indicating a lapse in ensuring resident satisfaction with the services provided.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a safe, functional, sanitary, and comfortable environment for a resident, as observed during a survey. The resident, who was severely cognitively impaired and required assistance for activities of daily living, was found without a pillowcase on his pillow. The resident expressed discomfort and dissatisfaction, stating that he used a T-shirt under his head to avoid lying directly on the old and frayed pillow. Despite his request, the pillowcase was not provided until prompted by the surveyor. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that it was the responsibility of Certified Nursing Assistants (CNAs) to ensure that bed linens were properly placed each day after being cleaned and delivered by housekeeping. The lack of a pillowcase was identified as a failure in maintaining a homelike environment, which could lead to resident dissatisfaction with the services provided by the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a Baseline Care Plan for a resident within 48 hours of admission, which is a requirement to ensure effective and person-centered care. The resident, who was admitted with multiple complex medical conditions including hypoxic ischemic encephalopathy, dementia, major depressive disorder, and respiratory failure, did not have a Baseline Care Plan completed. This omission was identified during a review of the resident's records and confirmed through interviews with facility staff. The resident's medical history included severe cognitive impairment, use of a wheelchair for mobility, and the need for maximal to moderate assistance with activities of daily living. The resident also had an indwelling urinary catheter, was frequently incontinent of bowel, and had a feeding tube. Despite these needs, the facility did not have a Baseline Care Plan in place, which is crucial for guiding staff in providing appropriate care and ensuring all staff are informed about the resident's care requirements. Interviews with various staff members, including the LVN, ADON, and DON, revealed that the responsibility for completing the Baseline Care Plan lay with the admitting nurse, with oversight from nurse management. However, there was a lack of a formal policy on Baseline Care Plans, and the facility's leadership acknowledged the importance of having such a plan to communicate care needs effectively to staff and family. The absence of a Baseline Care Plan could lead to staff not knowing how to treat the resident effectively, potentially compromising the resident's care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary personal hygiene services for a female resident who was unable to perform activities of daily living independently. The resident, who had Alzheimer's disease, major depressive disorder, and generalized anxiety disorder, was dependent on staff for personal hygiene, including shaving. Despite being scheduled for baths three times a week, observations revealed that the resident had noticeable facial hair that had not been removed, indicating a lapse in care. Interviews with staff, including a CNA, LVN, DON, and the Administrator, revealed inconsistencies in the execution of personal hygiene tasks. The CNA responsible for the resident admitted to not having provided care recently due to working in a different hall and acknowledged that new aides should attempt to remove facial hair. The LVN and DON confirmed that CNAs were responsible for shaving female residents, with oversight from nurses, and noted that any refusals should be documented. However, there was no documentation of the resident refusing care, and the facial hair remained unaddressed. The facility's policies on shaving and activities of daily living emphasized the importance of grooming to promote dignity and well-being. Despite these policies, the resident's facial hair was not removed, and there was no documentation of refusal, highlighting a failure in adhering to established care protocols. This deficiency in care could potentially impact the resident's self-esteem and dignity, as noted by the staff during interviews.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic drugs due to inadequate behavior and side effect monitoring. Specifically, the resident was prescribed Quetiapine, an antipsychotic medication, but there was no documentation of behavior or side effect monitoring during the months of July and August 2024. This lack of monitoring could prevent the facility from determining whether the medication was effective or if the resident was experiencing any adverse effects. The resident, who had severe dementia with behavioral disturbances and major depressive disorder, was admitted to the facility with a history of inappropriate behaviors. Despite being on Quetiapine, there was no order for side effect or behavioral monitoring noted in the resident's records. Interviews with the resident's responsible party and staff revealed that the facility did not adequately document or monitor the resident's response to the medication, which is crucial for assessing the need for continued use or dose adjustments. Interviews with facility staff, including the LVN, ADON, and DON, highlighted a lack of clarity and responsibility regarding the implementation of behavior and side effect monitoring. The staff acknowledged that such monitoring is essential for ensuring the medication's effectiveness and safety. However, the monitoring was not documented in the resident's chart, which could delay necessary treatment adjustments and prevent the physician from making informed decisions about the resident's care.

Penalty

Inspection fine: $16,055

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from abuse and neglect, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who physically and verbally abused a resident. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was subjected to derogatory language and physical shoving by CNA A. This incident was witnessed by another CNA, who reported that CNA A used inappropriate language and force while providing care to the resident. The resident involved in the incident had a history of severe cognitive impairment and was reliant on staff for all personal care needs. Despite this vulnerability, the resident was subjected to abusive behavior by a staff member, which included being shoved and spoken to in a derogatory manner. The resident's care plan indicated that she was incontinent and required assistance with all activities of daily living, highlighting her dependence on staff for proper care and protection. The incident was reported by CNA B, who witnessed the abuse and informed the Director of Nursing (DON) the following day. The facility's failure to prevent this abuse and neglect was identified as a deficiency, with the noncompliance being classified as Immediate Jeopardy (IJ) due to the potential risk it posed to the resident and others. The report indicates that the facility had not ensured the resident's right to be free from abuse and neglect, leading to this serious deficiency.

Removal Plan

• Facility notification of abuse incident to responsible party, MD, Ombudsman and HHSC.
• Completion of in-services on abuse. Abuse policy educates staff on identifying abuse and neglect as well as timeframes associated with reporting abuse and neglect to the State Agency.
• Termination of confirmed perpetrator.
• Residents of facility interviewed did not indicate that they had been abused and were safe. Safe surveys were conducted with residents and no resident reported feeling unsafe.

Penalty

Inspection fine: $16,055

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its written policies and procedures to prevent abuse, neglect, and theft, resulting in an incident involving a resident. A Certified Nursing Assistant (CNA), identified as CNA A, was reported to have physically and verbally abused a resident by shoving her and using derogatory language during care. This incident was witnessed by another CNA, identified as CNA B, who failed to report the abuse within the required two-hour timeframe as per the facility's policy. The Director of Nursing (DON) did not conduct a thorough investigation following the incident. The investigation was limited to only four safe surveys, and the resident involved was not interviewed. The DON was the first to be informed of the incident by CNA B, but the report was delayed, and the investigation did not include a comprehensive assessment of the resident's safety or well-being. The facility's failure to adhere to its abuse prevention policies and procedures could potentially affect any resident and contribute to further abuse. The incident highlights a breakdown in communication and reporting protocols, as well as inadequate investigation practices, which are critical in ensuring resident safety and compliance with regulatory standards.

Removal Plan

• Facility notification of abuse incident to responsible party, MD, Ombudsman and HHSC.
• Completion of in-services on abuse.
• Abuse policy educates staff on identifying abuse and neglect as well as timeframes associated with reporting abuse and neglect to the State Agency.
• Staff and management recognizing the steps to report abuse and neglect.
• ADM and DON being able to articulate the steps of an investigation.
• Termination of confirmed perpetrator.