Paradigm at the Oak

Inspectors wroteBased on interview and record review, the facility failed to provide an ongoing activity program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 (Residents #1, #2 and #3) of 7 residents reviewed for activities. The facility failed to provide activities for Resident #1 and Resident #2 to meet their psycho-social and mental well-being for the months of April 2026 and from May 1, 2026, through May 27, 2026. The facility failed to provide activities for Resident #3 to meet his psycho-social and mental well-being for the month of April 2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for one of two housekeeping carts (Housekeeping Cart #1) reviewed for hazards. The facility failed to ensure Housekeeping Cart #1, with chemicals inside the compartments, was locked when unsupervised. This failure could place residents at risk for injuries, illness, and hospitalization.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to survey were readily available to examine for 1 of 1 facility reviewed for resident rights in that: The required documents were not posted in a location readily accessible and visible to all residents, their legal representatives, or family members as required. This failure placed residents of the facility at risk of knowing past and present citations of the facility, and potentially being negatively affected by an area of citation. An observation conducted throughout facility on 03/31/26 at 1:12 PM revealed the survey results were not posted in the lobby or any common areas of the facility nor a sign indicating where the survey results were posted. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 of 19 residents (Resident #56 and Resident #59) reviewed for resident rights. The facility failed to ensure Resident #56 and Resident #59's room temperatures were maintained at comfortable temperatures (between 71 to 81 degrees) on 03/31/2026 when the temperatures were found to be 67 to 68 degrees. These failures could place residents at risk of being cold, living in an uncomfortable environment, and a diminished 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 the facility's only kitchen reviewed for food and nutrition services.1. The facility failed to date food and beverages found within the facility's freezers and refrigerator on 03/31/2026.2. The facility failed to date and properly seal food products in facility's freezers and refrigerator on 03/31/2026. These failures could place the residents who ate food from the kitchen at risk of cross contamination, loss of nutritional value, weight loss, and 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 one of two residents (Resident #7) reviewed for infection control. The facility failed to ensure RN F followed standard precautions during wound care for Resident #7's unstageable right heel pressure ulcer on 04/01/2026 when she failed to perform hand hygiene during wound care. This failure placed residents at risk for developing wound infections, and at risk for healthcare associated cross-contamination and infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure resident was treated with respect and dignity for 1 (Resident #26) of 10 residents reviewed for resident rights.1. The facility failed to ensure Maintenance Tech E knocked on Resident #26's door prior to entry and explained the purpose of the visit before performing work in the room on 03/31/2026.2. The facility failed to ensure HSKP G knocked on Resident #26's door prior to entry on 03/31/2026. The deficient practice could place residents at risk of feeling uncomfortable, embarrassment, and a decreased quality of life. Record Review of Resident #26's MDS Assessment, dated 01/19/2026, reflected he was a [AGE] year-old male, admitted [DATE] with a BIMS score of 01, which indicated severe cognitive impairment. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide reasonable accommodation of resident needs and preferences for one (Resident #38) of five residents reviewed for resident rights. The facility failed to ensure Resident #38's call light was within reach on 03/31/2026 and 04/02/2026. This failure could place residents at risk of needs and accommodation being unmet. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) Level I residents with a mental illness was completed correctly and were provided with a PASARR Level II assessment for one (Resident #4) of four residents reviewed for resident assessments. Resident #4's PASARR Level l was not updated to reflect his new diagnoses of PTSD (post-traumatic stress disorder) on 07/09/2025 after he was admitted on [DATE]. This failure could place residents who had a mental illness and/or intellectual or development disabilities at risk for not receiving the appropriate care, and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide bedrooms that measured at least 80 square feet per resident in multiple resident bedrooms for 3 of 7 resident rooms (rooms [ROOM NUMBER]) reviewed for environment. The facility failed to ensure resident bedrooms rooms, 25, 26, and 27 measured at least 80 square feet per resident. This failure could place residents at risk by limiting the amount of resident care equipment and personal belongings that could be accommodated in the resident's room. This may restrict the resident's' ability to move about the room freely and could negatively affect the residents' quality of life. Observations conducted on 3/31/26 during the initial pool screening beginning at 6:00 AM revealed 3 resident rooms did not have the required amount of living space for each resident. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1wing (1Upstairs wing) of 2 facility wings observed for environment. The facility failed to ensure the upstairs restrooms and shower rooms had hot water readily available. This deficient practice could place residents at risk of a decreased quality of life. During an observation on 3/4/26 at 11:30 a.m. restroom D revealed that the hot water faucet turned on but no water came out of faucet. During an observation on 3/4/26 at 11:35 a.m. restroom C revealed that the hot water after running for 2 minutes reached temperature of 74.4 degrees Fahrenheit. During an observation on 3/4/26 at 1:00 p.m. staff/visitor restroom F revealed that the hot water after running for 2 minutes reached temperature of 73.6 degrees Fahrenheit. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when on 02/07/2026 at approximately 10:00 AM LVN A told Resident #1 to sit right or he was going to fall back, and he would get blood all over the floor and LVN A would have to pick it up. LVN A pushed Resident #1's head forward in the dining room which humiliated him, and LVN A continued to be Resident #1's nurse after the incident and a the day after the incident. The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ) began on 02/07/2026 and ended on 02/11/2026. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 (Resident #1) of 6 residents reviewed for abuse and neglect. The facility failed to remove LVN A from duty and she continued to work with Resident #1 after witnessed abuse was reported to the administrator. The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ) began on 02/07/2026 and ended on 02/11/2026. The facility had corrected the noncompliance before the survey began. This failure could place the residents in the facility at risk for physical, mental, and/or psychosocial harm and lack of timely reporting of incidents.

Inspectors wroteBased on interviews and record review, the facility failed to have evidence that all allegations of abuse, neglect, or mistreatment were thoroughly investigated and documented for 1 of 6 residents (Resident #1) reviewed for abuse and neglect. The facility failed to have evidence that a thorough investigation was conducted following the allegation that on 02/07/2026 LVN A spoke tapped Resident #1 in the back of the head. The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ) began on 02/07/2026 and ended on 02/11/2026. The facility had corrected the noncompliance before the survey began. This deficient practice could place residents at risk for abuse and neglect by not investigating injuries of unknown origin.

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 caused the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the State Survey Agency in accordance with State law through established procedures for 1 of 6 residents (Resident #1) reviewed for reporting allegations of abuse. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure residents received adequate supervision, to the extent possible for 1 of 8 residents (Resident #2) reviewed for safety. The facility failed to ensure Resident #2 followed the facility safe smoking policy when on 12/14/2026 and additional unknown dates staff smelled cigarette smoke in Resident #2's room.on 01/31/2026 staff members observed two packages of cigarettes in Resident #2's roomon unknown dates CNAs observed Resident #2 with lighters. These failures could place residents at risk for avoidable accidents and injuries.

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 1 of 9 residents (Resident #1) observed for infection control practices. The facility failed to ensure LVN A followed standard precautions during wound care on 12/11/2025 for Resident #1's wounds when she failed to perform hand hygiene between glove changes. This failure could place residents at risk for healthcare-associated cross-contamination and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents for 1 of 1 facility reviewed for pest control observed and four (Resident #1, Resident #3, Resident #6, and Resident #7) of seven residents reviewed. The facility failed to keep roaches and rodents out of resident rooms, the facility kitchen, facility common areas, and rest rooms. These failures placed residents at risk of infection, feelings of fear, anxiety, disgust, helplessness, shame, and a diminished quality of life.

Inspectors wroteBased on record review and interviews, 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 for one (Resident #3) of six residents reviewed for pharmacy services. The facility failed to administer Resident #3's Lidocaine Pain Relief External 21 times between 08/08/25 and 09/06/25. This failure could place residents at risk of worsening of their condition, increased risk of falls, pain, and injury.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to serve foods that were palatable and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed and five (Resident #1, Resident #3, Resident #4, Resident #5, and Resident #6) of ten residents reviewed. The facility failed to serve warm food to residents. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life.

Inspectors wroteBased on record review and interview, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (Resident #2) of five residents reviewed for transfer and discharge rights, in that:The facility failed to:1. provide documentation that Resident #2's guardian received sufficient preparation and orientation when Resident #2 was discharged to a facility not within Resident #2's guardian's jurisdiction2. Provide documentation from Resident #2's psychiatric NP that Resident #2 was a danger to himself or other residents3. Provide documentation that the ombudsman was informed of the discharge4. Provide documentation that Resident #2 received a discharge notice. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge.

Inspectors wroteBased on record reviews and interviews, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care for one (Resident #3) of five residents reviewed for baseline care plans. The facility failed to create a baseline care plan for how to transfer Resident #3, a paraplegic, within 48hours of his admission. This failure could place residents at risk of not receiving goals and interventions for their individual needs for person centered care and safe transfers.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of 8 (Resident #1, Resident #2 and Resident #3) residents reviewed for a homelike environment. The facility failed to ensure Resident #1 and Resident #2's wheelchairs were clean and free of debris. The facility failed to maintain the cleanliness of the upstairs and downstairs dining rooms. The facility failed to clean the floors, leaving a sticky residue. The facility failed to provide toilet paper and paper towels in Resident #1, #2 and #3's bathrooms. These failures could place residents at risk of living in an uncomfortable and unsafe environment, decreased feelings of self-worth, and a diminished quality of life. During an observation on 7/7/25 at 4:49 p.m. [...]

Inspectors wroteBased on observations, interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The facility failed to ensure the halls outside of the rooms of Residents #1, #2, #3, #4, #5, #6, and #7 were thoroughly cleaned and sanitized. The walls had bare pieces of unpainted drywall. This deficient practice could place residents at risk of living in an unclean and unsanitary environment, which could lead to a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from abuse for 4 of 8 residents reviewed for abuse. Resident #1 and Resident # 2 had an altercation on 5/2/25 due to Resident # 1 was moving too slowly per Resident # 5. Resident #3 and Resident #4 had an altercation on 5/1/25 regarding possession of sunglasses. These failures could place residents at risk of physical harm, mental anguish, and/or emotional distress.

Inspectors wroteBased on interview and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of six residents reviewed for pharmaceutical services. The facility repeatedly failed to administer scheduled time-sensitive medications to Residents #1 from 02/05/25 through 02/24/25. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements or could result in worsening or exacerbation of chronic medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 resident (Resident #1) of six residents reviewed for pharmacy services. The facility repeatedly failed to administer scheduled time-sensitive medications to Residents #1 from 02/05/25 through 02/24/25. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 4 of 27 residents (Resident #26, Resident #54, Resident #58, and Resident #365) and 1 of 1 facility reviewed for a clean and homelike environment. A) The facility failed to ensure Resident #54, Resident #58, and Resident #365 had hot water to use for comfortable bathing/showers and ADL care. B) The facility failed to ensure Resident #26's wheelchair was maintained. C) The facility failed to: a. ensure the baseboard in the downstairs dining room next to the soda machine was attached to the wall and the damage to the sheetrock along the wall was repaired. b. ensure the flooring tiles around the soda machine and the ice machine in the dining room were securely attached to the floor and the missing floor tiles were replaced. c. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to develop a comprehensive care plan within seven days after completion of the comprehensive assessment for three ( Resident #4, Resident #21, and Resident #31) of six residents reviewed for care plans. The facility failed to ensure Resident #4, Resident #21, and Resident #31 comprehensive care plans were completed within seven after of their comprehensive assessments. This failure placed residents at risk of not receiving appropriate care and services to maintain the highest practical well-being.

Inspectors wroteBased on interview and record review, the facility failed, to provide an ongoing activities program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction on the secure unit. The facility failed to provide activities on the secure unit as scheduled for the month of January 2025. This failure placed residents at risk for boredom, depression, increased behaviors, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 9.68% based on 3 out of 31 opportunities, which involved 2 of 4 residents (Resident #17 and Resident #29) and 2 of 2 MA's (MA F and MA G) observed during medication administration reviewed for medication error. 1. The facility failed to ensure Resident #17's blood pressure medication Lisinopril and Losartan had blood pressure parameters for administration. On 01/27/2025 at 8:18 AM, MA F held the medications without physician orders. 2. The facility failed to ensure Resident #29's physician orders were followed for vitamin D tablet 50 mcg. On 01/27/2025 at 9:23 AM, MA G administered Resident #29 Vitamin D 25 mcg. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary Aide M wore a beard guard and Dietary Aide O wore a hair net when standing over the food prep table, clean dishes, and plates of food. 2. The facility failed to ensure Dietary Aide M used proper hand sanitation during food preparation for the lunch meal. 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 three of 16 residents reviewed for infection control practices. 1. The facility failed to ensure RN A used aseptic technique during tracheotomy suctioning and tracheotomy care for Resident #54 on 01/27/2025. 2. The facility failed to ensure RN A performed hand hygiene between glove changes during wound care for Resident #54. 3. The facility failed to ensure RN A performed wound care for Resident #54 using a sterile technique. 4. MA G failed to sanitize the blood pressure cuff during medication pass after using it on Resident #29. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive care plan that describes the services that are to be furnished to maintain the resident's highest practicable physical, mental, and psychosocial well-being for one resident (Resident #18) of 18 reviewed, in that: The facility failed to ensure Resident #18's Comprehensive Care Plan reflected a plan of care for her right-hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM). This failure could place residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of contractures.

Inspectors wroteBased on observations, interviews, 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 grooming and personal hygiene for 1 of 13 residents (Resident #58) reviewed for ADLs. The facility failed to ensure Resident #58's fingernails were cleaned 01/26/2025 through 01/28/2025. This failure could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development or worsening of pressure ulcers for one of five residents (Resident #54) reviewed for pressure ulcers. The facility failed to ensure RN A followed standard precautions during wound care on 01/27/2025 for Resident #54's right and left heels, right and left ischial and coccyx Stage IV pressure ulcers, when she failed to perform hand hygiene between glove changes, use a cleaning technique on the pressure ulcer that did not cross contaminate the pressure ulcer or prevent the pressure ulcer once cleaned from becoming re-contaminated. This failure could place residents at risk for worsening pressure ulcers leading to discomfort, pain, and potential infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1of 2 residents reviewed with limited range of motion (Resident #18), received appropriate treatment and services to prevent a decrease in range of motion. The facility failed to ensure Resident #18 had interventions in place for her right- hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) to prevent further decline of the range of motion in her right hand. This deficient practice placed residents with contractures at risk for decrease in mobility, range of motion, and could contribute to worsening of contractures. Findings Include: Review of Resident #18's face sheet dated 01/28/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections for one of one residents reviewed for catheters (Resident #54). The facility failed to ensure Resident #54 received care to prevent urinary tract infections when RN A placed his catheter bag on the bed with him during wound care. These failures could place residents with external catheters at risk for urinary tract infections and change of condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 1 of 1 resident (Resident #54) reviewed for tracheostomy care. The facility failed to ensure RN A used aseptic technique (a procedure that healthcare providers use to prevent the spread of germs that cause infection.) during tracheostomy care and tracheal suctioning for Resident #54 by not performing hand hygiene, placing barriers, or using sterile equipment. This failure could place residents at risk for respiratory infections and respiratory distress.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 7 residents (Resident #6) reviewed for unnecessary drugs. The facility failed to monitor Resident #6 for adverse effects of prophylactic antibiotic use. This failure could place residents at risk of nausea, diarrhea, and secondary infection.

Inspectors wroteBased on interview and record review the facility failed to establish an infection prevention and control program (IPCP) that included, at a minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 1 of 5 residents (Resident #6) reviewed for antibiotic stewardship program. The facility failed to follow antibiotic stewardship policy for Resident #6 by not ensuring a duration for medication. This deficient practice could place residents at risk for unnecessary antibiotic use, inappropriate antibiotic use and increased multi drug resistant organisms.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident bedside and toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 1 of 13 residents (Resident #58) reviewed for resident call system . The facility failed to provide a working communication system, that was easily at reach, that would allow Resident #58 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living.

Inspectors wroteBased on observation and interview and record review the facility failed to provide bedrooms that measured at least 80 square feet per resident in multiple resident bedrooms and at least 100 square feet in single resident rooms for 7 of 50 resident rooms (Rooms 21, 23, 24, 25, 26, 27 and 35) reviewed for room size variance. The facility failed to ensure resident bedrooms rooms 21, 23, 24, 25, 26, 27 and 35 measured at least 80 square feet per resident. This failure could place residents at risk of having the restricted amount of resident care equipment and residents' personal effects that could be accommodated in these resident rooms, limit the ability of the residents to move about the room, and decrease the residents' quality of life.

Inspectors wroteBased on observation, 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 3 residents (Resident #1) reviewed for accidents and supervision, in that: The facility failed to ensure Resident #1 received adequate supervision to prevent him from exiting the facility undetected on 12/09/24 and 12/31/24. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 12/09/24 and ended on 01/01/25. The facility corrected the non-compliance before the investigation began on 01/08/25. The Past Non-Compliance form (a document used to report a past violation that has been rectified, at the time of the current investigation) sent to Administrator on 01/17/25 at 3:20pm. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect Resident #1's right to be free of sexual abuse by Resident #2. The facility failed to keep Resident #1 from being sexual assaulted by Resident #2 on 11/02/24. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 11/05/24 at 3:47 PM and an IJ template was given. While the IJ was removed on 11/07/24 at 3:21 PM, the facility remained out of compliance at a level 2 of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of abuse, injury, and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to implement their written policies and procedures regarding prohibiting and preventing abuse for two (Resident #1 and Resident #2) of eight residents reviewed for developing and implementing abuse and neglect policies. The facility failed to implement the facility abuse and neglect policy when they failed to protect Resident #1 from being sexually assaulted by Resident #2. The ADM was notified, and she failed to action to keep Resident #1 from further abuse or psychosocial harm. She did not thoroughly investigate the incident or report it to HHSC. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 11/05/24 at 3:47 PM and an IJ template was given. [...]

Inspectors wroteBased on interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident for two (Resident #1 and Resident #2) of eight residents reviewed for administration. The facility Administrator failed to: - Investigate or report to HHSC an incident where Resident #2 was observed sexually assaulting Resident #1. - Allow LVN A to document the incident between Residents #1 and #2, notify law enforcement, or send Resident #1 to the hospital for evaluation. - Accurately document CNA B's witness statement without altering what she wrote regarding the incident between Residents #1 and #2. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 11/05/24 at 3:47 PM and an IJ template was given. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (Resident #3) of five residents reviewed for a homelike environment. The facility failed to fix a plumbing issue in Resident #3's closet for approximately six months which caused his closet to secrete a musty/moldy odor causing him to be embarrassed and humiliated to wear his clothes which embodied the odor. This failure could affect residents by placing them at risk for diminished quality of life and being in an unsafe environment.

Inspectors wroteBased on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and failed to protect and promote the rights of the residents for three (Resident #4, Resident #5, and Resident #6) of eight residents reviewed for resident rights. The facility failed to purchase cigarettes for approximately five days for Residents #4, #5, and #6. This failure placed residents at risk for a decreased quality of life, loss of enjoyment, and loss of freedom.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance for three (Resident #5, Resident #7, and CR #8) of eight residents reviewed for meal palatability. The facility failed to serve food that was palatable and aesthetically appetizing for Resident #5, Resident #7, and CR #8 . This failure could place residents at risk for altered nutritional status, weight loss, and a decline in quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect resulted in bodily injury, to other officials (including the State Agency) for one (Resident #1) of five residents reviewed for abuse. The facility failed report an incident of sexual abuse to HHSC after Resident #2 was observed sexually assaulting Resident #1. This deficient practice could place residents at risk of abuse and neglect.

Inspectors wroteBased on interview 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 one (Resident #1) of four residents reviewed for medications. The facility failed to ensure LVN A did not administer Resident #1 an injection of diphenhydramine HCl solution (an antihistamine) used for agitation without a physician's order. This deficient practice could place residents at risk of consuming unprescribed medications, harm, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. The facility failed to date food and beverages found within the facility's freezers and refrigerator. The facility failed to date and properly seal food products in facility freezers. The facility failed to remove dented cans from the dry storage area to prevent service to residents. The facility failed to clean the juice machine nozzle and industrial can opener. These failures could place the residents who ate food from the kitchen at risk of cross contamination, loss of nutritional value, weight loss, and foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure maintenance services necessary to maintain a sanitary, orderly, and comfortable interior environment for residents in the secured unit for ten (room [ROOM NUMBER], 5, 6, 7, 9, 11, 12, 13, 15, and 16) of sixteen occupied rooms. The facility failed to ensure that resident rooms had adequate pressure and hot water. The facility failed to ensure that the faucets in resident rooms had both hot and cold-water knobs. The facility failed to ensure that resident rooms faucets were free of leaks and operational. The facility failed to make repairs to a damaged metal door frame placing residents at risk for injury. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his quality of life for one (Resident #4) of one resident reviewed for rights. The facility failed to provide Resident #4 with dignity during breakfast and lunch service when they served his meals to him on a rolling tray table that faced a wall, while all other residents sat at dining tables in view of each other. The facility failed to ensure that Resident #4 was provided assistance when needed during meal times, which resulted in him eating food with his hands, off the tray table, off his wheelchair seat, and the floor. This failure placed the resident at risk of a decline of their sense of dignity, level of satisfaction with life, and feelings of self-worth.

Inspectors wroteBased on observation, interview and record review, the facility filed to ensure assessments accurately reflected the status of 1 of 15 residents reviewed for assessments (Resident #40) Resident #40's quarterly MDS assessment dated [DATE] incorrectly documented active diagnoses of pneumonia and septicemia. This failure could place residents at risk of not having individual needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) Level I residents with a mental illness was completed correctly and were provided with a PASARR Level II assessment for two (Resident #44 and Resident #52) of seven residents reviewed for PASARR assessments. Resident #44's PASARR Level l did not indicate a diagnosis of mental illness, although diagnosis was present upon admission. Resident #52's PASARR Level l did not indicate a diagnosis of mental illness, although diagnosis was present upon admission. These failures could place all residents who had a mental illness at risk for not receiving needed assessment, care, and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who are 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 1 (Resident #36) of 1 resident reviewed for trauma-informed care. The facility failed to accurately identify possible triggers for Resident #36 who had a diagnosis of Post-Traumatic Stress Disorder. This failure could place residents at increased risk for psychological distress due to re-traumatization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide special eating equipment and utensils for residents who need them for one (Resident #4) of one resident reviewed for feeding assistance. The facility failed to provide Resident #4 with a divided plate to assist him with eating independently. This failure could place residents at risk for loss of self-worth and empowerment for independent eating, which could lead to unplanned weight loss.

Inspectors wroteBased on observation and interview, the facility failed to provide a minimum of 80 square feet for 7 of 50 resident rooms (Rooms 21, 23, 24, 25, 26, 27, and 35), reviewed for room size variance. The facility failed to ensure resident bedrooms measured at least 80 square feet per resident. This deficient practice could place residents at risk for a decreased quality of life.