Focused Care of Gilmer

Inspectors wroteBased on observations, interviews, 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 4 residents (Resident #1) reviewed for resident rights in that: The facility failed to ensure CNA A provided linen change in a respectful and dignified manner on 7/19/2026. 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 provide sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 1 of 1 facility reviewed for care and services. The facility failed to provide sufficient CNAs according to the facility assessment on 05/18/2026, 05/21/2026, 05/22/2026, 05/23/2026, 05/24/2026, 05/30/2026, 05/31/2026, 06/06/2026, 06/09/2026, 06/13/2026, 06/14/2026, 06/15/2026 This failure placed residents at risk of inadequate supervision, an unsafe environment, falls, serious harm and injury, exacerbations of disease processes, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #1, Resident #2, and Resident #4) reviewed for infection control. The facility failed to ensure CNA B and CNA D followed enhanced barrier precautions when providing care to Resident #1 on 06/16/2026. The facility failed to ensure the ADON and the Treatment Nurse provided proper wound care to Resident #1 on 06/16/2026. The facility failed to ensure Resident #2 had proper signage to indicate he required the use of contact precautions. The facility failed to ensure RN F followed contact precautions when providing wound care to Resident #2 on 06/13/2026. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, for 1 of 1 facility reviewed for call lights. The facility failed to ensure the call light system was functioning properly. This failure could place residents at risk of injury, falls, and unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free from pests in 3 of 3 halls reviewed for pest control. The facility did not maintain an effective pest control program to ensure the facility was free of flies. This failure could place residents at risk for an unsanitary environment and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 4 residents (Resident #2) reviewed for resident neglect. The facility failed to ensure Resident #2 was given lunch and dinner on 06/13/2026. The facility failed to ensure Resident #2 was provided with incontinent care and turning and repositioning every 2 hours on 06/13/2026. These failures could result in pressure injuries, weight loss, infections, psychosocial harm, and a decreased quality of life.

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 receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 3 residents (Resident #3) reviewed for ADLs. The facility failed to ensure Resident #3 received bathing as scheduled for the months of May 2026 and June 2026. This failure could place residents at risk of not receiving needed services and care, decreased self-esteem, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 3 (Resident #1) residents reviewed for quality of care. The facility failed to ensure a skin assessment was conducted on Resident #1 after CNA B observed a new open wound on his front perineal area on 06/17/2026. This failure could place residents at risk for not receiving appropriate care and treatment, a decreased quality of life, and worsening pressure ulcers.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents. The facility failed to ensure CNA B and CNA D performed a proper transfer with the mechanical lift when they caused Resident #1's wheelchair to tip backward and failed to guide the bar of the mechanical lift so it would not make contact with Resident #1's head on 06/17/2026. This failure could place residents at an increased risk of falls and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #1) reviewed for indwelling urinary catheters. The facility failed to ensure Resident #1's urinary catheter was secured to his leg on 06/17/2026. This failure could place residents at risk for damage to the bladder, penis, or urethra (a hollow tube that lets urine leave your body), dislodging of the catheter, and urinary tract infections.

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 2 medication carts (100/300/400 Hall Medication Cart and the 200 Hall Medication Cart) reviewed for drugs and biologicals. The facility failed to ensure LVN O secured the 100/300/400 Hall Medication Cart and the 200 Hall Medication Cart, when they were not in use on 06/17/2026. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #1) reviewed for quality of care. 1. The facility failed to ensure RN A assessed Resident #1's vital signs and neurological status after his fall on 03/23/26. Vital signs were not checked until the next morning when the family requested the Resident to be sent to the emergency room. Resident #1 took Eliquis (anticoagulant medication). 2. The facility failed to obtain, review, and follow-up on Resident #1's hospital records after his return from the emergency room on [DATE]. These hospital records were not obtained until surveyor intervention. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards in that: 1. On 03/23/26, the facility failed to ensure that Resident #1 did not lay on the floor for approximately 2 hours and 20 minutes after falling out of bed. 2. The facility failed to ensure that RN A, LVN B, and CNA C appropriately transferred Resident #1 back to bed post fall. 3. The facility failed to ensure that RN A and CNA C monitored Resident #1 every 2 hours. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 04/07/26 at 10:18AM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide care and services in accordance with activities of daily living for hygiene-bathing, dressing, grooming, and oral care for residents a during a confidential interview for 13 of 13 residents (Unidentified Resident #1, Unidentified Resident #2, Unidentified Resident #3, Unidentified Resident #4, Unidentified Resident #5, Unidentified Resident #6, Unidentified Resident #7, Unidentified Resident #8, Unidentified Resident #9, Unidentified Resident #10, Unidentified Resident #11, Unidentified Resident #12, Unidentified Resident #13)reviewed for ADLs. The facility failed to ensure the residents had a sufficient number of towels in the facility for ADL care. This failure could place residents at risk of no showers, hand hygiene, not receiving services/care and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who need respiratory care were provided with such care, consistent with professional standards of practices for 3 of 25 residents (Resident #14, Resident #35, and Resident #2) reviewed for respiratory care. The facility failed to ensure that oxygen filters were clean for Resident #14's oxygen concentrator. The facility failed to change the oxygen tubing for Resident #35's oxygen concentrator. The facility failed to ensure Resident #2's oxygen reservoir was changed weekly. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments for 3 of 23 residents reviewed for storage of drugs and biologicals (Resident #9, Resident #32, and Resident #30) and 2 of 4 medication carts (Medication Cart #2 and Treatment Cart #4) reviewed for medication storage. The facility failed to securely store wound care chemicals for Resident #9. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that:1. The facility failed to dispose of expired prepackaged green onions that were actively decomposing.2. The facility failed to label and date bread, butter, and baked items. These deficient practices could place residents who received meals from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 16 residents (Resident # 17, Resident #52, and Resident #69) reviewed for resident rights.1. The facility failed to ensure Resident #17 was able to access her bedroom furnishings.2. The facility failed to ensure Resident #69 was able to access her call light. This failure could place residents at risk for unmet needs and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident had the right to be free from misappropriation of property and exploitation for 1 of 4 residents (Resident #3) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #3's Hydrocodone (Norco) (a combination medicine that is commonly taken for severe pain). This failure could place residents at risk for uncontrolled pain. Record review of Resident #3's face sheet, dated 2/24/2026, indicated Resident #3 was an [AGE] year-old male who was readmitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #35) reviewed for care plans. The facility failed to implement the comprehensive person-centered care plan for Resident #35 by not documenting resident's need for oxygen therapy. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 5 residents (Resident #16 and Resident 64) reviewed for skin integrity. The facility failed to ensure Resident #16 and Resident 64's pressure- redistribution mattress (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was on the correct settings. This failure could place residents at risk for developing pressure ulcers and could contribute to developing avoidable pressure ulcers.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who had an indwelling catheter with a drainage bag had a securing device for 1 of 5 residents (Resident #18) reviewed for catheter care. The facility failed to ensure Resident #18's indwelling foley catheter (drains urine from your urinary bladder into a bag outside your body) had a catheter securement device to anchor the catheter to her leg. This failure could place residents at risk for friction, pulling, pain and trauma.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 16 residents (Resident #18 and Resident #36) reviewed for infection control practices. 1. The facility failed to ensure CNA B removed her gown when she entered the hallway to get gloves while providing incontinent care and catheter care for Resident #18 on enhanced barrier precautions on 2/22/26. 2. The facility failed to ensure Resident #36's feeding tubing port was capped and off the floor. These failures could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 3 residents (Resident #52) reviewed for resident call system. The facility failed to ensure Resident #52 had a call light button attached to the call light system. Resident #52 did not have a call light available from 2/22/26 until 2/24/26. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity.

Inspectors wroteBased on interview and record review, the facility failed to provide normal transportation for residents to medical services outside of the facility for 1 of 6 residents (Resident #1) reviewed for transportation. The facility failed to provide transportation for Resident #1 to a doctor's appointment on 10/14/25. This failure could place residents at risk of possible adequate evaluation, hospitalization and unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 11 residents (Resident #3) reviewed for the physical environment. The facility failed to ensure Resident #3's room was clean and free of strong urine odors. This failure could place residents at risk for a decreased quality of life and an unsanitary environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 residents (Resident #1 and Resident #2) reviewed for incontinent care. 1. The facility failed to ensure CNA A changed gloves and performed proper hand hygiene before going from dirty to clean during Resident #1's catheter and incontinent care on 11/25/25. 2. The facility failed to ensure CNA B performed hand hygiene before applying new gloves and changed gloves before going from dirty to clean during Resident #2's incontinent care on 11/25/25. These deficient practices could place residents at risk for decreased quality of life, infection, and skin breakdown due to improper care practices.

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 1 of 1 residents reviewed for infection control practices (Resident # 7). 1. The facility failed to ensure CNA A and CNA B wore personal protective equipment while providing incontinent care for Resident #7 who was on EBP with a Foley catheter (a thin, flexible tube inserted through the urethra into the blader to facilitate urine drainage), Gastrostomy tube (is a feeding tube that delivers nutrition to your stomach) and a wound on 11/1/2025. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 5 residents (Resident #1, Resident #41 and Resident #206) reviewed for pharmaceutical services. The facility failed to ensure Physician Ordered medications were ordered and available for administration for each of the 3 residents (Resident #1, Resident #41 and Resident #206). 1. MA E did not administer Resident #1's Pepcid (used to treat gastroesophageal reflux) 20 milligrams medication during a medication pass on 12/03/2024 as ordered by the physician on 06/24/2022. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the medication error rates were not 5 percent or greater. The facility had a medication error rate of 15.22%, based on 7 errors out of 46 opportunities, which involved 4 of 5 (Resident #1, Resident #17, Resident #41 and Resident #206) residents and 1 of 1 medication aide (MA E) and 1 of 1 LVN reviewed for medication errors. 1. MA E did not administer Resident #1's Pepcid during the medication pass as ordered by the physician on 12/3/24 due to medication not available. 2. MA E failed to administer the correct dose of vitamin C to Resident #17 on 12/03/2024 as ordered by the physician and mixing a medications and protein supplement (polypharmacy) together instead of preparing them individually. 3. [...]

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 for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food stored in the kitchen refrigerator was labeled, dated and not expired. 2. The facility failed to ensure food stored in the kitchen dry storage area was not expired. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for three of twelve Residents (Resident #21, Resident #42 and Resident #23) reviewed for food and nutrition services. 1. The facility failed to ensure the refrigerator for Resident #21 was clean and contained food items that were labeled and dated. 2. The facility failed to ensure the refrigerator for Resident #42 did not contain expired broccoli cheddar soup. 3. The facility failed to ensure the refrigerator for Resident #23 did not contain expired peaches and pears. These failures could place residents at risk for foodborne illness.

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 4 of 7 residents (Resident #1, #17, #41, and #206) and 3 of 5 staff (MA E, CNA C, and CNA D) reviewed for infection control. 1. CNA C and CNA D failed to change gloves and perform hand hygiene during incontinent care for Resident #17 on 12/02/2024. 2. MA E failed to sanitize her hands while administering medications to Resident # 1, Resident #17, Resident #41 and Resident #206 on 12/03/24. 3. MA E failed to clean and disinfect the blood pressure cuff used on Resident #17 and Resident #41 after use during medication pass on 12/3/2024. [...]

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 and personal and oral hygiene for 1 of 12 residents (Residents #30) reviewed for activities of daily living. The facility failed to ensure Resident #30 received nail care. This failure could place residents at risk of not having their needs met which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relayed the call directly to a staff member or to a centralized staff work area from toilet and bathing facilities for 2 of 18 residents (Residents #107 and #110) reviewed for call lights . The facility failed to ensure Residents #107 and #110's bathrooms had a call light pull cord on 12/02/2024 and 12/03/2024. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program for 2 of 15 employees (CNA G and CNA L) reviewed for training. The facility failed to ensure the quality assurance and performance improvement training was provided to CNA G and CNA L. This failure could place residents at risk for not being aware of facility programs, implementation, and monitoring.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 9 residents (Resident #'s 1 and #2) reviewed for abuse. The facility failed to ensure CNA G did not verbally and physically abuse Resident #1 during incontinent care. The facility failed to ensure CNA G did not verbally and physically abuse Resident #2 during incontinent care. This failure could place residents at risk of abuse, humiliation, intimidation, fear, mental distress, depression, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen. * The facility failed to ensure baking sheets did not have brown and/or black baked on build up and stacked together. * The facility failed to ensure muffin pans did not have brown baked on build up and stacked together. * The facility failed to ensure a scoop was not left in the bulk corn meal. * The facility failed to ensure the ice machine did not have a pink slimy substance in the drop chute. This failure could place residents who ate food from the kitchen at risk of foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS fiscal year 2023 for 2 of 4 quarters reviewed for payroll data information. (Quarter 1 and Quarter 4) The facility failed to submit accurate staffing information to CMS for the 1st and 4th quarter of the fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 10 residents reviewed for comprehensive care plans. (Residents #6 and #42) The facility did not develop a care plan for Resident #6 addressing his smoking, behaviors, resistance to care, or his full code status upon readmission. The facility did not develop a care plan for Resident #42 addressing his bipolar disorder diagnosis, Factor 5 Leiden mutation diagnosis, or anticoagulant medication upon admission. This failure could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 2 errors out of 32 opportunities, resulting in a 6.25% percent medication error involving 1 of 6 residents (Residents #37) reviewed for medication pass. MA A failed to administer 2 scheduled doses of the medication Lyrica 50 mg (used to treat chronic pain) as ordered by the physician for Resident #37 on 11/13/23 beginning at 9:08 a.m. This failure could place residents at risk for inaccurate drug administration resulting in a decline in health and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 12 residents (Resident #4) reviewed for MDS assessment accuracy. The facility did not accurately document Resident #4's weight and inaccurately indicated weight loss on her MDSs dated 10/07/22, 12/16/22, 02/07/23, 05/05/23, and 08/05/23. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals identified with MI, DD or ID were screened for 1 of 6 residents reviewed for PASRR (Resident #42) The facility did not have an accurate PASRR level 1 screening for Resident #42 upon admission, therefore a PASRR Evaluation was not conducted. This failure could place residents who have a diagnosis of mental disorder, developmental disability or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 2 residents (Residents #38) reviewed for enteral feeding. The facility failed to change Resident #38's enteral feeding set/bag every 24 hours on 11/12/23 and did not follow physician order to provide enteral feeding only 20 hours daily on 11/13/23. These failures could place residents receiving enteral nutrition at increased risk of not receiving the proper nutrition and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 2 errors out of 32 opportunities, resulting in a 6.25% percent medication error involving 1 of 6 residents (Residents #37) reviewed for medication pass. MA A failed to administer 2 scheduled doses of the medication Lyrica 50 mg (used to treat chronic pain) as ordered by the physician for Resident #37 on 11/13/23 beginning at 9:08 a.m. This failure could place residents at risk for inaccurate drug administration resulting in a decline in health and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs when used without adequate monitoring for 1 of 13 residents (Resident #13) reviewed for unnecessary medication. The facility failed to monitor Resident #13 for side effects from 11/01/23 to 11/15/23 of the anticoagulant medication Eliquis (a blood thinning medication). This failure could place residents at risk for adverse consequences such as bleeding, bruising, and black colored stools related to the use of the anticoagulant medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 1 for 5 residents (Resident #3) reviewed for infection control during medication pass. The facility failed to ensure MA A did not touch medications with her bare hand on 11/13/23 at 9:50 a.m. This failure could place residents at risk for the spread of infection and cross contamination.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 4 residents (Residents #1 and #2) reviewed for abuse. The facility failed to implement their Abuse Policy and ensure all allegations of abuse were reported to HHSC within 2 hours of the allegation for Residents #1 and #2. This failure could place residents at risk of further abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator or the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for 2 of 4 residents (Residents #1 and #2) reviewed for abuse. The facility failed to report allegations of abuse immediately, but not later than 2 hours to HHSC when Resident #1 was in Resident #2's room yelling at him. This failure could place residents at risk of verbal abuse, mental anguish, and emotional distress.