Clyde W Cosper Texas State Veterans Home

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 3 of 4 residents (Resident #1, Resident #2 and Resident #3) reviewed for range of motion. The facility failed to ensure Resident #1, Resident #2, and Resident #3's referrals for customized wheelchairs were made. These failures could place residents at risk of not having their individualized needs met, decreased range of motion and a decline in their quality of care and life.

Inspectors wroteBased on observation and interview, the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 13 medication carts (Treatment cart) reviewed for pharmacy services. The facility failed to ensure the Treatment Cart was properly secured when it was left unattended on 07/23/2026. These failures could place residents at risk for not receiving drugs and biologicals as needed and a drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 2 of 2 shower rooms (A Hall and C Hall) reviewed for homelike environment. The facility failed to ensure the shower stalls in the C Hall shower room did not have black grime buildup. The facility failed to ensure the shower stalls in the A Hall shower room did not have yellowish-brownish and pink grime buildup. These failures could place the residents at risk for a decreased quality of life, an uncomfortable, unhomelike environment due to unsanitary conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident and determined that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 7 medication carts (600 Hall Medication Aide Medication Cart) and 2 of 3 (A Hall Medication Storage Room and Memory Care Medication Storage Room) reviewed for pharmacy services. The facility failed to ensure Resident #118's lorazepam gel with expiration date of 04/14/2026 and acetaminophen 650 mg suppositories with expiration date of 03/2026 were removed from the Memory Care Medication Storage Room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 5 residents (Resident #20, and Resident #161), 2 of 7 medication carts (200 Hall Nurse Medication Cart and 600 Hall Medication Aide Medication Cart), ) medication storage rooms reviewed for drugs and biologicals. 1. The facility failed to ensure UTI-Stat and Pro-Stat on the 600 Hall Medication Aide Medication Cart were dated after opened. 2. The facility failed to ensure a package of budesonide ampules in the 200 Hall Nurse Medication cart was labeled properly. 3. The facility failed to ensure Resident #161's medication labels for his glipizide, finasteride, gabapentin, and metformin matched his physician orders. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure:The deep fryer was clean and free of food debris. One medium-sized skillet was free from black buildup on the inside and outside. One large-sized skillet with Teflon coating was free from peeling on the inside. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 6 residents (Resident #76) reviewed for resident rights. The facility failed to ensure CNA Z called Resident #76 by his preferred name while providing care on 04/28/26. This failure could place residents at risk for diminished quality of life, loss of dignity, and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 35 residents (Resident #28) reviewed for MDS assessment accuracy. Resident #28's quarterly MDS, dated [DATE], identified the resident was not receiving oxygen therapy. This failure could place residents at risk of not receiving adequate care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the coordination and provision of services agreed upon during the IDT meeting for 1 of 5 residents (Resident #12) reviewed for PASARR. 1. The facility failed to provide documentation of Resident #102's psychosocial rehabilitative services (group), psychosocial rehabilitative services (individual), and routine case management services as requested in the PCSP Form.2. The facility failed to refer Resident #86 for PASARR Level ll assessment when a diagnosis of major depressive disorder, was diagnosed after admission on [DATE]. These failures could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs, for 1 of 35 (Resident #28) residents reviewed for care plans. The facility did not ensure Resident #28 had a floor mat on each side of the bed. This failure could place residents at risk of accidents and falls with injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 7 residents (Resident #56 and Resident #28) reviewed for respiratory care.1. The facility failed to ensure Resident #56's oxygen concentrator filter was cleaned. 2. The facility failed to ensure Resident #28's oxygen concentrator filter was cleaned. This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease.

Inspectors wroteBased on interview and record review the facility failed to provide or obtain laboratory services to meet the needs of its residents for 1 of 7 residents (Resident #12) reviewed for laboratory services. 1. The facility failed to ensure Resident #12's Pre-Albumin (measures the level of a liver-produced protein in the blood to assess nutritional status and monitor for malnutrition) was drawn bi-weekly and Albumin (measures the level of albumin, a protein produced by the liver, in the blood or urine to assess liver/kidney function and nutritional status) was drawn monthly for Resident #12. 2. The facility failed to ensure Vitamin D and Lipid panel test were drawn every year for Resident #12. Vitamin D (measures the levels of vitamin D in your blood. Vitamin D helps your body absorb calcium to build healthy bones and teeth). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure menus met the nutritional needs of residents in accordance with established guidelines and ensure menus were followed for 1 of 2 meals (the lunch meal) reviewed for nutritional adequacy. The facility failed to ensure [NAME] B used a #16 scoop to serve the pureed roll on 04/27/2026. The facility failed to ensure the Assistant Dietary Manager served one cup of the regular chicken cacciatore pasta on 04/27/2026. These failures could place residents at risk of weight loss, not having their nutritional needs met, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure therapeutic diets were prescribed by the attending physician for 1 residents (Resident #2) reviewed for health shakes. The facility failed to ensure Resident #2 received his health shake, as ordered by the physician. This failure could place residents at risk of not maintaining adequate nutritional status including unintentional weight loss.

Inspectors wroteBased on interview and record review, the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech therapy-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity, as required in the resident's comprehensive plan of care for 1 of 7 residents (Resident #67) reviewed for specialized rehabilitative services. The facility did not ensure Resident #67 received physical therapy after a therapy screening on 03/11/26. This deficient practice could place residents at risk of a decline or decrease in their physical capabilities.

Inspectors wroteBased 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 7 residents (Resident #73 and Resident #86) reviewed for infection control.1. The facility failed to ensure LVN E wore PPE (gown and mask) while performing a blood sugar check on Resident #73 on 04/28/26, who was on droplet precautions (Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions).2. The facility failed to ensure CNA CC and Nurse DD performed proper glove changes while providing incontinent care to Resident #86 on 4/27/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 6 residents (Resident #1) reviewed for assessments: The facility failed to ensure Resident #1's Quarterly MDS assessment accurately reflected the use of antidepressants. This failure could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1's wheelchair was properly secured in the facility transport van on 12/05/2025. Resident #1 sustained a contusion to his head when the wheelchair tipped over as the van turned a corner during transport. This failure could place residents transported via facility van at risk for accidents resulting in serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide liquids consistent with the residents' needs for 2 of 3 (Resident #1 and Resident #2) residents reviewed for liquid inconsistency. 1. The facility failed to ensure LVN A checked the lunch tray appropriately for Resident #1, who required nectar-thick liquids on 11/10/25. 2. The facility failed to ensure Resident #1, and Resident #2 did not have thin liquids at their bedside on 11/11/25. These failures could affect residents by placing them at risk for aspiration and not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 6 Residents (Resident #74) reviewed for pressure injuries. 1. The facility failed to provide care to prevent pressure ulcer or injury development for Resident #74. Resident #74 broke his right ankle and a soft splint was applied on 07/13/24. The facility failed to obtain a clarification order from the doctor related to Resident #74's splnt care. Resident #74 developed 4 unstageable deep tissue injuries to his right foot and possible osteomyelitis. An IJ was identified on 02/05/25. The IJ template was provided to the facility on [DATE] at 4:57 PM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provided supervision to prevent avoidable accidents for 1 of 5 residents (Resident #134) reviewed for supervision. The facility failed to ensure Resident #134 received adequate supervision to prevent exiting the facility without facility knowledge on 01/25/2025, when Resident #134 was found outside sitting on the curb of the facility's parking lot with her wheelchair tipped over. The facility failed to ensure adequate interventions were placed for Resident #134 after exit seeking attempts on 11/18/2024 and 01/25/2025. The facility failed to review Resident #134's exit incidents to determine triggers that increased her risk for elopement and develop person centered interventions to prevent elopement. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents who were trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 4 of 32 residents (Resident #402, Resident #401, Resident #22, and Resident #45) reviewed for trauma-informed care. 1. The facility did not ensure Resident #402 had a trauma screening completed upon admission that identified possible triggers when Resident #402 had a history of trauma and PTSD (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). 2. The facility did not ensure Resident #401 had a trauma screening completed upon admission. 3. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 32 residents (Resident #103), 1 of 13 medication carts (600 hall Nurse Medication Cart), and 1 of 2 medication storage rooms (Secure Unit Medication Room) reviewed for drugs and biologicals. The facility failed to ensure LVN M secured the 600 hall Nurse Medication Cart, when it was not in use on 02/03/2025. The facility failed to ensure a lock box in the Secure Unit Medication Room refrigerator with 4 bottles of Ativan (controlled medication for anxiety) was permanently affixed. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 3 of 7 residents (Resident #49, Resident #22, and Resident #103) reviewed for laboratory services. 1. The facility failed to ensure Resident #49's T4 Free and a PSA lab test were drawn yearly. T4 Free (a test that measures the amount of free thyroxine (T4) in the blood. T4 is a hormone produced by the thyroid gland that plays a vital role in metabolism). Prostate-Specific Antigen also known as PSA test (blood test that measures the amount of (PSA) in your blood. It can help to diagnose prostate cancer. 2. The facility failed to ensure Resident #49's Vitamin D test was drawn every 6 months. (Vitamin D measures the levels of vitamin D in your blood. Vitamin D helps your body absorb calcium to build healthy bones and teeth). 3. [...]

Inspectors wroteBased on observations, interviews, 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 reviewed for 3 of 32 residents (Resident #49, Resident #95, and Resident # 39) reviewed for infection control. 1. The facility failed to ensure MA BB wore PPE while entering Resident #49's room while on contact isolation precautions on 02/04/25. 2. The facility failed to ensure Housekeeper NNN wore PPE while cleaning Resident #49's room while he was on contact isolation precautions on 02/04/25. 3. The facility did not ensure LVN E performed hand hygiene while providing wound care to Resident #95. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 32 residents (Resident #2) reviewed for resident rights. The facility failed to ensure CNA FFF treated Resident #2 with respect and dignity when Resident #2 asked CNA FFF to provide incontinent care before he ate his lunch and CNA FFF failed to comply with Resident #2's request during lunch on 02/03/25 and she told him I just changed you 5 minutes ago. This failure could place residents at risk for diminished quality of life, loss of dignity, and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to be free from any physical restraints imposed for purposes of convenience and not required to treat medical symptoms for 1 of 5 residents (Resident #59) reviewed for restraint use. The facility failed to ensure Resident #59 was free of physical restraints when CNA ZZ held his wrist against the bed while providing care on 02/03/2025. This failure could place residents at risk for a decreased quality of life, a decline in physical functioning and injury.

Inspectors wroteBased on interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 2 of 14 residents (Residents #55 and #61) reviewed for PASRR. The facility did not ensure the correct PASRR (a preliminary assessment completed for all individuals before admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability) Level 1 Screening was submitted to the local authority for Residents #55 and #61 who had a diagnosis of mental illness upon admission. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 resident (#402) of 12 residents reviewed for baseline care plans. The facility failed to address Resident #402's PTSD diagnosis and triggers in his baseline care plan. This deficient practice could affect residents who are admitted to the facility with specialized needs and result in missed care.

Inspectors wrote2. Record review of a face sheet dated 02/05/2025 indicated Resident #59 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition caused by lack of blood that carries oxygen and nutrients to a part of the brain and can cause problems with reasoning, planning, judgment, and memory). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #59 was able to make himself understood and understood others. The MDS assessment indicated Resident #59 had a BIMs score of 10, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #59 required partial to moderate assistance with toileting, showering/bathing self, personal hygiene, and dressing. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 7 residents reviewed for respiratory care (Resident #105). The facility failed to ensure Resident #105's oxygen mask tubing was changed out and dated on 01/29/25. This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease. Findings Included: [...]

Inspectors wroteBased on interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 32 residents (Resident # 93 and Resident # 114) reviewed for pharmacy services. The facility failed to ensure Resident #93's blood pressure met the parameters for the administration of an anti-hypertensive medication on 01/16/2025 and on 01/27/2025. The facility failed to ensure Resident #114's blood pressure met the parameters for the administration of an anti-hypertensive medication on 01/03/2025 and on 01/16/2025. These failures could place residents at risk of serious harm, not receiving their medications as ordered, illnesses, hospitalizations, exacerbation of their disease processes, coma, and death.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Resident's #30 and #299) reviewed for infection control practices related to droplet precautions and 4 of 11 facility staff members (MA C, LVN A, LVN F, and Speech Therapist D) reviewed for infection control practices related to medication pass and droplet precautions. The facility further failed to ensure facility personnel handled, stored, processed, and transported linens so as to prevent the spread of infection for 1 of 5 staff members (CNA N) reviewed for transportation of linens. 1. [...]

Inspectors wroteBased on interview and record review, and interview the facility failed to coordinate assessments with pre-admission screening and resident review (PASARR ) program under Medicaid to the maximum extent practicable to avoid duplicative testing effort which included referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment ensure a PASRR screening was completed for residents with mental disorders or an intellectual disability for 4 of 7 residents (Residents #129, #26, #57, and #121) reviewed for PASRR Level I screenings. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained free of accidents hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 6 residents (Resident #33 and Resident #92) and 2 of 7 halls (Halls 700 and 800) reviewed for accidents and supervision. 1. The facility failed to ensure the bathroom for Resident #33 and Resident #92 was free of leaking water. 2. The facility failed to ensure the Residents on Hall 700 and Hall 800 were adequately supervised. These failures could put residents at risk of serious bodily harm, physical impairment, or death. Findings Include: 1. Record review of Resident #33's face sheet, dated 01/25/24, indicated Resident #33 was an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 1 of 9 residents with a nebulizer machine (Resident #57) and 4 of 11 residents who received oxygen (Resident's #130, #47, #57, and #81) that were reviewed for respiratory care. 1. The facility failed to ensure Resident #47 oxygen was placed on 2 LPM as ordered by the physician. 2. The facility failed to administer oxygen at 2L via nasal cannula as prescribed by the physician for Resident #57. 2a. The facility failed to properly store Resident #57's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask while not in use. 3. The facility failed to ensure Resident #130's nasal cannula tubing was changed weekly. 3a. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 3 residents (Resident #12) reviewed for medications at their bedside and 1 of 6 (500 Hall) medication carts reviewed for storage of medications. 1. The facility did not ensure Resident #48's Nystatin Powder was not unsecured in Resident #12's room. 2. The facility did not ensure LVN A kept the medication cart on 500 Hall locked or within her line of site, while administering medications. This failure could place residents at risk for misuse of medication and overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their own established smoking policy for 3 of 4 residents (Resident #62, Resident #6, and Resident #127) reviewed for smoking. The facility failed to follow the policy on smoking by not completing a smoking screen assessment quarterly on Resident #62, Resident #6, and Resident #127. This failure could place residents at risk of unsafe smoking and injury.

Inspectors wroteBased on interview and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional for 1 of 30 residents (Resident #57) reviewed for comprehensive assessments and timing. The facility did not ensure Resident #57's admission MDS assessment was completed within 14 days of admission. This failure could place residents at risk of not having their needs identified and met.

Inspectors wroteBased on interviews and record review, the facility failed to develop or implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 7 residents reviewed for care plans related to PTSD. (Resident #68) The facility failed to ensure Resident #68's care plan reflected his diagnosis of PTSD, that included triggers for potential re-traumatization. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and potential re-traumatization.

Inspectors wroteBased on observation, interview and record review, 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, personal and oral hygiene for 2 of 30 (Residents #57 and #299) residents reviewed for ADL care. 1. The facility did not ensure Resident #57 was provided his scheduled bath/showers. 2. The facility failed to ensure Resident #299 received his shower as scheduled on 01/22/2024. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on observation, interviews, and record review, the facility failed provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 6 residents (Resident #85) reviewed for medication administration. The facility did not ensure Resident #85's furosemide (diuretic), metoprolol tartrate (blood pressure medication), valproic acid (anticonvulsant), and lacosamide (anticonvulsant) labels from the pharmacy matched the orders placed in the electronic charting system. This failure could place residents at an increased risk for inaccurate drug administration and not receiving the care and services to meet their individual needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 2 residents reviewed for insulin administration. (Resident #300) The facility did not ensure LVN A administered Resident #300's Novolog (insulin aspart) FlexPen (insulin medication) according to the manufacturer's instructions. This failure could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents in obtaining routine dental services to meet the needs of 1 of 2 (Resident #124) residents reviewed for dental services. The facility failed to ensure Resident #124 received dental services when he had jagged, black teeth and missing teeth. This failure could place residents at risk of not receiving needed dental care, difficulty eating, toothaches, tooth infections, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for existing staff, consistent with their expected roles for 1 of 21 employees (ADON) reviewed for required annual trainings. The facility failed to ensure the ADON received required restraint training annually in January 2023. The facility failed to ensure the ADON received required HIV training annually in January 2023. This failure could place residents at risk for inappropriate restraints and exposure to HIV.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 10 (Resident #1) residents reviewed for abuse. The facility failed to protect Resident #1 from physical abuse by CNA A on 5/14/2023. CNA A had a history of a physical abuse allegation in December 2022 towards Resident #2. The facility failed to implement measures to protect residents from further abuse. The facility failed to train staff on how to manage residents with behaviors that could lead to abusive behaviors. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/15/23 at 4:25 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement written policies to prevent abuse, neglect, and exploitation for 1 of 10 (Resident #1) residents reviewed for abuse. The facility failed to follow facility policy of each resident having the right to be free from abuse, corporal punishment, and involuntary seclusion by not protecting Resident #1 from physical abuse by a staff member. The facility failed to implement their policy by providing training to manage residents with behaviors that could lead to abusive behaviors. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/15/23 at 4:25 p.m. [...]

Inspectors wroteBased on interview and records review the facility failed to ensure residents were free of any significant medication errors for 2 of 7(Resident #3 and Resident #4) residents reviewed for medication errors. The facility failed to ensure Resident #3 received only medication he was prescribed. The facility failed to ensure Resident #4 received long-acting insulin instead of short-acting insulin. The noncompliance was identified as PNC. The noncompliance began on 1/14/23 and ended on 5/30/23. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for not receiving the intended therapeutic benefit of the medications or experiencing adverse reactions relating to receiving a medication that was not ordered for them. Finding Include: 1. [...]

Inspectors wroteBased on interview and records review the governing body failed to appoint an administrator who is Licensed by the State, where licensing is required; responsible for management of the facility; and reports to and is accountable to the governing body. The facility failed to appoint a Licensed Administrator after the immediate resignation by the previous Administrator. This failure could result in the facility not being managed in a responsible manner, which could affect the health and safety of all residents. Findings Include: 1. Record review of the Notice of Termination dated 11/09/23 for the previous Administrator indicated the effective date of termination was 11/08/23. The Notice of Termination indicated the previous Administrator's termination reason was resignation. The Notice of Termination indicated the previous Administrator was not eligible for rehire. [...]