Harmony Care at Beaumont

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 8 resident rooms (room [ROOM NUMBER]) reviewed for environment. The facility failed to repair a missing closet door and replace torn/worn curtains in a timely manner in room [ROOM NUMBER] as of 07/23/26. The facility failed to ensure one closet was clean and free of spider webs, insect carcasses, and a ball shaped brown unknown substance in room [ROOM NUMBER] as of 07/23/26. These failures could place residents at risk of an uncomfortable environment and a decrease in quality of life and self-worth.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents received adequate supervision, to the extent possible for 1 of 3 residents that smoke on the secure unit (Resident #33), 3 of 3 residents (Residents #6, #9 & #14) of the general population that smoke and for 1 of 1 unoccupied resident room reviewed for safety. 1. The facility failed to ensure Resident #6, and Resident #14 did not smoke unsupervised within 25 feet of the flammable gas water heater. 2. The facility failed to ensure Resident #33's environment was free of hazards, on 4/13/26 Resident #33 was observed smoking outside on the secure unit patio area, there was no designated signage, no fire extinguisher, no fire blanket, no ash tray and no fire-safety can. 3. On 4/13/26 the facility failed to supervise Resident #9 while smoking. 4. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure they had an RN for 8 consecutive hours 7 days a week for 1 of 3 months reviewed for RN coverage. The facility did not have 8 hours of RN coverage on 12/13/2025, 12/14/2025, 12/20/2025, 12/21/2025, 12/27/2025, and 12/28/2025. This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions for 1 of 1 kitchen reviewed for food served under sanitary conditions. The facility failed to ensure the ham (approximately 10-inch by 4-inches) was stored in the refrigerator, covered and on a clean surface. The facility failed to ensure the deep fryer did not have dark cooking oil and was free of thick black buildup of grease and burnt food particles around to top of the deep fryer. The facility failed to ensure the kitchen hallway were free of a trash can with trash piled 3 feet above the can and on the floor approximately 3 feet around the trash can. These failures could place residents at risk for food contamination, food borne illness and a diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also consider non-smoking residents for 1 of 2 smoking areas (main smoking area under the car port) reviewed for smoking safety. The facility failed to ensure paper and plastic trash were not discarded into the fire safety cans on 04/13/26. This failure could place residents at risk of injury, burns, and an unsafe smoking environment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the nurse call system was accessible for 1 of 6 (Resident #30) reviewed for resident call system. The facility failed to ensure Resident #30'a call light was within reach after her incontinent care was finished on 04/13/2026. This failure could place the residents at risk of not being able to directly contact the staff to obtain assistance for activities of daily living or help in an event of an emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 20 residents (Resident #6) reviewed for MDS assessment accuracy. The facility incorrectly coded Resident #6's annual MDS assessment dated [DATE] as not using tobacco when he did use tobacco. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review 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 of 3 residents (Resident #30) reviewed for baseline care plan. The facility failed to revise Resident 30's baseline care plan included her g-tube This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were given the appropriate treatment and services to maintain or improve his or her ability to carry out activities of daily living (ADLs) to maintain good personal hygiene, for 1 of 3 residents (Resident #30) reviewed for ADLs. The facility failed to ensure Resident #30 was provided with a shower on 04/08/2026, 04/10/2026, and 04/13/2026. This failure could place residents at risk of not receiving care and services needed to maintain quality of life and prevent decline in their mental and psychological well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for 4 residents of 14 sampled reviewed for the environment. The facility did not maintain an effective pest control program to ensure the Resident #6 and Resident #34's room was free of gnats and flies. The facility did not maintain an effective pest control program to ensure Resident #23 and Resident #45's room was free of roaches. The failures could place residents at risk of potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the residents had the right to be free from abuse for 1 of 7 (Resident #1) residents reviewed for abuse. The facility failed to ensure Resident #1 was free from physical abuse by CNA B. The non-compliance was identified as PNC. The IJ began on 03/05/26 and ended on 03/13/26. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk for abuse/neglect, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to determine that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 2 of 4 months of controlled drug count records reviewed. The facility failed to ensure the controlled drug (medication) count record was signed acknowledging that the controlled drugs (medications) were counted by LVN A, LVN B, LVN C, MA D, LVN E and LVN F. The facility failed to ensure LVN A, LVN B, LVN C, MA D, LVN E and LVN F signed the controlled drug count records acknowledging the controlled drugs were counted and correct each time they took possession of the medication cart for the months of January and February. This failure could place the facility at risk for drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse for 1 of 19 residents reviewed for abuse. (Resident #39)The facility failed to ensure Resident #39 was free from physical abuse when on 11/30/25 CNA A slapped Resident #39 in the face. The noncompliance was identified as PNC. The IJ began on 11/30/25 and ended on 11/30/25. The facility corrected the noncompliance before the survey began. This failure could place residents at risk for emotional distress, fear, decreased quality of life, and further abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure they had an RN for 8 consecutive hours 7 days a week for 8 of 8 months reviewed for RN coverage. * The facility did not have RN coverage every day in April 2025, May 2025, June 2025, August 2025, September 2025, October 2025, and November 2025.* The facility did not have an RN for 8 consecutive hours every day in April 2025, May 2025, June 2025, July 2025, and August 2025. These failures could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters.

Inspectors wroteBased on interview and record review the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 4 quarters reviewed for payroll data information. (Quarter 3 2025) *The facility failed to submit staffing information to CMS for the 3rd quarter of the fiscal year 2025. 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 observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 2 units (secure unit) and room [ROOM NUMBER] and room [ROOM NUMBER] reviewed for homelike environment. 1. The facility failed to provide home-like furniture in TV room and dining room area just with a table. 2. The facility failed to ensure the walls of room [ROOM NUMBER] and room [ROOM NUMBER] did not have scratches and areas of missing paint. 3. The facility failed to provide a clean and sanitary bathroom for room [ROOM NUMBER]. These failures placed the staff and visitors at risk of living and working in conditions of institution which can lead to decline of mental, social skills and increase of behaviors.

Inspectors wroteBased on interview and record review the facility failed to implement the written abuse policy that prohibit mistreatment, neglect, and abuse of residents, for 7 of 7 staff reviewed for abuse. (LVN A, LVN F, Former SW, CNA B, CNA G, CNA M, and CNA Q)The facility did not screen potential employees LVN A, LVN F, Former SW, CNA B, CNA G, CNA M, and CNA Q to include attempting to obtain information from previous employers and/or current employers. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure food items in the dry pantry were labeled, dated, and sealed. This failure could place residents that eat out of the kitchen at risk for foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility's governing body failed to operate and provide services in compliance with all applicable Federal, State and local laws, regulations, and codes for 1 of 1 facility reviewed for Social Worker (SW). The facility did not employ or contract a SW as required by state regulations. This failure could place residents at risk of administrative duties not being carried out attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain essential equipment in safe operating condition for 1 or 1 facility kitchen. The walk-in freezer had excessive accumulation of ice build- up. This failure had the potential to affect residents by placing them at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for staff for 1 of 1 facility kitchen floor reviewed for environmental concerns. The floor under the back of the stove was missing 8-10 tiles. These failures could place staff at risk for exposure to an unclean, unsanitary environment, risk of falls and other injuries due to an unsafe environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 of 10 residents (Resident #9) reviewed for advanced directives. The facility failed to ensure Resident #9 who was listed as a DNR (Do Not Resuscitate) had valid Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that was not missing required information. This failure could place residents at risk of not having their end-of-life wishes honored and incomplete records.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident drug regimen was free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications. (Resident #4)* The facility did not have appropriate diagnoses for Resident #4's Abilify (antipsychotic).* The facility did not have behavior monitoring for Resident#4's Lexapro (antidepressant). These failures could place residents at risk for unintended, harmful events attributed to the use of a medication without the appropriate monitoring or indication for use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 1 of 16 residents reviewed for accuracy of assessments. (Resident #16) The facility did not accurately complete the MDS assessment to indicate Resident #16 used tobacco. This failure could place the 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 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 of care for 1 of 3 residents (Resident #16) reviewed for new admissions. The facility did not accurately complete a baseline care plan within 48 hours of admission for Resident #16 to address his smoking. This failure could lead to residents not receiving necessary care and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 16 residents (Resident #4) reviewed for care plans. The facility failed to ensure that Resident #4's care plan addressed his psychiatric diagnoses or his psychotropic medications. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 1 treatment carts (treatment cart) of 1 of 3 medication carts (200 Hall cart) reviewed for medication storage. - The facility failed to ensure the medication treatment cart was locked when left unsecured and unsupervised at the main nurse station. - The facility failed to ensure Hall 200 Nurse Cart was locked when left unsecured and unsupervised at the main nurse station. These failures could place residents at risk of adverse reactions to medications, misappropriation of medications and not receiving therapeutic effects of medication.

Inspectors wroteBased on observations, interviews, and record reviews 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 during medication pass for 1 of 4 medication carts (Hall 200 medication cart) reviewed for infection control. The facility failed to ensure the Hall 200 medication cart was clean and free of spills and buildup of grime. This failure could place residents at risk for medications being stored in unsanitary cart and infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow their own established smoking policy for 1 (Residents #30) of 2 residents reviewed for smoking. The facility failed, on12/03/25, to ensure that Resident #30 did not keep his personal cigarettes and lighter in his possession and was attempting to smoke unsupervised. This failure could place residents at risk of an unsafe smoking environment and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse and neglect for 10 of 25 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #9, Resident #11, Resident #14, and Resident #216) reviewed for abuse. 1. The facility failed to ensure Resident #6 was free from sexual abuse when Resident #25 came into Resident #6's room and rubbed her right leg under the covers on 08/21/2025.2. The facility failed to ensure Resident #5 was free from physical and verbal abuse by CNA F when CNA F called Resident #5 retarded, pushed and held him down on the bed during incontinent care, pulled him off the low bed, landing on the floor and held him down by his shoulder trying to put his shirt on and pinned him against the wall and stomped on his feet on 7/01/2025. 3. [...]

Inspectors wroteBased on observation, 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 measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 7 of 25 residents (Resident's #1,2,3,4,5, 6, 25) reviewed for care plans. 1. The facility failed to develop and implement interventions in Resident #25's the care plan revised 08/22/2025 to prevent Resident #25's inappropriate and unwanted touching of Resident #6 on 08/21/25. 2. The facility failed to ensure Resident #1's care plan was updated to indicate Resident #1 had an incident of resident-to-resident aggression on 03/19/2025, 07/24/2025 and 09/05/2025. 3. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the abuse coordinator for immediate intervention and all alleged violations involving abuse were reported no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency in accordance with State law through established procedures for 3 of 25 residents (Resident #5, #7 and #8) reviewed for abuse. 1. The facility failed ensure ST R reported a witnessed allegation of physical and verbal abuse immediately to the Abuse Coordinator approx. 1.5 weeks prior to 7/1/2025. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for the residents in rooms #203, #215, and #220 (three of ten resident rooms) that were observed for physical environment. 1. The facility failed to ensure the rooms and bathrooms for rooms #203, #215, and #220 were clean and free of dead bug carcasses and dead cock roaches on 09/22/2025 and 09/23/2025.2. The facility failed to ensure the bathroom vanity for room [ROOM NUMBER] was in good repair. Two of two doors for the bathroom vanity were missing on 09/23/25. 3. The facility failed to ensure the broken and missing tile was repaired and replaced in the bathroom for room [ROOM NUMBER] and caulk and flooring around the toilet were stain free on 09/23/25. These failures could place the residents at risk for diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 5 residents (Resident #16) reviewed for infection control. CNA W and CNA CD did not complete hand hygiene after changing gloves and when going from dirty to clean, while providing incontinent care for Resident #16. This deficient practice could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive plan of care was developed within 7 days after completion of the comprehensive assessment and revised to reflect the current status for 3 of 5 residents (Resident #2, Resident #3, and Resident #4) reviewed for care plan timing The facility did not develop a comprehensive care plan within 7 days of the completion of the comprehensive assessment for Residents #2, #3, and #4. This failure could place residents at risk of not receiving appropriate care and services timely.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 1 of 5 residents (Resident #2) reviewed for accuracy of assessments. The facility did not accurately complete the MDS assessment to indicate Resident #2's active diagnoses. This failure could place the 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 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 4 residents (Residents #1) reviewed for infection control. The facility failed to ensure LVN A utilized enhanced barrier precautions with wearing a gown while providing wound care to Resident #1. These failures could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for the residents in rooms 217 through 224 (8 rooms for this hallway) and 1 resident of 8 residents (Resident #1) that were observed for physical environment. The facility failed to ensure the hallway and the attached rooms 217 through 224 were free of odors. The facility failed to ensure a dresser in Resident #1's room was in good repair. These failures could place the residents at risk for diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program, so the facility was free of pests and rodents for five (Residents #1, # 2, #3, #4, and #5) of fifty-five residents reviewed for effective pest control. The facility failed to ensure Resident #1, # 2, #3, #4, and #5's rooms were free of pests. These failures could place residents at risk of exposure to bugs and bug bites.

Inspectors wroteBased on interviews and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 5 (Resident #1) residents reviewed for grievances. The facility did not thoroughly investigate or take prompt action to resolve grievances voiced by Resident #1 that she did not want CNA A or CNA B enter her room or provide care. This failure could place residents at risk of unresolved grievances and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week reviewed for RN coverage for 24 of 45 days reviewed for nursing services. (10/7/24, 10/9/24, 10/10/24, 10/11/24,10/14/24, 10/15/24, 10/21/24, 10/22/24, 10/23/24, 10/24/24, 10/25/24, 10/28/24, 10/29/24, 10/30/24, 10/31/24, 11/1/24, 11/2/24, 11/3/24, 10/19/24, 10/20/24, 11/9/24, 11/10/24, 11/16/24 and 11/17/24) The facility did not have 8 consecutive hours a day for 7 days a week of RN coverage for 24 days. This failure could place residents at risk of lack of nursing oversight and a higher level of care.

Inspectors wroteBased on interview and record review, the facility failed to electronically 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 for 2 of 3 quarters reviewed for administration (Quarter 2 2024 (January 1-March 31), Quarter 3 2024 (April 1-June 30), Quarter 4 2023 (July1- September 30) 1. The facility failed to submit staffing information to CMS for FY Quarter 2 2024 (January 1-March 31); and 2. The facility failed to submit staffing information to CMS for FY Quarter 3 2024 (April 1-June 30). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stove, 1 of 2 walk-in coolers, 1 of 1 milk box in the kitchen; and 1 of 15 resident rooms on 1 of 2 Halls (long part of Hall 200) reviewed for essential equipment. * The facility failed to ensure the gas stove was in safe operating condition. Two burners on the back of the stove and 1 burner on the front of the stove would not ignite when the knobs were turned. The side of the griddle next to the burners had black buildup. * The facility failed to maintain the walk-in freezer. The walk-in freezer had a door gasket that was loose and hanging. * The facility failed to maintain the milk box. The milk box had a loose gasket with mildew on it. [...]

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 did not ensure baking sheets and baking pans did not have dark colored build up on the outside and inside. The facility did not ensure the foods labeled were disposed of after the use by date. The facility did not ensure foods removed from their original package were labeled with the required information of what the food was in the container and the use by date or date it was placed in the container. The facility did not ensure red bucket of sanitizing solution to clean surfaces in the kitchen had the right amount of cleaning solution. These failures could place residents who ate food from the kitchen at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for 1 of 2 Halls (Hall 200 long) and the dining room reviewed for physical environment. The facility failed to maintain the 200 long hall. Door frames of resident's rooms were not intact. Floor tiles were discolored tiles. There was a buildup of glue, paint, and debris behind all the doors to resident's rooms. The facility failed to maintain the exit corridor from the long hall 200 to the smoking area. There were 6 missing floor tiles that each measured 12 inch by 12 inch. The facility failed to maintain the main dining room floor. The tile in the main dining room along the back wall on the floor had a 2-inch-wide buildup of old paint and dried glue. There was one missing tile near the door. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 1 (Resident #28) of 13 residents reviewed for pharmacy services. The facility failed to ensure Resident #28's nystatin powder (prescription powder treats fungus or yeast) was not left on her nightside table and within the eyesight of the nurse This failure could place residents at risk for medication overdose, medication under-dose, ineffective therapeutic outcomes, and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse for 2 of 15 residents (Residents #1 and Resident #2) reviewed for abuse. The facility failed to ensure Resident #1 and Resident #2 were free from sexual abuse. On 6/15/2024 at 2:03 p.m., Resident #1 provided oral sex to Resident #2 in the dining room of the facility. The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 06/15/2024 and ended on 10/07/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse were reported, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, to the State Survey Agency, for 4 of 15 residents (Resident #4, Resident #5, Resident #6, and Resident #7) reviewed for reporting allegations of abuse. 1. The facility failed to report an allegation of abuse to the State Agency within 2 hours when it was reported on 01/25/2024 that Resident #4 cursed at and hit Resident #5. 2. The facility failed to report an allegation of abuse to the State Agency within 2 hours when it was reported on 08/27/2024 that Resident #6 hit Resident #7. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the PASRR comprehensive service plan was implemented for 1 of 2 residents reviewed for PASRR assessments. (Closed Record #8) The facility did not provide and arrange for specialized physical therapy, occupational therapy, and speech therapy services for Closed Record #8 as recommended and agreed upon by the IDT within the time frame set by PASRR. This failure could place residents who are PASRR positive at risk of not receiving the necessary services that would enhance their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse for 2 of 6 residents (Residents #Unnamed & Resident #4) reviewed for abuse. 1. On 08/02/24 Resident #1 was grabbing Resident #Unnamed breasts. 2. On 08/25/24 Resident #1 touched Resident #4's breast. On 10/05/24 at 4:40 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/06/24, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of the Plan of Removal. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 6 residents (Resident #4 and Resident #Unnamed) reviewed for abuse and neglect. 1. The facility failed to implement their written policies and procedures to prevent sexual abuse and potential further sexual abuse by Resident #1 when Resident #1 grabbed Resident #Unnamed's breast. 2. The facility failed to implement their written policies and procedures to prevent sexual abuse and potential further sexual abuse by Resident #1 when Resident #1 touched Resident #4's breast. On 10/05/24 at 4:40 p.m. an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure they had a full time DON and failed to ensure there was an RN for 8 consecutive hours 7 days a week for 1 of 1 facility reviewed for DON and RN coverage. The facility did not have a full-time DON as of 08/16/24. The facility did not have RN coverage for 8 consecutive hours on from 09/16/24 through 09/20/24, 09/23/24 through 09/25/24, 09/27/24, and 09/30/24. These failures could place residents at risk of lack of nursing oversight and a higher level of care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record, and indicate the duration for the PRN order for 3 of 3 residents (Resident #s 1, 2, and 3) reviewed for pharmacy services. 1. The facility failed to ensure Residents #1, #2, and #3 had a stop date for PRN anti-anxiety and antipsychotic medications. 2. The facility failed to monitor Resident #1's behaviors for his prescribed Ativan during the months of August and [DATE]. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse were reported, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, to the State Survey Agency, for 2 of 6 residents (Resident #Unnamed and Resident #4) reviewed for reporting allegations of abuse. The facility failed to report an allegation of sexual abuse to the State Agency when it was reported on 08/02/24 that Resident #1 touched Resident #Unnamed breasts. The facility failed to report an allegation of sexual abuse to the State Agency when it was reported on 08/25/24 that Resident #1 touched Resident #4's breast. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interview and record review the facility failed to maintain acceptable parameters, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise and the facility failed to offer a therapeutic diet when there was a nutritional problem and the healthcare provider ordered a therapeutic diet for 5 of 5 residents (Resident #s 1, 2, 3, 4, and 5) reviewed for weight loss and nutrition. The facility failed to ensure systems were in place to monitor for weight changes. 1. The facility failed to ensure Resident #1 did not sustain a significant weight loss of 47 lbs./20% weight loss X 1 month, 51 lbs./22% weight loss X 3 months, and 49 lbs./21% weight loss X 6 months. 2. [...]

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 7 residents (Resident #6) reviewed for infection control. 1. The facility failed to ensure Resident #6's central line (a tube that is inserted into a large vein in the neck, chest, groin, or arm to give fluids, blood, medications, or to do medical tests quickly) dressing was changed every seven days per the physician's order. 2. The facility failed to ensure the Treatment Nurse changed gloves and performed hand hygiene between glove changes during wound care, after picking up a packaged mint off the floor, and before and after entering and exiting Resident #6's room. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care and that was developed within 48 hours of a resident's admission for 1 of 7 residents (Resident #6) reviewed for baseline care plans. The facility failed to ensure Resident #6 had a baseline care plan completed within 48 hours of his admission on [DATE]. This failure could place newly admitted residents at risk of receiving inadequate care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 7 residents (Resident #9) reviewed for care plans. The facility failed to ensure Resident #9's care plan was not closed on 12/19/23 and was being reviewed and revised quarterly. This failure could place residents at increased risk of not having their individual needs met and a decreased quality of life.

Inspectors wroteBased observation, interview and record review the facility failed to ensure a resident with limited range of mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable for 1 of 5 residents (Resident #1) reviewed for range of motion. The facility failed to assess and provide hand rolls and/or positioning devices in Resident #1's right hand to prevent future decline in ROM. This failure could place resident 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 permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for 1 of 6 residents (Resident #1) reviewed for discharge requirements. The facility failed to ensure Resident #1 was readmitted to the facility, after being treated at a behavior hospital. This failure could place discharged residents and residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after they were hospitalized for 1 of 6 residents (Resident #1) reviewed for discharge requirements. The facility failed to follow the written policy to ensure Resident #1 was readmitted to the facility, after being treated at the Behavior Hospital and after being treated at Hospital C. This failure could affect discharged residents and placed residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts were made to resolve resident grievances for 1 of 22 residents (Resident #2) reviewed for grievances. There was no grievance available or evidence of resolution when Resident #2 reported to CMA H she did not want CNA M to come in her room or provide her care. This failure could place all residents at risk of unresolved grievances and decreased quality of life.

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 includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 12 residents (Resident #1) reviewed for comprehensive person-centered care plans. The facility failed to develop and implement a care plan for Resident #1's aggressive behaviors toward others. This failure could place residents at risk of not having individual needs met and a decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure services provided or arranged by the facility as outlined by the comprehensive care plan meets professional standards of quality for 3 of 6 residents (Resident #s 1, 2, and 3) reviewed for skin assessments. The facility failed to ensure Residents #1, #2, and #3 received a weekly skin assessment. This failure could place the resident at increased risk of not having their individual needs met and of not receiving adequate care and medical interventions to maintain their health and prevent worsening health conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene for 1 of 12 residents (Resident #1) reviewed for ADLS. The facility failed to ensure Resident #1's fingernails were trimmed. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of physical, mental and psycho-social well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to immediately consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental or psychosocial status for 2 of 7 residents (Resident #1 & #2) reviewed for resident rights. The facility failed to ensure Resident #1's physician and responsible party were immediately notified on 04/19/24 after Resident #1 placed a pillow over Resident #2's face and said she tried to kill her. The facility failed to ensure Resident #2's physician was immediately notified on 04/19/24 after she reported Resident #1 had put a pillow over her face while she was sleeping and tried to kill her. On 04/22/24 at 11:03 a.m., an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse for 2 of 7 residents (Residents #2 and #3) reviewed for abuse. 1. On 04/03/24 Resident #3 self-propelled her wheelchair into Resident #1's room and Resident #1 pulled Resident #3 out of her wheelchair onto the floor. 2. On 04/19/24 Resident #1 placed a pillow over the face of Resident #2 and later admitted she was trying to kill Resident #2. On 04/20/24 at 02:29 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/21/24, the facility remained out of compliance at a severity level with the potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of thei Plan of Removal. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents and supervision. The facility failed to place Resident #1 on one-on-one supervision or move her to a private room after she pulled Resident #3 out of her wheelchair after Resident #3 self-propelled her wheelchair into Resident #1's room. The facility failed to place Resident #1 on one-on-one supervision after Resident #1 tried to kill Resident #2 (her roommate) by placing a pillow over her face. On 04/20/24 at 02:29 p.m. an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment for 3 of 7 residents (Residents #1, #2, and #3) reviewed for comprehensive person-centered care plans. 1. Resident #1's comprehensive person-centered care plan was not updated to reflect behavior of physical aggression toward another resident. 2. Resident #2's comprehensive person-centered care plan was not updated to reflect an altercation when another resident had been physically aggressive with her. 3. Resident #3's comprehensive person-centered care plan was not updated to reflect when another resident had been physically aggressive with her. These failures could place residents at risk for not receiving the necessary care and services they required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 2 residents (Resident #1) reviewed for CPR. The facility failed to ensure staff utilized the AED (automated external defibrillator- a medical device that analyzes the heart's rhythm and, if necessary, delivers an electrical shock to the heart in attempt to re-establish an effective rhythm) when Resident #1 was found on [DATE] unresponsive, not breathing, and no pulse. Resident #1 was pronounced deceased on [DATE]. An IJ was identified on [DATE] at 3:57 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was consulted for a change of condition for 1 of 11 residents (Resident #1) reviewed for notification of changes. The facility did not notify the physician when Resident #1 had a decline of meal intake. This failure could place residents at risk for delay in treatment and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Resident #1 received treatment and care in accordance with professional standards of practice for 1 of 11 resident (Resident #1) reviewed quality of care. The facility did not notify the physician when Resident #1 had a decline of meal intake. The facility did not obtain labs- CBC (complete blood count- used to measure different parts and features of blood), CMP (Complete Metabolic Panel-test used to monitor the blood sugar levels, the balance of electrolytes and fluid as well as the health of kidneys and liver), lipid (levels of cholesterol and other fats in the blood), A1C (blood test that measures average blood sugar levels over the past 3 months), thyroid (blood tests used to measure how well the thyroid gland is working), vitamin B12 and vitamin D hydroxy 25 as ordered by NP C on 02/23/24. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain laboratory services ordered by physician for 1 of 11 residents (Resident #1) reviewed for labs. The facility did not obtain labs- CBC (complete blood count- used to measure different parts and features of blood), CMP (Complete Metabolic Panel-test used to monitor the blood sugar levels, the balance of electrolytes and fluid as well as the health of kidneys and liver), lipid (levels of cholesterol and other fats in the blood), A1C (blood test that measures average blood sugar levels over the past 3 months), thyroid (blood tests used to measure how well the thyroid gland is working), vitamin B12 and vitamin D hydroxy 25 as ordered by NP C on 02/23/24. This failure could place residents at risk of a delay in treatment.

Inspectors wroteBased on interview and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure all allegations of abuse or neglect were reported to the Administrator immediately. This failure could place residents at risk of 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, which included 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 of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure the abuse coordinator and/or designee reported immediately to HHSC after Resident #1 threatened if she had a knife she would stab herself and someone else in the heart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy for 4 of 7 residents (Residents #1, #2, #3, and #4) reviewed for personal privacy in that: CNA A failed to provide privacy for Resident #1 during bed mobility and personal care while Resident #2 was in the room. The facility failed to provide privacy for Residents #3 and #4. The room did not have a privacy curtain to allow for privacy when the residents were in the room. These failures could place residents at risk for low self-esteem, loss of dignity, and decreased quality of life due to a lack of privacy during their care.

Inspectors wroteBased on observation and interview, the facility failed to equip each room to assure full visual privacy for each resident for 2 (Rooms 221 A & B and room [ROOM NUMBER] A & B) of 26 dual rooms reviewed for privacy. The facility failed to provide curtains to ensure residents' privacy in 2 dual occupancy rooms throughout the facility. This failure could place residents at risk of decreased self-worth by being exposed during resident care.