Every finding on record at Avir at Gainesville

Based on observations, interviews, and record review, the facility failed to ensure residents have a right to a safe, clean, comfortable and homelike environment including comfortable and safe temperature levels, for one (dining area) of two common areas for residents on Hall 300 and two (Resident #2 and Resident #3) of nine residents reviewed for resident rights. The facility failed to ensure dining area for Hall 300. The facility failed to ensure Resident #2 and Resident #3 had comfortable temperatures in their room on 08/24/26. These failures could place residents at risk for heat exhaustion, unsafe and uncomfortable living environment.Findings included: Observation on 08/24/26 at 3:19 PM with Maintenance Director C from sister facility revealed Maintenance Director C took temperatures with a thermometer infrared device of dining area for residents on Hall 300 (secured unit) and the temperatures were 82.4 F and 83.6 F. There were 7 residents in the dining room area during observations of temperature. He stated any resident areas or room temperatures over 81 F were too warm. He stated he used this type of infrared temperature gun device to check temperatures in resident areas. Observation and interview on 08/24/26 at 3:21 PM of Resident #2 and Resident #3's room revealed Maintenance Director C took temperature of 84.6 and 86 F. Resident #2 had a fan near his bed blowing on him and stated it had been hotter in his room for the last day or two. Resident #3 did not complain about the warm temperature in his room. Review of Resident #2's admission MDS assessment dated [DATE] reflected Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of type 2 diabetes (chronic condition characterized by insulin resistance and high blood sugar levels), dementia (the loss of cognitive functioning including thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and moderate protein-energy malnutrition (condition where individual's caloric intake in insufficient to meet metabolic demands). Resident #2 had a BIMS score of 5 indicating he was severely cognitively impaired. Review of Resident #3's admission MDS assessment dated [DATE] reflected Resident #3 was a [AGE] year-old male admitted to the facility on [DATE] with primary diagnosis of Dementia (the loss of cognitive functioning including thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). Resident #3 has a BIMS score of 15 indicating he was cognitively intact. Interview on 08/24/26 at 3:35 PM with CNA D and LVN E revealed it had been hot on the secured unit today, especially the dining area. She stated they had come out recently to service the air conditioning. CNA D stated resident room [ROOM NUMBER] tended to be warmer than the other rooms in the secured unit. They stated they try to keep the area cooler by using fans and the split air conditioning unit. They both stated the air conditioning issues caused it to be hotter. Interview on 08/24/26 at 3:55 PM with Regional Nurse Consultant revealed they will contact an air conditioning vendor to come out this evening to look at the air conditioning on 300 hall (secure unit). She stated she was not aware of any issues with the air conditioning prior to this conversation. She stated she was providing coverage for the Administrator and DON who were both off this week. She stated Regional Maintenance Director told her they had an air conditioning vendor come look at the a/c and it was fixed. She stated she would look for the invoice to see what was fixed. Follow-up interview with Regional Nurse Consultant revealed air conditioning vendor was on their way to the facility but she was not certain of what time they would arrive since she was not given an ETA. At 4:31 PM Regional Nurse Consultant stated they are monitoring the room temperatures in common dining area of Hall 300 and resident room for Residents #2 and #3. She stated if room temperatures do not come down below 81 F they will report it to the State. Policies for air conditioning and general maintenance policy were requested. Observation on 08/24/26 at 5:24 PM revealed the split air conditioning unit was set up in the dining area where the 14 residents of Hall 300 were eating their dinner. At 5:31 PM the room temperatures were 83 and 85.6 in common dining area of Hall 300. Interview on 08/24/26 at 6:18 PM with Maintenance Director E revealed the air conditioning vendor was on the way to the facility and should arrive shortly. At 7:25 PM Maintenance Director E stated the air conditioning vendor was able to fix the unit by replacing the capacitor and were cleaning the coils of the air conditioning unit. Interview on 08/24/26 at 6:47 PM with Regional Nurse Consultant revealed the air conditioning vendor had arrived to the facility to look at the air conditioner unit on Hall 300. At 7:39 PM she stated they will keep residents out of the dining area on Hall 300 and will move the air conditioning split unit once all residents were out of the dining area for the night and will move it into resident room [ROOM NUMBER] to assist with cooling the room down so Resident #2 and #3 will be comfortable. She stated the facility did not have a policy on air conditioning or general maintenance policy but stated they follow the state regulations for room temperatures. They did report the incident to the state of the warm temperatures in dining area of Hall 300 and for the residents #2 and #3's room. Observation on 08/24/26 at 7:48 PM revealed the last resident was pushed in his wheelchair to his room by staff to be transferred into bed. Observation and interview on 08/24/26 at 7:50 PM revealed facility's Maintenance Director moved the split air conditioning unit to assist with getting room temperature below 81 F for Residents #2 and #3's room. Observation on 08/24/26 at 7:51 PM revealed temperature in dining area of 300 hall was 80.4 F. Interview on 08/25/26 at 1:07 PM with facility's Maintenance Director revealed he was contacted about the air conditioning unit on the 300 hall dining area not working on Friday (08/21/26) and he contacted an air conditioning vendor to come out to look at it in which they came in the evening. He stated they had charged the air conditioning unit meaning they added freon and the air conditioner was working again. He was not contacted over the weekend on Saturday or Sunday about any issues with the air conditioning on Hall 300 so he thought it was fixed. He stated there were 2 air conditioner units on Hall 300 and the air conditioner that went out yesterday was for the dining area. He stated the facility staff monitored the dining area and Resident #2 and Resident #3's room temperatures throughout the night. He stated the air conditioner vendor G fixed the unit yesterday and was able to get the air conditioning running. He stated Residents #2 and #3 had issues with the air conditioner not working so they would keep the split unit in the residents' room to ensure the temperatures were comfortable for the residents. He stated it was important to have air conditioning working in resident areas and resident rooms to ensure safe and comfortable room temperatures. Review of Air conditioner vendor F's service documentation dated 08/21/26 reflected technician completed work on 08/21/26 at 7:13 PM - charged unit.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of four residents (Resident #1) reviewed for incontinence care. The facility failed to ensure Resident #1 was provided timely incontinent on 08/24/26 by day shift staff. This failure could place residents at risk of a delay in receiving assistance and not receiving appropriate care to address their incontinence and could increase the risk of urinary tract infections. Findings included: Review of Resident #1's face sheet, undated, reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of nonalcoholic steatohepatitis (liver disease defined by excess fat buildup, inflammation, and cell damage in the liver of people who drink little or no alcohol), Type 2 Diabetes (chronic condition where your body has high blood sugar because it does not use insulin properly or make enough insulin), Hypertension (high blood pressure) and Chronic Obstructive Pulmonary Disease (group of progressive lung conditions that block airflow and make it hard to breathe). Review of Resident #1's admission MDS assessment, dated 08/03/26, reflected Resident #1 needed substantial/maximal assistance with transfers and was dependent on staff for toileting hygiene. Resident #1 was always incontinent of bowel and bladder. Resident #1 had a BIMS score of 14 indicating she was cognitively intact. Review of Resident #1's baseline care plan, dated 07/28/26, reflected Resident #1 was dependent on staff for toileting hygiene. It reflected Resident #1 was always incontinent of bowel and bladder. Review of Resident #1's Bowel and Bladder Elimination ADL task reflected on 08/24/26 the following: 5:31 AM Resident #1 was incontinent. Review of Resident #1's Comprehensive Care plan last updated on 08/25/26 did not reflect a care plan for incontinence of bowel and bladder. Observation and interview on 08/24/26 at 9:39 AM revealed Resident #1 was sitting in her electric wheelchair in her room. She stated she had asked staff to provide incontinent care to her about an hour ago at least but was told they did not have enough staff to transfer and provide incontinent care to her. She stated she was last changed and was transferred into her electric wheelchair via mechanical lift by night shift at 4:30 AM this morning and day shift had not provided any incontinent care or any mechanical lift transfers. She stated sometimes she did have to wait to be changed but did not specify how long. During an interview on 08/24/26 at 9:56 AM LVN A was informed that Resident #1 wanted to be changed and needed to be transferred via mechanical lift. She stated she would get another staff member since Resident #1 is a 2-person assist. Interview on 08/24/26 at 10:05 AM CNA B stated she was about to transfer Resident #1 via mechanical lift once LVN A came to assist and then would provide incontinent care to Resident #1. She stated she had not changed Resident #1, who required 2-person assistance for incontinent care and mechanical transfer, since the beginning of shift due to staffing issues since they had only 2 CNAs and 3 nurses today on day shift. She stated she was the only aide for 3 halls and the only other CNA was assigned the secured unit along with 1 nurse. Observation on 08/24/26 at 10:08 AM revealed LVN A and CNA B completed Resident #1's mechanical lift transfer from motorized wheelchair to bed. At 10:15 AM, LVN A and CNA B started to provide incontinent care to Resident #1. Observation on 08/24/26 at 10:24 AM revealed Resident #1's brief which was saturated with urine and a small amount of bowel movement. Interview on 08/24/26 at 12:14 PM with LVN A revealed Resident #1 had no open skin areas on her bottom and Resident #1 should have been changed earlier but they were short CNAs today on day shift and Resident #1 required 2-person assistance with incontinence and transfers. LVN A stated they usually had at least three to four CNAs on the day shift so staffing issues today did affect Resident #1's delay in getting incontinent care. Interview on 08/24/26 at 3:05 PM with ADON revealed she was the staffing coordinator she was aware this morning they had 2 CNAs call in on day shift leaving only 2 CNAs and 3 nurses instead of at least 4 CNAs. She stated she attempted to get more help for day shift. She stated Resident #1 not being changed from 5:30 AM to 10:15 AM was a delay in care for incontinent care. Interview on 08/24/26 at 3:57 PM with Regional Nurse Consultant revealed Resident #1 should have been provided incontinent care and rounded on. She stated this placed Resident #1 at a delay in incontinent care and could have placed her at risk of skin breakdown. Regional Nurse Consultant was informed of policies requested at this time for ADL care and incontinent care. The facility failed to provide a policy for ADL care and incontinent care prior to exit on 08/25/26.

Based 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 2 (Resident #1) residents reviewed for infection control. The facility failed to ensure CNA B changed gloves and completed hand hygiene during a mechanical lift transfer for Resident #1 on 08/24/26. This failure could place residents at risk for infection and cross contamination.Findings included: Review of Resident #1's face sheet undated reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of nonalcoholic steatohepatitis (liver disease defined by excess fat buildup, inflammation, and cell damage in the liver of people who drink little or no alcohol), Type 2 Diabetes (chronic condition where your body has high blood sugar because it does not use insulin properly or make enough insulin), Hypertension (high blood pressure) and Chronic Obstructive Pulmonary Disease (group of progressive lung conditions that block airflow and make it hard to breathe). Review of Resident #1's admission MDS assessment dated [DATE] reflected Resident #1 was substantial/maximal assistance with transfers and dependent of toileting hygiene ADL. Resident #1 was always incontinent of bowel and bladder. Resident #1 had a BIMS of 14 indicating she was cognitively intact. Review of Resident #1's baseline care plan dated 07/28/26 reflected Resident #1 was dependent for toileting hygiene. It reflected Resident #1 was always incontinent of bowel and bladder. Review of Resident #1's Comprehensive Care plan last updated on 08/25/26 did not reflect a care plan for incontinence of bowel and bladder. Observation on 08/24/26 at 10:09 AM revealed CNA B touched Resident #1's door with gloved hands, and failed to change gloves and complete hand hygiene prior to mechanical lift transfer. Resident #1 was sitting in her motorized wheelchair while LVN A and CNA B completed Resident #1's mechanical lift transfer from motorized wheelchair to bed. Interview on 08/24/26 at 3:09 PM CNA B stated she should have taken her gloves off after she touched the door with her gloved hands and washed hands putting on new gloves before transferring Resident #1. She stated she usually did take her gloves off when gloves get contaminated and completed hand hygiene prior to care, but she was in a hurry since they were short-staffed this morning. Interview on 08/24/26 at 3:12 PM with ADON revealed CNA B should have changed her gloves, completed hand hygiene and put new gloves on prior to Resident #1's mechanical lift transfer. She stated not completing hand hygiene could place Resident #1 at risk of infection. She stated the DON was the infection preventionist for the facility but she was on leave this week. Interview on 08/24/26 at 3:57 PM with Regional Nurse Consultant revealed CNA B should not have gloves on when closing the door. She should have taken gloves off and washed her hands prior to Resident #1's mechanical lift transfer to prevent the spread of infection. Review of facility's policy Handwashing/Hand Hygiene last updated January 2025 reflected This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Hand hygiene is indicated: a. immediately before touching a resident.e. after touching the resident's environment.5. The use of gloves does not replace hand washing/hand hygiene.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs for 1 of 7 residents (Resident #1) reviewed for care plans in that:The facility failed to include interventions for ADLs in Resident #1's care plan.This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.Findings included:Record review of Resident #1's face sheet dated 08/17/2026 revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Neurocognitive Disorder (a decrease in mental function), Atrophic Disorder of Skin (the thinning of one or more layers of skin), Delusional Disorders (fixed false beliefs that are not based on reality), Hypertension (high blood pressure), Venous Insufficiency (leg vein valves weaken) and Cellulitis (skin infection that affects the deep layers of the skin and tissues).Record review of Resident #1's MDS assessment, dated 07/20/2026, reflected a BIMS score of 8, which indicated moderate cognitive impairment. Section GG-Functional Abilities revealed Resident #1 was independent for eating and oral hygiene. Resident #1 required assistance prior to or following personal and toileting hygiene, dressing, putting on/taking off footwear, and shower/bathing.Record review of Resident #1's Comprehensive Care Plan dated 07/18/2026 failed to address ADLs as a focus of care. During an interview on 08/17/2026 at 11:08 a.m., the Regional MDS Coordinator stated the MDS Coordinator was responsible for care plans. She stated care plans were developed within 21 calendar days after admission. She stated the comprehensive care plan should have included ADLs to ensure staff knew how to care for residents. She stated she was responsible for ensuring the MDS Coordinator included ADLs in the care plan. She stated the MDS Coordinator started that day and was in training.During an interview on 08/17/26 at 2:30 p.m., the DON stated it was important for ADLs assistance to be care planned because care plans painted a picture of the residents' issues and preferences. She stated ADLs tailored the specific needs of residents and related healthcare needs. She stated the absence of ADLs in care plans jeopardized their care.During an interview on 8/17/26 at 2:58 p.m., the Administrator stated the expectation was for care plans to be completed within the regulated time frames. He stated it was important for ADLs to be included in care plans for resident functioning, appropriate level of care, and to prevent the resident's abilities from diminishing.Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised March 2022 revealed, The comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: the resident's stated goals upon admission and desired outcomes.

Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for two of seven (Resident #1 and Resident #2) residents reviewed for physical environment. The facility failed to ensure Resident #1's and Resident #2's shower was in good working order and did not have broken tile, caved in wall and running water on 06/10/26. These failures placed residents at risk of resident restroom in an unsafe environment and a lack of a functional shower.Findings included:Resident #1Record review of Resident #1's admission MDS assessment, dated 05/14/26, reflected a [AGE] year-old, male admitted [DATE]. Resident #1's BIMS was 11 which indicated he was moderately cognitively impaired. He required supervision assistance with ADLs including showers. Diagnoses included Malignant neoplasm (cancer) of the brain and lungs, chronic obstructive pulmonary disease (restrictive air flow and breathing difficulties) and long-term use of anticoagulants (blood thinners).Resident #2Record review of Resident #2's admission MDS assessment, dated 05/27/26, reflected a [AGE] year-old male with an admission of 05/18/26. Resident #2's BIMS was 15 which indicated he was cognitively intact. He required supervision assistance with ADLs including showers. Diagnoses included dementia (decline in mental ability) and hallucinations (seeing or hearing things that are not there).During an interview with Resident #1's family member on 06/09/26 at 4:33 p.m., the family member stated they moved Resident #1 to the facility around the first of May 2026, and Resident #1 received hospice services. The family member stated they had not been to the facility to see Resident #1 until they were notified by the facility that they were sending him out to the hospital on [DATE]. The family member stated they went to the facility after Resident #1 returned from the hospital the same day on 06/02/26 around 07:00 p.m. and was disgusted at the condition of Resident #1's and Resident #2 room. She stated the residents' room was filthy and what looked like blood was on the wall and floor, and stated Resident #2 looked dirty. She stated the bathroom was in poor condition and there was a mop bucket and mop stored in the shower stall in their bathroom. She stated the unit had an awful smell and stated she saw a large bug run across the floor. She stated she spoke with the Administrator on the telephone and sent pictures for him to see the condition of the room. She stated Resident #1 had to go back to the hospital on [DATE] where he remained as of 06/10/26. She stated Resident #1 appeared well cared for and clean when she saw him on 06/02/26 and the family had no concerns about the care Resident #1 received at the facility. The family member stated they were just appalled at the condition of his room and reported what she saw to the Administrator.During an observation on 06/10/26 at 8:45 a.m., Resident #1's and Resident #2's room was clean, with no stains on the walls or floor and no pervasive odors. Observation of the bathroom revealed the back wall of their shower, an area that was approximately two square feet in diameter, was caved in with visible gaps between the grout where the wall behind the tile could be seen. Observation further revealed the front of the shower had approximately 6 tiles that were buckling and pulling away from the wall. Observation revealed on the back shower wall, at the base of the shower, next to the door frame, there was a missing tile with exposed wood, and black wall covering. There was a large amount of puttylike substance on the adjoining tile above the missing tile.During an interview with Resident #2 on 06/10/26 at 8:50 a.m., he stated he did not use the shower in his bathroom. He stated they assisted him down the hall to a shower room. Resident #2 stated he was not sure why they do not use the shower in his room.During an interview with Housekeeper A on 06/06/26 at 8:55 a.m., she stated they cleaned the memory care unit right after breakfast and again after lunch every day. She stated they left for the day at 3:00 p.m. and the nursing staff was responsible for doing spot cleaning after they left. She stated they had done a deep clean on Resident #1's and Resident #2's room after the family member complained about the room. She stated she had not seen any bugs recently and stated pest control came out right after the family member's complaint and sprayed. She stated the shower in Resident #1's and Resident #2's room had been like that for over 3 months. She stated she assumed the Maintenance Director was aware of it. During an interview with CNA B on 06/06/26 at 9:15 a.m., she stated none of the showers on the memory care unit had running water. She stated they were told by the previous owners they had turned off the water to the showers for fear of residents turning on the shower and burning themselves. She stated they took all of the residents to the shower room at the front of hall. She stated she was not sure how long the shower tiles were missing or broken in Resident #1's and Resident #2's bathroom. She stated the CNAs were responsible for spot cleaning after housekeeping left for the day. She stated Resident #1 frequently coughed up blood and spit it on the floor, so there probably was blood on the floor when the RP came to see him. She stated she had not seen any bugs recently and stated the facility always had pest control out anytime they reported insects. During an interview with CNA C on 06/06/26 at 9:20 a.m. she stated she had worked at the facility for about 3 months and stated Resident #1's and Resident #2's shower had been in the condition it was as long as she had been there. She stated she assumed it had been reported. She stated she was not sure why none of the resident room showers worked on the memory care unit. She stated they took everyone to the shower room at the front of the hallway. During an interview with the ADON on 06/10/26 at 9:45 a.m. she stated she had seen the condition of Resident #1's and Resident #2's shower last Friday (06/05/26) but stated she had not put it in the maintenance notification system. During an observation and interview on 06/10/26 at 9:50 a.m., the Maintenance Director stated he was not aware the shower was in the condition it was in. The Maintenance Director stated it appeared the wall had caved in behind the tile and would most likely need a contractor to repair the shower. He stated he was aware none of the resident room showers on the memory care unit had running water to them. He stated that was a decision made by the previous owners and was not sure what the rationale was for that. He stated he would talk with the Administrator to see what he wanted to do about the shower.During an interview with the Administrator on 06/10/26 at 1:36 p.m., he stated his expectations for repairs and maintaining the bathrooms were that everything worked. He stated he had just started at the facility on 06/01/26 and had a laundry list of things that needed addressing. He stated he was aware of the condition of the shower in Resident #1's and Resident #2's shower after he had received the grievance from Resident #1's family member. He stated he had toured the memory care unit, had pest control come out and spray again, and had housekeeping deep clean the room. He stated they would have to hire a contractor to repair the shower. He stated he was not aware the water was not working in the showers and would have to follow up with Corporate to determine what steps needed to take place. He stated there were several things the previous management had left undone as far a maintenance needs and he was tackling them as fast as he could. He stated his expectations was a safe, clean and appealing environment for all of the residents in the facility.Record review of the facility's policy titled, Maintenance Service, dated December 2009, reflected, .The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.Functions of maintenance personnel include, but are not limited to.maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.maintaining the building in good repair and free from hazards.maintaining the.plumbing fixtures.in good working order.

Based on observation, record review, and interviews, the facility failed to assist residents who were unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 6 residents (Resident #3) reviewed for quality of life. The facility failed to groom Resident #3's facial hair on 2/17/26.The facility failed to assist Resident #3 with showers on 2/3/26 and 2/14/26. These failures could place residents at risk of exposure to infectious diseases, and affect their dignity.Record review of Resident #3's face sheet dated 2/17/26 reflected she was a [AGE] year-old female with an original admission date of 5/31/25 and a readmission date of 9/28/25. Resident #3 had the following active diagnoses: muscle wasting and atrophy (decrease size, mass and strength of muscle tissue), muscle weakness, need for assistance with personal care, and Depression (a medical illness characterized by a persistent, intense, and long-lasting low mood, loss of interest and decreased energy). Record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected Resident #3 had moderate cognition and a BIMS of 10. She had upper and lower limitations of her extremities on both sides. Resident #3 required partial/moderate assistance for showers, baths, transfers, and supervision for personal hygiene to include shaving. Record review of Resident #3's shower sheets dated February 1, 2026 to February 17, 2026 reflected Resident #3 received showers on 2/5/26, 2/9/26, and 2/12/26. She refused one shower on 2/7/26. There were no shower sheets for her scheduled shower days on 2/3/26 and 2/14/26 , or any other day. Observation and interview of Resident #3 on 2/17/26 at 10:32 am revealed she was wearing clothing that was stained and dirty. It was noted Resident #3 had facial hair on her chin that was significantly visible. Resident #3 stated she frequently asked staff to shave her facial hair, but they frequently ignored her request. Resident #3 could not recall the last time she had gotten her chin hair shaved. Resident #3 stated it had been a while since they had shaved her ,and she recalled it was during a shower. Resident #3 stated she also had not gotten a shower in a long time. She stated she had gone days without showering, despite asking for a shower. An interview with CNA A on 2/17/26 at 10:06 am revealed she could not recall when she last bathed or shaved Resident #3. She acknowledged Resident #3 had visible facial hair, and she stated she was scheduled to bathe her today. CNA A stated she shaved Resident #3 before, but not recently. CNA A stated Resident #3's shower days were Tuesday, Thursday and Saturday. She did not recall whether she bathed her on Tuesday or Thursday of last week because the night shift may have bathed her. CNA A denied Resident #3 had ever requested to be shaved outside of her shower days. CNA A stated having facial hair as a female would have made her insecure and affected her dignity.An interview with CNA B on 2/17/26 at 12:42pm revealed when a resident refused a shower, she would offer it to the resident at least 3 times throughout her shift and then notified the nurse of the refusal. CNA B stated they were required to groom both male and females every shower, unless the resident refused it. An interview with the ADON on 2/17/26 2:34 pm revealed Resident #3 would, at times ,refuse to allow her facial hair to be cut. The ADON stated she did not know when she was last shaved or whether she had refused grooming recently. The ADON stated the expectation for staff would be to cut female residents' facial hair daily because women should not have facial hair. The ADON stated at minimum residents should have gotten shaven on their shower days and upon request or when facial hair was visible. It would affect residents' dignity when they have facial hair. The ADON stated Resident #3 had 3 showers since February 1, 2026, 1 shower she refused and could not state the reason the other two showers had not occurred. She stated they had no documentation Resident #3 had refused showers on 2/3/26 or 2/14/26. The ADON stated the risk to the resident of irregular showers could have been issues with residents' dignity, risk of infection, and skin breakdown.An interview with the DON on 2/17/26 at 3:00 pm revealed she had not noticed Resident #3's facial hair. She stated she was aware the resident would refuse care at times, but could not say definitively it was the reason she had facial hair. The DON stated showers, and shaving should be done 3 times per week or upon request. She stated if a resident refused, CNAs were supposed to ask residents if they wanted a bath on 3 separate occasions, if they still refused, then the CNAs would have told the nurse so she could encourage the residents to bathe and if they still refused, they would document the refusal. The DON stated facial hair of residents should be cut every shower day or as requested by the residents. An interview with the Administrator on 2/17/26 at 3:36pm revealed it was the responsibility of CNAs to shower and shave residents. The Administrator stated female resident should be showered on their shower days and if they had facial hair, they should have been shaven on their shower days. The Administrator stated it could affect a female resident's dignity if she had facial hair and wanted it removed. Record review of the facility's policy Activities of Daily Living (ADL), Supporting revised on February 2025 reflected . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); .

Based on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 2 of 6 residents (Resident #1 and Resident #2) reviewed for care plans. 1. The facility failed to ensure Resident #1's comprehensive care plan was complete and reflected his need for a therapeutic diet. 2. The facility failed to ensure Resident #2's comprehensive care plan was complete and reflected her need for a therapeutic diet. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. Record review of Resident #1's face sheet dated 2/17/26 reflected he was a [AGE] year-old male with an admission date of 1/9/26. Resident #1 had the following active diagnoses: muscle wasting and atrophy (decrease size, mass and strength of muscle tissue), Hypothyroidism (endocrine disorder where the thyroid fails to produce sufficient thyroid hormones), Hypotension (abnormally low blood pressure) and Type 2 Diabetes (a metabolic disorder characterized by high blood sugar levels). Record review of Resident #1's Initial MDS assessment dated [DATE] reflected Resident #1's cognition was intact, and he had a BIMS of 14. Section K noted a therapeutic diet on admission and while a resident. Record review of Resident #1's Baseline Care Plan dated 1/9/26 reflected regular with thin liquids diet. Record review of Resident #1's Comprehensive Care Plan Report date 1/21/26 reflected a one page report with only one completed care area related to his code status. The document did not reflect a care area related to his need for a therapeutic diet.Record review of Resident #2's Initial MDS Assessment date 2/4/26 reflected she was a [AGE] year-old female with an admission date of 1/30/26. Resident #2 had the following active diagnoses: Hypertension (high blood pressure), Renal Failure (occurs when kidneys lose the ability to effectively filter waste products, toxin and excess fluid from blood), Diabetes Mellitus (a metabolic disorder characterized by high blood sugar levels) and Irritable Bowel Syndrome (chronic functional disorder of the gastrointestinal tract characterized by recurrent abdominal pain, discomfort and changes in bowel habit). Resident #2's cognition was intact with a BIMS of 15. Section K noted a therapeutic diet while a resident.Record review of Resident #2's Order Summary Report dated 2/17/26 reflected resident had an order for Controlled Carbohydrate Diet with a start date of 1/30/26.Record review of Resident #2's Baseline Care Plan dated 1/30/26 reflected a regular diet with thin liquids. Record review of Resident #2's Comprehensive Care Plan Report date 1/21/26 reflected a one-page report with only one completed care area related to her code status. The document did not reflect a care area related to her need for a therapeutic diet.An interview with the MDS Nurse Coordinator on 2/17/26 at 2:25pm revealed she was responsible for the completion of all residents' comprehensive care plans. The MDS Nurse Coordinator stated when she completed the residents' MDS assessments, she had one to two weeks to complete their care plan. The MDS Nurse Coordinator stated Resident #1 and Resident #2's care plans were incomplete. She stated she had two weeks from the time she completed the residents' MDS assessments. She stated she was not sure if that was the policy of the facility. She stated she was working on Resident #2's Care Plan that day. She stated she was behind on completing care plans for new admission residents and Resident #2's Care Plan was due by 2/18/26. She stated Resident #1's Care Plan was due 1/29/26. She stated Care Plans listed the residents' needs and how they were being addressed. She stated therapeutic diets would have been listed on a care plan. She stated the only risk to the residents of not having a complete Care Plan was if the Care Plan was used by the nurses to determine the type of care the residents needed, but she stated most nurses referred to the chart for the residents' needs; not their care plan. An interview with the DON on 2/17/26 at 3:10 pm revealed all residents should have a complete comprehensive care plan. The DON stated the Care Plans should have included important things like therapeutic diets, therapies, behaviors, resident refusals to name a few. She stated the care plan should provide a comprehensive plan for the residents' care. An interview with the Administrator on 2/17/26 at 3:39 pm revealed he was aware the MDS Nurse Coordinator was behind on the completion of resident care plans. The Administrator stated they had identified the Care Plans as an issue and was one of the systematic changes in their QAPI meeting. The Administrator stated they were going to have the MDS Nurse Coordinator update and complete Care Plans during their stand up meetings daily. The Administrator stated the risk to the resident of not having had a completed care plan was the residents' needs may not have been met timely. Record review of the facility's policy Care Planning-Interdisciplinary Team revised December 2024 reflected .The interdisciplinary team is for the development of resident care plans.1.Resident care plans are developed according to the timeframes and criteria established by S483.21. 2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT).

Based on observation, record review, and interviews, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely for 2 of 6 residents (Resident #3 and Resident #4) reviewed for resident rights: The facility failed to provide clean bed linens for Resident #1 and Resident #2's bed on 2/17/26. This failure could place residents at risk of exposure to infectious diseases and other unsanitary health hazards.Record review of Resident #3's face sheet dated 2/17/26 reflected she was a [AGE] year-old female with an original admission date of 5/31/25 and a readmission date of 9/28/25. Resident #3 had the following active diagnoses: muscle wasting and atrophy (decrease size, mass and strength of muscle tissue), muscle weakness, need for assistance with personal care, and Depression (a medical illness characterized by a persistent, intense, and long-lasting low mood, loss of interest and decreased energy). Record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected Resident #3 had moderate cognition and a BIMS of 10. She had limitations for upper and lower extremities on both sides. Resident #3 was noted to be incontinent of bowel and bladder. During an observation of Resident #3's bed on 2/17/26 at 9:59am AM reflected sheets and a washable incontinent pad on the bed. The incontinent pad had a yellow stain on the lower right side of it about 4 inches long and 3 inches wide in an oval shape. An interview and observation of Resident #3's bed with CNA A on 2/17/26 at 10:06 am revealed she did not recall when she last changed Resident #3's sheets and incontinent pad. CNA A noted the stain on the pad and stated she had gotten Resident #3 up and ready but hadn't had a chance to change her sheets. She immediately took all the sheets off the bed, including the incontinent pad and removed them from the room. She stated the risk to the residents of not changing their sheets when dirty would be the spread of infection. Record review of Resident #4's face sheet dated 2/17/26 reflected he was a [AGE] year-old male with an original admission date of 3/10/23 and a readmission date of 9/25/25. Resident #4 had the following active diagnoses: Huntington's Disease (a fatal neurodegenerative disorder that causes progressive breakdown of nerve cells in the brain), need for assistance with personal care, urinary tract infections and post-traumatic stress disorder (mental health disorder that is characterized by flashbacks, nightmares and severe anxiety from past traumatic events experienced). Record review of Resident #4's Comprehensive MDS assessment dated [DATE] reflected Resident #4 had severe deficits in cognition and a BIMS score of 7. He had limitations to his upper extremities on both sides. Resident #4 needed substantial assistance with toileting and was occasionally incontinent of bladder. An observation of Resident #4's bed on 2/17/26 at 10:03 am reflected sheets and a washable incontinent pad was on the resident's bed. The incontinent pad had two small red circles on the right side. An interview and observation of Resident #4's bed with CNA A on 2/17/26 at 10:06 am revealed she last changed Resident #4's bed sheets on 2/16/26. She stated the stain on his incontinent pad looked like blood and immediately stated she could change it at that time. CNA A stated she typically changed the incontinent pads when she saw they were dirty but had not noticed Resident #4's was dirty. An interview with LVN C on 2/17/26 at 10:25 am revealed she had not been in Resident #4's room since she started her shift at 6 am because Resident #4 had been in the living room the whole time, and she had not checked her bed linens. She also stated she had not assisted Resident #4 to her room and therefore had not seen the linens on her bed. LVN C stated when she noticed beds were soiled, she would let the patient know that she had gotten someone to assist to change the linens. LVN C stated residents' bed linens should have been changed any time there was anything on them. An interview with CNA B on 2/17/26 at 12:42 pm revealed bed linens should be changed every shower days or as needed when visibly soiled. CNA B described visibly soiled as any sign of dirt, stains, or bodily fluids on the sheets. An interview with the ADON on 2/17/26 at 2:34 pm revealed the expectations for bed linen changes were they should have been changed on shower days and as requested.The ADON stated the incontinent care pads should have been changed with every incontinent care episode. The residents were at risk of skin breakdown if they had dirty sheets. An interview with the DON on 2/17/26 at 3:00 pm revealed she did not know what was on the incontinent pad for Resident #3 but believed the red stuff on Resident #4's pad was his red juice because Resident #4 had poor muscle control and sometimes spilled his drinks from his cup. The DON stated the expectation on bed linens was they should be changed when visibly soiled and on shower days. The DON stated soiled bed linens could have affected the residents' dignity and how they felt at the facility. The DON stated the residents should have had a clean home. An interview with the Administrator on 2/17/26 at 3:36 pm revealed the expectation at the facility was residents should have been provided with a clean home environment. It was the responsibility of the CNAs to ensure residents' bed linens were always clean. The Administrator stated the risk to the residents of not having clean bed linens was issues with infection control. Requested the facility's policy on cleanliness of the facility related to bed linens and was informed by the Administrator, on 2/17/26 at 3:07 pm, they did not have a policy for bed linens or cleanliness of the facility.

Based on observation, record review, and interviews, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs for 2 of 6 residents (Resident #1 and Resident #2) reviewed therapeutic diets: The facility failed to provide Resident #1 with food that was consistent with his prescribed fortified food plan diet on 2/17/26.The facility failed to provide Resident #2 with food that was consistent with her prescribed Low Concentrated Sugar diet on 2/9/26 and 2/10/26. These failures could place residents at risk of declining health and significant fluctuations with their weight.Record review of Resident #1's face sheet dated 2/17/26 reflected he was a [AGE] year-old male with an admission date of 1/9/26. Resident #1 had the following active diagnoses: muscle wasting and atrophy (decrease size, mass and strength of muscle tissue), Hypothyroidism (endocrine disorder where the thyroid fails to produce sufficient thyroid hormones), Hypotension (abnormally low blood pressure) and Type 2 Diabetes (a metabolic disorder characterized by high blood sugar levels). Record review of Resident #1's Initial MDS assessment dated [DATE] reflected Resident #1's cognition was intact, and he had a BIMS score of 14. Section K noted a therapeutic diet on admission and while a resident. Record review of Resident #1's Order Summary Report dated 2/1/26 reflected resident had an order for Fortified Food Plan Diet Regular Texture, Regular Liquids consistency with a start date of 1/23/26. Record review of Resident #1's Breakfast Ticket dated 2/16/26 reflected .Diet: Low Concentrated Sugar/Consistent or Controlled Carbohydrates. An observation and interview with Resident #1's in his room on 2/17/26 at 9:52am reflected an untouched tray of food that contained 1 sausage, 1 square egglike substance, a cup of oatmeal, 1 French toast, maple syrup, and a red juice. On the tray was the breakfast ticket reflected resident received a Low Concentrated Sugar/Consistent or Controlled Carbohydrate tray. Resident #1 stated he had not eaten any of his breakfast because he had no appetite. An interview with the Dietary Manager on 2/17/26 at 1:14pm revealed she did not recall the diet Resident #1 was prescribed. She checked her records and stated she had been providing Resident #1 an Low Concentrated Sugar diet, but just noticed the physician had changed Resident #1's diet to Fortified Food Plan which required the resident being offered bigger portions and more food equaling more calories. She stated the Low Concentrated Sugars was essentially smaller portions equaling lesser calories. She stated she did not recall receiving notification of diet change from the nurses or the dietician. She stated the risk to the residents of not having gotten the proper diet was possible weight loss. Record review of Resident #2's Initial MDS Assessment date 2/4/26 reflected she was a [AGE] year-old female with an admission date of 1/30/26. Resident #2 had the following active diagnoses: Hypertension (high blood pressure), Renal Failure (occurs when kidneys lose the ability to effectively filter waste products, toxin and excess fluid from blood), Diabetes Mellitus (a metabolic disorder characterized by high blood sugar levels) and Irritable Bowel Syndrome (chronic functional disorder of the gastrointestinal tract characterized by recurrent abdominal pain, discomfort and changes in bowel habit). Resident #2's cognition was intact with a BIMS score of 15. Section K noted a therapeutic diet while a resident. Record review of Resident #2's Order Summary Report dated 2/17/26 reflected resident had an order for Controlled Carbohydrate Diet with a start date of 1/30/26. Record review of Resident #2's Lunch ticket dated 2/9/26 reflected .Regular Diet. Record review of Resident #2's Lunch ticket dated 2/10/26 reflected .Regular Diet. An interview and observation with Resident #2 in her room on 2/17/26 at 12:06 pm revealed she had gotten a regular diet and not a diabetic diet. She stated she had gotten regular portions of carbohydrates. She also had gotten regular sugar and desserts. She showed the surveyor the meal tickets she saved in her drawer, and they were dated 2/9/26 and 2/10/26. She stated the tickets said, Regular Diet. At 12:45pm Resident #2 received her lunch food tray and the tray had her lunch ticket which reflected .Low Concentrated Sugar/Controlled Carbohydrate Diet. She stated it was the first time she had received a ticket labeled with that diet. She stated she had spoken to the Dietary Manager that morning and she told them she had not been receiving a diabetic diet. Observation of the food on her tray reflected a smaller portion of mashed potatoes, green beans, a dinner roll, meatloaf, Jello, tea and two packets of sweetener. An interview with the Dietary Manager on 2/17/26 at 1:14pm revealed she met with Resident #2 in the morning and the resident had told her she was diabetic. The Dietary Manager stated Resident #2 was on Regular Low Concentrated Sugar Diet and had been on it since she was admitted . She stated when a ticket reflected regular for the diet section it means there were no restrictions to their diet. She stated when a resident was Diabetic, they were given a Low Concentrated Sugar Diet and not a Regular diet. She stated if Resident #2 had received tray tickets that displayed Regular then Resident #2 got regular meals with no restrictions. The Dietary Manager stated Resident #2's order reflected she was prescribed a Low Concentrated Sugar diet. She was unsure of the reason Resident #2 had been receiving regular diet meals. The Dietary Manager stated Resident #2 told her she had not wanted to cut out any sweets. The Dietary Manager stated she followed the physician orders or dietician orders to determine which diet was provided to residents. She stated, at admission, she was provided a Low Concentrated Sugar Diet, but Resident #2 had not gotten it until that day. The risk to the residents of receiving a regular diet was she could have been consuming more sugar than she should which could affect her Diabetes. An interview with the ADON on 2/17/26 at 2:44 pm revealed the speech therapist, dietician, or physician could write a diet order. The orders should have been given to the Dietary Manager, as soon as they were changed. An interview the DON on 2/17/26 at 3:10 pm revealed it was the responsibility of the Dietician to notify the Dietary Manager of changes in therapeutic diets. She stated she believed the reason Resident #1's diet was not changed timely was because the Dietician was new and she had erroneously sent an incomplete spreadsheet of residents on therapeutic diets to the Dietary Manager. The DON stated she was unsure of why Resident #2 had gotten a regular diet instead of the Low Concentrated Sugar diet. She stated there was little to no risk for Resident #2 of having gotten a regular diet because there was not a big difference between a regular diet and Low Concentrated Sweet Diet. The risk for Resident #3 having gotten the wrong diet was it could increase weight loss. An interview with the Administrator on 2/17/26 at 3:39 pm revealed he believed the error with the diets for Resident #1 and Resident #2 was the Dietician changing diets without their knowledge resulted in an oversight of the changed diets for the two residents. The Administrator stated the risk to the residents of having been served the wrong diet would depend on the resident and the reason the diet was prescribed, but it could affect their health. Record review of the facility's policy Therapeutic Diets revised 10/2017 reflected .Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. 2. A therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider). The attending physician may delegate this task to a registered or licensed dietitian as permitted by state law. 3. Diet order should match the terminology used by the food and nutrition services department. 4. A 'therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: a. diabetic/calorie-controlled diet, b. low sodium diet; c. cardiac diet; and d. altered consistency diet.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards in the facility's only kitchen. 1. The facility failed to ensure fryer was free of sediments and failed to ensure oil had been replaced. 2. Dietary [NAME] I and Dietary Aide J failed to ensure hair was covered or properly restrained during lunch meal service on 12/11/25. These failures could place residents at risk for food-borne illness and contamination Findings included: 1. Observation on 12/09/25 at 10:43 AM revealed fryer revealed about 2 inches sediment around the edges of the fryer and food particles in dark brown oil. Interview on 12/09/25 at 10:45 AM with Dietary Manager revealed the fryer was last used on Friday (12/05/25) and the oil is supposed to be changed weekly on Friday. She stated it was not changed last Friday (12/05/25) since she was out of oil to replace it. She stated her shipment was coming and will be changed once she got the oil. 2. Observation on 12/11/25 at 11:58 AM revealed Dietary [NAME] I was putting food on resident lunch plates with uncovered hair about 0.5 inch above both ears and 0.5 inch in back of her head. Observation on 12/11/25 at 12:01 PM revealed Dietary Aide J's hair restraint was not covering about 1 inch in front of both ears and about 1.5 inches in back of her head. Interview on 12/11/25 at 12:18 PM with Dietary Manager revealed dietary staff not wearing effective hair restraints can place the risk of hair falling in the food and contaminating the food. She stated not changing the oil for the fryer or filtering the oil could place the food at risk of contamination. Record Review of the facility's policy Cleaning Instructions: Deep Fat Fryer dated 2023 reflected Fryers will be cleaned after each use. Procedure: 4. Oil should be changed at least every 10 times the fryer is used. When the oil starts to turn a dark brown, starts to smell or the consistency changes, it is time to change the oil. 5. Remove food particles from the oil after each use. The U.S. Food and Drug Administration Food Code, dated 2022, noted the following regarding body hair, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-serve and single-use articles.

Based on observation, interview and record review the facility failed to ensure residents had a right to a safe, clean, comfortable and homelike environment for two of 10 residents (Resident #18 and Resident #59) and four of 4 shared bathrooms (room [ROOM NUMBER] and 304, room [ROOM NUMBER] and 308, room [ROOM NUMBER] and 309, and room [ROOM NUMBER] and 312) reviewed for homelike environment. 1. The facility failed to ensure Resident #18's restroom tile around the toilet was in good working condition on 12/09/25. 2. The facility failed to ensure Resident #59's restroom toilet was working properly, and fan blower wires were not exposed in bathroom ceiling on 12/09/25. 3. The facility failed to ensure the restroom handrails were in good repair for bathrooms shared by room [ROOM NUMBER] and 304, room [ROOM NUMBER] and 308, room [ROOM NUMBER] and 309, and room [ROOM NUMBER] and 312. These failures placed residents at risk of resident restroom in an unsafe environment and a lack of homelike environment for residents. Findings included:1. Record Review of Resident #18's Annual Assessment reflected Resident #18 was admitted to the facility on [DATE] with included diagnoses of coronary artery disease and heart failure. Resident #18 had a BIMS score of 15 indicating her cognition was intact. Resident #18 was independent with toileting. Observation on 12/09/25 at 11:46 AM revealed Resident #18's bathroom tile of about 3 inches was missing around the sides of the toilet and 6 inches behind the toilet. There were rocks where the missing tile was. Interview with Resident #18 revealed the tile had been like this since about June 2025 2. Record Review of Resident #59's admission assessment dated [DATE] reflected Resident #59 [was admitted to the facility on [DATE] with diagnoses of hip fracture, dementia (significant cognitive decline severe enough to disrupt daily life) and polyneuropathy (condition affecting multiple peripheral nerves in different body parts are damaged). Resident #59 was moderately impaired with cognitive skills for daily decision making. Resident #59 was dependent with ADLs. Resident #59 was on hospice services. Interview on 12/09/25 at 11:20 AM with Resident #59's RP revealed the wires showing in ceiling of bathroom had been like that since admission. Resident #59's RP stated the toilet was clogged and had been like this for a while. She stated Resident #59 was on hospice services. Interview on 12/11/2025 at 2:50 PM with the Maintenance Director revealed toilets on hall 200, including Resident #59's toilet was clogged/not working properly for the last week. He stated the wires in the ceiling of Resident #59's bathroom was from the fan blower. He stated he was having difficulty finding a replacement cover for the fan blower. He stated Resident #18's toilet had been fixed where they had to drill through the bathroom floor. He stated he was aware of the missing tile around the toilet but had not gotten to it yet. Interview on 12/11/2025 at 1:36 PM with the Administrator revealed his expectations for repairs and maintaining the bathrooms were that everything worked and there was a home-like environment. He said staff have been educated on how to report issues in the electronic maintenance system, which notified him and the Maintenance Director immediately. He said the Maintenance Director has 30 days to fix an issue unless the facility needed to hire a contractor; then it depended on who was hired. He stated the impact on residents would be not having a homelike environment.3. An observation on 12/09/2025 at 10:15 am in the [NAME] and [NAME] bathroom (a shared bathroom with two doors, connecting two separate bedrooms) for room [ROOM NUMBER] and 304 revealed the round handrails located in the bathrooms next to the toilets, were rusted around the lower part of the handrail where it was attached to the wall approximately 2 up the handrail.An observation on 12/09/2025 at 10:18 am in the [NAME] and [NAME] bathroom for room [ROOM NUMBER] and 308 revealed the round handrails located in the bathrooms next to the toilets, were rusted around the lower part of the handrail where it was attached to the wall approximately 3 up the handrail.An observation on 12/10/2025 at 10:45 am in the [NAME] and [NAME] bathroom for room [ROOM NUMBER] and 312 revealed the round handrails located in the bathrooms next to the toilets, were rusted around the lower part of the handrail where it was attached to the wall approximately 3 up the handrail.An observation on 12/11/2025 11:18 am in the [NAME] and [NAME] bathroom for room [ROOM NUMBER] and 309 revealed the round handrails located in the bathrooms next to the toilets, were rusted around the lower part of the handrail where it was attached to the wall approximately 2 up the handrail.In an interview on 12/10/2025 at 10:50 am with the Maintenance Director it was revealed that he was responsible for replacing or repairing grab bars in the facility if they were loose, broken or rusted. He said any staff, resident or guest could report needed repairs by scanning the QR code posted throughout the facility, which directed them to the facility's TELS system.In an interview on 12/10/2025 at 12:06 pm with CNA H she said she knew if there were repairs that needed to be repaired, she would notify the Maintenance Director.In a follow-up interview on 12/11/2025 1:15 pm with the Maintenance Director he said he was not aware of the rusted safety bars in the affected rooms. He said he would get them replaced now that he was made aware of them.In an interview on 12/11/2025 at 1:36 pm the Administrator stated his expectations for repairs and maintaining the bathrooms were that everything works and has a home-like environment. He said staff have been educated on how to report issues in TELS, which notifies him and the Maintenance Director immediately. He said the Maintenance Director has 30 days to fix an issue unless the facility needs to hire a contractor then it depends on who is hired. He said he was not aware of the rusted safety bars in the affected rooms. He said the impact would be resident rights and not having a homelike environment.Record review of the facility's Homelike Environment policy last revised February 2021 reflected Residents are provided with a safe, clean, comfortable and homelike environment.The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment. Record review of the facility's Maintenance Service policy dated December 2009 revealed: 1.The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.2. Functions of maintenance personnel include, but are not limited to:a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.b. maintaining the building in good repair and free from hazards.i. providing routinely scheduled maintenance service to all areas.j. others that may become necessary or appropriate.

Based on record reviews and interviews, the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of the State Long-Term Care Ombudsman of the residents' transfer or discharge and the reasons for the move, for 1 of 4 residents (Resident #24) reviewed for the discharge process. Resident #24 was discharged on 10/15/2025, 11/08/2025 and 11/26/2025 without a notice to the Long-Term Care Ombudsman. This failure could place residents at risk of not knowing their rights or receiving the services of the state Long-Term Care Ombudsman.The findings included:A record review of Resident #24's face sheet printed 12/11/2025 revealed diagnoses of Unspecified Fracture of Lower End of Right Humerus (a break near the elbow, causing pain, swelling, bruising, and stiffness), Calculus of Kidney (known as a kidney stones), Shortness of Breath, Obesity, Acute Kidney Failure, and Type 2 Diabetes.A record review of Resident #24's MDS assessment dated [DATE], reflected a BIMS score of 04 indicating his cognition was severely impaired, and most of his functional abilities required substantial to maximal assistance (the helper does more than half the effort) with his activities of daily living.A record review of Resident #24's electronic medical record revealed a progress note dated 10/15/2025 stating Resident #24 was transferred to the hospital.A record review of Resident #24's electronic medical record revealed a progress note dated 11/08/2025 stating Resident #24 left facility via ambulance.A record review of Resident #24's electronic medical record revealed a progress note dated 10/26/2025 stating Resident #24 was transferred to the emergency room.A record review of the facility's transfer and discharge summary revealed resident #24 was discharged on 10/15/2025, 11/08/2025 and 11/26/2025.A record review of the medical record revealed no evidence of a written discharge notice being provided to the LTC ombudsman on 10/15/2025, 11/08/2025, and 11/26/2025.During an interview with the Social Worker on 12/10/2025 she said she did not send any written notices to the Ombudsman.During an interview with the ADON on 12/10/2025, she said the charge nurse called the physician, DON, family, and Administrator, and documented in the EMR. She was not aware of anything given in writing.During an interview with the DON on 12/11/2025, she said the charge nurse verbally notified the family and documented the notification in their EMR. She said the impact on a resident/family if they were not informed, when the resident was transferred, was fear of not knowing where their loved one was and not getting the opportunity to be with the resident during a difficult traumatic time.During an interview with the Administrator on 12/11/2025 , he said when a resident was transferred or discharged nursing verbally informed the responsible party, physician, and the ombudsman by calling them.During an interview with the facility's Ombudsman on 12/11/2025, she said the facility does not call her to inform her of transfers or discharges. She said in 2025 the facility sent a transfer/discharge report three times, in March, April, and Aug.A record review of the facility's Transfer or Discharge, Facility-Initiated Policy dated October 2022 revealed: 1. Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: a. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility. Notice of Transfer or Discharge (Emergent or Therapeutic Leave)1. When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, NOT discharges, because the resident's return is generally expected.2. Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility. Residents who are sent to the acute care setting for routine treatment/planned procedures are also allowed to return to the facility.3. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: a. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident;b. The resident's health improves sufficiently to allow a more immediate transfer or discharge;c. An immediate transfer or discharge is required by the resident's urgent medical needs; ord. A resident has not resided in the facility for 30 days.4. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements).5. Notice of Facility Bed-Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer.6. Notices are provided in a form and manner that the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments.Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge.

Based on observation, interview and record review, the facility failed to ensure that 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 4 (Resident #2, Resident #3, Resident #19, and Resident #24) of ten residents reviewed for respiratory care.1. The facility failed to ensure Resident #2's oxygen tubing (flexible tube used to deliver oxygen to the nose through two prongs) was stored properly when not in use on 12/09/2025.2. The facility failed to ensure Resident #3's oxygen tubing was stored properly when not in use on 12/09/2025. 3. The facility failed to ensure Resident #19's suction tubing (used to keep the airway clear) was stored properly when not in use on 12/10/2025.4. The facility failed to ensure Resident 24's oxygen tubing and CPAP (machine delivers continuous stream of air to keep airway open during sleep) mask was stored properly when not in use on 12/10/2025.These failures could place residents at risk for respiratory infection and not having their respiratory needs met.Findings included: Resident #2Record review of Resident #2's face sheet, dated 12/10/2025, reflected a [AGE] year-old female who admitted on [DATE]. The resident was diagnosed with COPD (disease of the lungs and airway that affects breathing). Record review of Resident #2's Quarterly MDS (tool used to assess health needs and functional capabilities) Assessment, dated 11/17/2025, reflected the resident was cognitively intact with a BIMS (tool used to assess cognitive function) score of 14 (no or very little cognitive impairment). The Quarterly MDS Assessment reflected active diagnoses which included COPD and respiratory failure. Record review of Resident #2's Comprehensive Care Plan, dated 09/09/2025, reflected the resident was at risk for respiratory infection, shortness of breath, and cough related to a diagnosis of COPD. Interventions included administration of oxygen and nebulizer treatments as ordered. Record review of Resident #2's Physician Order, dated 04/10/2025, reflected to administer oxygen via nasal cannula at 3 LPM at night as needed for shortness of breath and to maintain oxygen greater than 90% every shift. Record review of Resident #2's Physician Order, dated 11/21/2025, reflected Oxygen tubing and delivery device (mask, nasal cannula) is to be stored in bag when not in use every shift.During an observation on 12/09/2025 at 9:41AM, Resident #2 was not in her room. An oxygen concentrator was next to her bed. Oxygen tubing was connected to the concentrator, and the tubing was on the floor. The oxygen tubing was not in a bag. Resident #3Record review of Resident #3's face sheet, dated 11/17/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with respiratory disorder.Record review of Resident #3's Quarterly MDS Assessment, dated 11/13/2025, reflected the resident was cognitively intact with a BIMS score of 13 ( no or very little cognitive impairment). The Quarterly MDS Assessment indicated the resident was on oxygen therapy. Record review of Resident #3's Comprehensive Care Plan, dated 11/10/2025, reflected the resident required supplemental oxygen and one of the interventions was to provide oxygen therapy as ordered. Record review of Resident #3's Physician Order, dated 11/21/2025, reflected to administer oxygen via nasal cannula at 3 LPM as needed for shortness of breath and to maintain oxygen greater than 90% every shift. Record review of Resident #3's Physician Order, dated 04/10/2025, reflected CPAP tubing and delivery device (mask, nasal cannula) is to be stored in bag when not in use every shift.During an observation and interview on 12/09/2025 at 9:33 AM, Resident #3 was sitting in a wheelchair in her room. A portable oxygen concentrator was on the windowsill next to her bed. Oxygen tubing was connected to the concentrator. The oxygen tubing was not in a bag. Resident #3 stated she did not know the oxygen tubing was supposed to be in a bag. During an interview on 12/09/2025 at 9:48 AM, CNA E stated the oxygen tubing should have been in a bag. CNA E stated if she saw oxygen tubing on the floor, she replaced it with new tubing and put it in a bag. She stated it was important to prevent infection.During an observation and interview on 12/09/2025 at 9:52 AM, LVN C went with the surveyor to Resident #2 and Resident #3's room. She stated the oxygen tubing should have been stored in a bag. She stated the oxygen tubing collected germs and put the residents at risk for respiratory issues. LVN C removed the tubing and stated she would replace it and ensure it was in a bag. During an interview on 12/09/2025 at 3:20 PM, the ADON stated the expectation was for oxygen tubing to be stored in a bag for infection control. Resident #19Record review of Resident #19's face sheet, dated 12/10/2025, reflected a [AGE] year-old male who initially admitted on [DATE], and readmitted on [DATE]. Resident #19 had diagnoses which included traumatic brain injury (damage to the brain caused by an external physical force) and tracheostomy status (tube inserted through a surgical opening in the neck to help you breathe). Resident #19 was on hospice care.Record review of Resident #19's MDS Assessment and Care Screening, dated 09/08/2025, reflected a BIMS was not appropriate. Section C (Cognitive Patterns) indicated the resident was severely impaired with cognitive skills for daily decision making. Section O (Special Treatments, Procedures, and Programs) reflected oxygen therapy, tracheostomy care, and suctioning.Record review of Resident #19's Comprehensive Care Plan, dated 09/10/2025, reflected the resident had a tracheostomy and was at risk for increased secretions, congestion, and respiratory infections. One intervention was to monitor for suctioning of increased secretions and assess for relief. Record review of Resident #19's Physician Order, dated 09/04/2025, reflected to suction oral and respiratory secretions every shift as needed. During an observation and interview on 12/10/2025 at 7:11 AM, Resident #19 was lying in bed with his eyes closed. A suction pump was on the resident's nightstand next to the bed. Connective tubing was connected to the suction pump, and the tubing was on the floor under the edge of the bed. The connected tubing did not have a suction catheter (device to suction secretions) attached. RN D was in the hallway and stated the suction tubing should be in a bag. She stated she did not see it when she was in Resident #19's room earlier. RN D removed the connective tubing and discarded it. She stated it was important to avoid any type of infection to the resident. Resident #24Record review of Resident #24's Face Sheet, dated 12/10/2025, reflected a [AGE] year-old male who initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #24 had diagnoses which included mild persistent asthma (causes the airway to narrow and can make breathing difficult) and pneumonia (infection in lung). Record review of Resident #24's Quarterly MDS Assessment, dated 11/05/2025, reflected moderately impaired cognition (noticeable decline in memory and thinking abilities) with a BIMS score of 12. The Quarterly MDS Assessment reflected respiratory treatments which included CPAP and oxygen therapy. Record review of Resident #24's Comprehensive Care Plan, dated 12/02/2025, reflected the resident required supplemental oxygen and one of the interventions was provide oxygen therapy as ordered. Record review of Resident #24's Comprehensive Care Plan, dated 12/02/2025, reflected the resident used a CPAP for sleep apnea. One intervention was to encourage the resident's use of the CPAP.Record review of Resident #24's Physician Order, dated 04/10/2025, reflected CPAP tubing and delivery device (mask, nasal cannula) is to be stored in bag when not in use every shift.Record review of Resident #24's Physician Order, dated 11/21/2025, reflected Oxygen tubing and delivery device (mask, nasal cannula) is to be stored in bag when not in use every shift every shift.During an observation and interview on 12/10/2025 at 7:31 AM, Resident #24 was lying in bed awake. Resident #24's oxygen tubing was connected to the oxygen concentrator next to his bed. The tubing was on the floor and not in a bag. Resident #24's CPAP mask was on the floor at the head of the bed. Resident #24 stated he removed the mask. LVN A came to Resident #24's room and stated Resident #24 removed the CPAP mask himself. She stated he wore it at night and oxygen during the day. She stated Resident #24 did not want to put oxygen on earlier. She stated it should have been in a bag to reduce infection. During an interview on 12/11/2025 at 11:05 AM, the ADON stated respiratory items should be stored in a bag when not in use. She stated it was important for infection control and prevention of respiratory infections. The ADON stated staff would be in-serviced on monitoring respiratory items. During an interview on 12/11/2025 11:43 AM, the DON stated all staff should observe if oxygen tubing was on the floor or not stored in a bag. She stated staff members should report it directly to the nurse. She stated CNAs could remove tubing and alert the nurse to change the tubing. She stated the connective tubing for the suction machine should be changed weekly or as needed. She stated if it was on the floor, it should be changed. She stated it was important for infection control and the residents' health and safety. On 12/11/2025 at 1:20 PM, the Administrator stated the facility did not have a policy related to the storage of respiratory items when not in use. The facility did not submit a policy by the date, 12/11/25 and time of exit, 4:30pm.

Based 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 (Resident #11) of five residents reviewed for infection control. The facility failed to ensure CNA G performed hand hygiene and changed gloves during Resident #11's incontinent care on 12/10/2025.This failure could place residents at risk of cross-contamination and development of infections. Findings include:Review of Resident #11's Face Sheet, dated 12/11/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident had diagnoses which included dementia (decline in cognitive function that interferes with daily life) and diabetes mellitus (the body does not use insulin properly which leads to elevated blood glucose levels).Review of Resident #11's Quarterly MDS Assessment, dated 11/15/2025, reflected the resident had severely impairment cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated Resident #11 was incontinent of bowel and bladder. Review of Resident #11's Comprehensive Care Plan, dated 09/22/2025, reflected Resident #11 was incontinent of bowel and bladder related to cognitive deficit. One intervention was to clean resident after each incontinence episode. During an observation and interview on 12/10/2025 at 11:12 AM, CNA F and CNA G provided incontinent care for Resident #11. The curtain was pulled around the bed to provide privacy. The supplies were on the resident's bedside table and CNA G was wearing gloves. CNA G pulled down the front of the brief and cleaned the resident. CNA F knocked on the door and entered the room to assist CNA G. CNA F washed her hands in the resident's restroom and put on gloves. CNA F assisted Resident #11 to roll to his left side. CNA G cleaned the resident's bottom and removed the soiled brief. CNA G did not change gloves. CNA G picked up the clean brief and placed it under Resident #11. CNA F assisted Resident #11 to roll to his right side and CNA G straightened the brief under the resident and secured the tabs in the front. CNA G pulled up Resident #11's blanket and covered him. CNA F washed her hands in the resident's restroom before exiting the room. CNA G removed her gloves. She did not wash her hands or use hand sanitizer before leaving the resident's room. CNA G took the bag of trash to another room on the hall. Upon exiting the room, she applied hand sanitizer from a pump on the wall. CNA G stated she knew to change gloves if the resident had a bowel movement, but was not sure, if the brief was wet. CNA G stated she should have washed her hands or used hand sanitizer after removing the gloves. CNA G stated it was important to change gloves and use hand sanitizer for infection control when providing resident care. During an interview on 12/10/2025 at 11:37 AM, LVN B stated CNA G should have washed her hands after cleaning Resident #11. She stated CNA G should have washed her hands before exiting the resident's room. She stated it was important to prevent cross contamination and infection when caring for residents. During an interview on 12/11/2025 11:05 AM, the ADON stated after cleaning Resident #11, CNA G should have removed her gloves, washed her hands or used hand sanitizer, and put on clean gloves before touching anything else. The ADON stated CNA G should have washed or sanitized her hands before exiting the room. She stated it was important to prevent skin breakdown, urinary tract infection, or any skin infection. During an interview on 12/11/2025 at 11:43 AM, the DON stated it was important to perform hand hygiene during incontinence care to prevent infection and for skin integrity. She stated the staff were provided in-service training. Record review of the facility's policy entitled Standard Precautions, revised September 2022, reflected Hand hygiene is performed with ABHR or soap and water. before and after contact with the resident. after contact with items in the resident's room. after removing gloves.Gloves are changed and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care.Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident.After gloves are removed, hands are washed immediately to avoid transfer of microorganisms to other residents or environments.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth 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 a resident for one (Resident #24) of five residents reviewed for care plans. The facility failed to ensure Resident 24's Comprehensive Care Plan reflected the use of oxygen therapy on 12/10/2025. This failure could place the residents at risk of not receiving the necessary care and services needed.Findings included:Record review of Resident #24's Face Sheet, dated 12/10/2025, reflected a [AGE] year-old male who initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #24 had diagnoses which included mild persistent asthma (causes the airway to narrow and can make breathing difficult) and pneumonia (infection in lung). Record review of Resident #24's Quarterly MDS (tool used to assess health needs and functional capabilities) Assessment, dated 11/05/2025, reflected moderately impaired cognition (noticeable decline in memory and thinking abilities) with a BIMS (tool used to assess cognitive function) score of 12 (moderate cognitive impairment). The Quarterly MDS Assessment indicated Resident #11 received oxygen therapy. Record review of Resident #24's Comprehensive Care Plan, dated 12/02/2025 did not reflect oxygen therapy.Record review of Resident #24's Physician Order, dated 11/21/2025, reflected to administer oxygen via nasal cannula at 3 LPM as needed for shortness of breath and to maintain oxygen greater than 90% every shift. During an observation on 12/10/2025 at 7:31 AM, Resident #24 was lying in bed awake. Resident #24's oxygen tubing was connected to the oxygen concentrator next to his bed. During an interview on 12/10/2025 at 1:14 PM, the Regional Reimbursement Coordinator stated Resident #24 had a recent decline and a new order for oxygen therapy. She stated she would look at Resident #24's medical records and if he did not have a care plan for oxygen, she would add it.During an interview on 12/10/2025 at 1:40 PM, the Regional Reimbursement Coordinator stated Resident #24 did not have a care plan for oxygen and she added one. She stated it was important to ensure the resident's care plan was updated so he received the appropriate care. During an interview on 12/11/2025 at 11:05 AM, the ADON stated she and the DON checked residents' admission records and worked together to add care plans relating to residents' orders. She stated the MDS Coordinator followed up to ensure care plans were appropriate. She stated care plans included nursing interventions to help residents reach goals. She stated it was also a way to monitor new interventions. During an interview on 12/11/2025 11:43 AM, the DON stated it was important to ensure oxygen therapy was included in Resident #24's care plan. She stated if the resident was not getting the oxygen he needed, it could cause deoxygenation, confusion, or a change in condition. She stated when a care plan was added, tasks were assigned to different staff members, and everyone was able to see it. Record review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised March 2022, reflected A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on interview and record review, the facility failed to designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident and to ensure facility obtained documentation from hospice for 1 of 2 residents (Resident #59) reviewed for hospice care. 1. The facility failed to ensure there was a designated member of the interdisciplinary team for hospice coordination of care. 2. The facility failed to ensure Resident #59's hospice election form and physician recertification of terminal illness for Resident #59 was available. These failures place residents at risk of lack of coordination of care and decrease in quality of care. Record Review of Resident #59's admission assessment dated [DATE] reflected Resident #59 was admitted to the facility on [DATE] with diagnoses of hip fracture, dementia (significant cognitive decline severe enough to disrupt daily life) and polyneuropathy (condition affecting multiple peripheral nerves in different body parts are damaged). Resident #59 was moderately impaired with cognitive skills for daily decision making. Resident #59 was on hospice services. Record Review of Resident #59's Hospice K book revealed there was no election form and physician certification of terminal illness for Resident #59. Interview on 12/11/2025 at 11:32 AM with the DON revealed she could not find Hospice K's election form and physician certification of terminal illness for Resident #59. She stated the risk of the facility not having resident hospice documentation could place hospice residents at risk for inappropriate care. She stated she was not sure which facility staff member was the designated hospice coordination of care person She was not aware who the hospice liaison was. Review of facility's Hospice Program policy last revised July 2017 reflected Hospice services are available to residents at the end of their life.12. Our facility has designated (blank) to coordinate care provided to the resident by our facility staff and the hospice staff.d. Obtaining the following information from the hospice:.(2) Hospice election form (3) Physician certification and recertification of the terminal illness specific to each resident . Interview on 12/11/2025 at 2:59 PM with the DON revealed the hospice policy did not have a designated staff member for hospice coordination of care. She stated the risk was the hospice residents had no one to ensure the coordination of care for their hospice services.

Based on interview and record review, the facility failed to maintain medical records that were accurate and complete in accordance with acceptable professional standards for 2 (Residents #23 and #24) of 4 residents reviewed for clinical records.1. Resident #23 had an OOH-DNR in their record that was missing information in Section B, Declaration by legal guardian, agent, or proxy on behalf of the adult person who is incompetent or otherwise incapable of communication.2. Resident #35 had an OOH-DNR in their record that the family member signed in sections they were not supposed to, the family member missed a required signature at the bottom, and the two witnesses to the family members signature did not sign until 14 days after the family member did.The facility's failure could place residents at risk for not receiving healthcare as per their or their legal representatives' wishes. Findings included:1.Record review of Resident #23's face sheet printed [DATE] revealed he was an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Cognitive Communication Deficit (difficulty in expressing or understanding messages due to impaired thinking skills), Dementia (significant decline in mental abilities), Major Depressive Disorder, and Dysphagia (difficulty starting a swallow, involving problems in the mouth or throat). Resident #23 was listed as having an OOH-DNR.Record review of Resident #23's last MDS was a change of condition assessment completed on [DATE] revealing he had a BIMS score of 04 indicating his cognition was severely impaired, and his functional abilities required substantial to maximal assistance (the helper does more than half the effort) with his activities of daily living.Record review of Resident #23's care plan revealed Resident #23 was an OOH-DNR per his advanced medical directive, with the goal being the Resident's right to decline, in advance, resuscitative measures at death would be honored. The interventions if arrest occurs CPR will not be given.Record review of the clinical record for Resident #23 revealed a DNR dated [DATE] with the following: section B - Declaration by legal guardian, agent or proxy on behalf of the adult person who is incompetent or otherwise incapable of communication - there was a signature and a printed name, but no date of when the OOH-DNR form was signed.2.Record review of Resident #35's face sheet printed [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Heart Failure, Age-Related Cognitive Decline (subtle decreases in thinking speed, multitasking, and word-finding), and Dementia (significant decline in mental abilities). Resident #35 did not have a resuscitation status documented on his face sheet.Record review of Resident #35's care plan revealed Resident was an OOH-DNR per his choice with the goal of resident's wishes to be honored and the interventions being CPR would not be given.Record review of the clinical record for Resident #35 revealed an OOH-DNR with two different dates. The first date in section B - Declaration by legal guardian, agent or proxy on behalf of the adult person who is incompetent or otherwise incapable of communication was dated [DATE] and the second date in section Two Witnesses dated [DATE]. The family member signed sections that they were not supposed to, including, section A Declaration of the adult person, section C Declaration by legal guardian, agent or proxy on behalf of the adult person who is incompetent or otherwise incapable of communication, and section E Declaration on behalf of the minor person, but missed a required signature at the bottom.In an interview on [DATE] with the Social Worker, who worked at the facility for 1 month, she said she was primarily responsible for completing the OOH-DNRs. She said the legal guardian, agent, or proxy who signed the OOH-DNR, must sign, date, and print their information in the legal guardian, agent, or proxy section and the two witnesses must witness the legal guardian, agent, or proxy sign the OOH-DNR's and then the witnesses would sign, date, and print their name under the Two Witnesses section of the form. The Social Worker said OOH-DNR was not valid if it was not completed correctly. She said in November she completed an OOH-DNRs audits.In an interview on [DATE] with the ADON, who has worked at the facility for 2.5 years, she said the OOH-DNR's were completed by the facility's part time Social Worker and usually the ADON and DON, if the part time Social Worker was not in the building. She was not sure how the form was to be filled out correctly and said she would need some training.In an interview on [DATE] with the DON, who has worked at the facility for 1 month, she said the facility had initiated OOH-DNR training for the charge nurses, and she received training on them yesterday by the Social Worker. She said a resident would be considered full code status (meaning they would receive CPR) until the OOH-DNR was completed properly. She verified that an audit was completed on OOH-DNR's in November. She said the impact on a resident if their advanced directive was not executed properly was administering care to the residents that they did not want.Record review of the facility's Advanced Directive policy dated [DATE] revealed under the section Policy Interpretation and Implementation: Upon admission the Social Service Director/designee will determine if the resident has any advanced directives in place and will provide the residents and/or the RP with written information regarding advance directives.Advance directives that have been completed will be copied and uploaded into the resident's EHR and the EHR will be updated to reflect whether or not the resident has executed any advance directive.Social Service Director/designee will meet with the newly admitted resident or RP within 72 hours of admission to orally review and discuss the written information referenced above and the importance of planning for end-of-life care, and to verify the code status of the resident. The discussion will be documented in the EHR.The Social Service Director/designee will complete an Advance Care Planning plan of care and indicate the resident's choice regarding advance directives and code status. The social worker/designee will also ensure that: a). Ensure that a copy of any OOH-DNR is uploaded into the EHR and that a copy was submitted to the physician for timely signature; andb) An order for code status is reflected in the EHR which will read either Full Code or Do Not Resuscitate based on the resident's advance directives.Social Service Director /designee will review all advance directives in the quarterly care plan meetings.At a minimum, advance directives must be reviewed with the resident and/or RP annually and upon any change of condition.Record review of the OOH-DNR Order instructions for issuing an OOH-DNR Order revealed: Purpose: The OOH-DNR Order.complies with Health and Safety Code, Chapter 166 for use by qualified persons or their authorized representatives to direct health care professionals to forgo resuscitation attempts and to permit the person to have a natural death with peace and dignity.Applicability: This OOH-DNR Order applies to health care professionals in out-of-hospital settings, including physicians' offices, hospital clinics, and emergency departments.Implementation: A competent adult person, at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The OOH-DNR Order may be executed as follows:Section A - If an adult person is competent and at least [AGE] years of age, he/she will sign and date the Order in Section A.Section B - If an adult person is incompetent or otherwise mentally or physically incapable of communication and has either a legal guardian, agent in a medical power of attorney, or proxy in a directive to physicians, the guardian, agent, or proxy may execute the OOH-DNR Order by signing and dating it in Section B.Section C - If the adult person is incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, or proxy, then a qualified relative may execute the OOH-DNR Order by signing and dating it in Section C.Section E - If the person is a minor (less than [AGE] years of age), who has been diagnosed by a physician as suffering from a terminal or irreversible condition, then the minor's parents, legal guardian, or managing conservator may execute the OOH-DNR Order by signing and dating it in Section E.In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E

Based on observations, interview, and record review, the facility failed to protect a resident's right to be free from neglect for one (Resident #1) of 8 residents reviewed for resident neglect. The facility failed to ensure Resident #1 was free from neglect by RN A on 05/31/25. RN A failed to perform an assessment on 05/31/25 when Resident #1 reported he needed to go to the hospital complaining of leg pain. RN A failed to notify and follow-up to ensure Resident #1 was sent to the hospital. RN A failed to notify the physician or any licensed nurse of Resident #1 requesting to go to the hospital. RN A called 911 to report Resident #1's behavior, but RN A failed to report Resident #1 wanted to go to the hospital on [DATE]. When police arrived at the facility on 05/31/25, RN A did not notify the police of Resident #1 wanting to go to the hospital or assist in sending Resident #1 to the hospital. The local police called EMS and Resident #1 was transferred to the emergency room. Resident #1 was admitted to the hospital on [DATE] and placed on a heparin drip as a precaution until test results were completed to rule out a DVT. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 06/05/25 at 5:10 PM. While the IJ was removed on 06/06/25 at 8:15 PM, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk for serious injuries, abuse, serious harm, and death. Findings included: Review of Resident #1's face sheet undated reflected Resident #1 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] from the hospital. Resident #1 had diagnoses of acute embolism and thrombosis of right femoral vein (presence of a blood clot in the femoral vein of the right leg), atrial fibrillation (irregular heartbeat), acute embolism and thrombosis of right lower extremity bilateral (presence of blood clots in the deep veins in both legs), chronic pulmonary edema (the buildup of fluid in your lungs), peripheral vascular disease (condition where blood vessels outside the heart and brain are affected, reducing blood flow to the limbs). Resident #1 was his own responsible party. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS of 15 indicating he was cognitively intact. Resident #1 required set up assistance to independent with ADLs. Review of Resident #1's Comprehensive Care Plan reflected the following: -dated 04/21/25 Resident will call [transportation] to go to the hospital wanting IV pain medication. Even when offering his pain medication he has on hand. -dated 06/02/25 high probability of [deep vein thrombosis] to lower extremities. Refuses to take any type of anticoagulant. Intervention included to notify provider and send resident to ER when [complaint of shortness of breath]. -dated 06/02/25 Risk for deep vein thrombosis. Interventions include evaluate legs for swelling and monitor legs for changes in skin color, temperature. Review of Resident #1's Nurse progress note by RN A dated 05/31/25 reflected the following: [LVN D] notified this nurse that resident wanted to talk. when this nurse arrived at resident room. resident stated, I said to that other nurse that when I need to go he hospital . I need to go. this nurse said, alright you can go then, resident interrupted nurse and stated, you know what get out of here. now! get the hell out of here. this nurse said OKAY and stared walking down the hall. Resident followed this nurse down the hall and became aggressive and started yelling at this nurse, you f****** bitch I will destroy you. I will ruin you. f*** you. resident waving hands in the air. This nurse left and went to shelter in 300 unit, then police were called. nurse asked the police to speak to resident because of the potential for scalation and that, he might physically attack this nurse later. this nurse also asked the police to request resident to delete the videos on his phone that he have been recording of this nurse on the previous morning in the lobby area of this facility. resident left facility via EMS. nurse was not notified of this. Review of local police call record dated 05/31/25 at 6:14 PM a call for a welfare check at the facility reflected patient is being aggressive towards staff with caller as the RN Nurse for night shift who is concerned for her safety. The caller reported patient verbally assaulted the caller. At 6:34 PM police arrived to the facility and 6:45 PM a request for EMS for patient transport possible blood clot. EMS notified. EMS transport one at 7:00 PM. Review of Resident #1's EMS record dated 05/31/25 reflected Patient was noted to be sitting on the edge of the bed with the left leg swollen. Patient stated that he was having some sudden trouble breathing with leg pain as well. Patient stated that he has history of blood clots and that today it was getting worse. Patient states that it's gotten even more unbearable for the last 45 minutes when his shortness of breath started. Patient stated that he tried telling the nurse staff but they would not take him seriously. Patient then stated he got irritated and raise his voice at the staff and law enforcement was called .Medic 2 transported one patient code [emergent] to [hospital] without incident. Review of Resident #1's hospital records reflected Resident #1 was admitted to the hospital on [DATE] from nursing home with a history of factor V Leiden deficiency (inherited disorder that increases the risk of developing blood clots) with a history of chronic bilateral lower extremity DVTs .who was brought to the [emergency department] from the nursing nurse via EMS with a chief complaint of worsening of his lower extremity edema with pain associated with worsening dyspnea over the last 2 days .He became concerned for new DVT probably [pulmonary embolism] because of his shortness of breath, requested EMS .In the [emergency department] venous dopplers currently ordered but are pending. CT angiogram of the chest revealed no pulmonary embolism .Labs include a CBC that revealed a mild normocytic anemia .Patient was initially on a heparin drip pending the venous doppler. He is being admitted for further management . Observation and Interview on 06/03/25 at 9:59 AM with Social Worker revealed Resident #1 was in his room sitting on his bed. Resident #1 stated he wanted the social worker to stay in the room. Resident #1 stated on 05/31/25 he asked to speak to RN A. He stated RN A came to his room and he told her he needed to go to the hospital for shortness of breath and leg pain. Resident #1 stated RN A refused to send him to the hospital on [DATE] at the beginning of her shift and RN A did not care what happened to me. He stated he did get upset yelled at RN A. He stated the police were called to the facility by staff. He stated the police called EMS for him noticing he was short of breath. He stated the EMTs took me to the hospital for possible blood clot. He stated he was complaining of shortness of breath and leg pain. He stated on 05/31/25 he told CNA C about RN A refusing to send him to the hospital. He stated RN A would not even print off his face sheet so he could have it when EMTs transporting him to the hospital. He stated he tried to do the right thing by letting RN A know he needed to go to the hospital. He stated he returned back to the facility from the hospital yesterday on 06/02/25. He stated the Administrator was aware of the allegation and he was told by Administrator that RN A would not be returning back to the facility. Interview on 06/03/25 at 10:35 AM with DON revealed she received a phone call on 05/31/25 from RN A about not wanting to take care of Resident #1 anymore because he was being verbally aggressive towards me and asked if LVN B could take care of him. DON stated she advised RN A to inform LVN B to take care of Resident #1 for the rest of the shift. DON stated it was not reported to her of Resident #1 wanting to go to the hospital. She stated at 6:38 pm she spoke to CNA C about RN A calling the police on Resident #1 but did not know why RN A called the police. DON stated she reached out to RN A who told her Resident #1 was being aggressive towards her and she was afraid of Resident #1. DON stated she was not notified about Resident #1 wanting to go to the hospital. She further stated she was not informed Resident #1 was sent to the hospital. She stated she should have been notified of Resident #1 being sent to the hospital. DON stated she did not find out Resident #1 had been sent to the hospital or in the hospital until 06/02/25 when she was at the facility. She stated she reached out to Resident #1 on 06/02/25 via telephone who reported to her about RN refusing to send him to the hospital on [DATE] when he reported having trouble breathing and needing to go to the hospital. She stated she immediately reported the neglect allegation to the Administrator. She stated Administrator reached out to RN A who was suspended pending investigation on 06/02/25. Interviews on 06/03/25 at 1:11 PM with CNA C revealed on 05/31/25 Resident #1 was concerned about leg pain and swollen leg thought he might have a blood clot. She stated Resident #1 reported to her he wanted to be sent to hospital CNA C stated Resident #1 told her that he tried to do it their way by notifying RN A of needing to go to the hospital so they can send him to hospital but Resident #1 stated RN A blew him off. CNA C stated she did not have an opportunity to report Resident #1 wanting to be send to the hospital to LVN B because she got distracted when the police arrived to the facility. She stated she contacted the DON via telephone on 05/31/25 about police in the facility and RN A had called the police on Resident #1. CNA C stated Resident #1 was walking slowly and was flustered with RN A. She stated Resident #1 went back to his room and police contacted EMT to send him to the hospital. She stated she did not know if LVN B was aware of Resident #1 wanting to go to the hospital. CNA C stated Resident #1 had issues with RN A but RN A was still Resident #1's nurse. She stated RN A would ask LVN B to give Resident #1 his medications. She stated her last in-service on abuse/neglect was about a couple weeks ago to maybe a month ago. She stated she had not been in-serviced on 05/31/25 or after on abuse/neglect policy including reporting. She stated she had not spoke to Administrator or DON to give them a statement about the incident on 05/31/25 with Resident #1. Interview on 06/04/25 at 8:09 PM with CNA C revealed she reported to the DON about RN A not sending Resident #1 to the hospital when she reported to DON about RN A calling the police on Resident #1. She stated she should have called the Administrator who is the abuse coordinator immediately to report the allegation of neglect of Resident #1 reporting RN A did not send him to the hospital. She stated she was verbally counseled for failure to report the allegation to the Administrator immediately. She stated RN A worked the rest of her shift on 05/31/25 and worked on 06/01/25 night shift until 6 AM on 06/02/25. Interview on 06/03/25 at 2:52 PM with Social Worker revealed Resident #1 reported on 05/31/25 to RN A he was short of breath and was concerned about a possible blood clot. She was not aware of RN A refusing to send him to the hospital until 06/03/25. Social Worker stated RN A had an attitude problem and Resident #1 reported to her RN A was mouthy to him. Interview on 06/04/25 at 11:05 AM with Police Officer H revealed the police officer who was dispatched to the facility on [DATE] worked the night shift. He stated he would leave a message to call surveyor. He stated based on his review of the report it reflected on 05/31/25 a nurse from the facility called to report Resident #1 having a verbal altercation with nurse. He reviewed the call details report reflecting Resident #1 complained of leg pain when police arrived at the facility and police notified EMTs to send Resident #1 to the hospital. Interview on 06/04/25 at 8:44 PM with LVN D revealed she had been administering Resident #1's medications to Resident #1 when RN A was assigned as his nurse for the last couple of weeks She stated RN A told her that she could not administer medications to Resident #1 and DON was aware of it. She stated she did not follow up with DON or the Administrator about RN A not administering Resident #1's medications on her shifts and requesting her to give Resident #1 his medications. She stated she was not asked to be Resident #1's charge nurse on 05/31/25. She stated the police officer asked her to print off Resident #1's face sheet but did not understand why RN A was not more involved in Resident #1 being sent to the hospital. She stated she did not know why Resident #1 was sent to the hospital. She stated she did not make any notifications of Resident #1 going to the hospital since he was RN A's resident on 05/31/25. She stated she heard Resident #1 cussing right after shift change but she did not really think anything of it since it stopped. She stated Resident #1 did verbally cuss out staff. She stated as the charge nurse if a resident reports to her wanting to go to the hospital, she would assess, find out more information about what was going on with resident and take vitals. She stated residents have a right to go to the hospital if he or she wants to. She stated she would contact the physician to report her assessment of the resident and what was going on with resident. She stated if a resident wants to go to the hospital she would report it to physician and DON. Interview on 06/05/25 at 9:14 AM with DON revealed RN A called the police on Resident #1. She stated RN A told her Resident #1 was cussing and yelling at her. DON stated RN A told her she was in fear for her life so this is why she called the police. DON stated she expected the nurse to assess resident including head to toe, vital, and asking to find out more about resident's change of condition. She stated RN A should have notified the physician and if resident wanted to be sent out to the hospital to send resident out to the hospital. She stated Resident #1 was his own responsible party. She stated if she had known on 05/31/25 of RN A refusing to send Resident #1 to the hospital she would have reported an allegation of abuse/neglect to the Administrator immediately. She stated prior to this incident there had been customer service complaints of RN A's tone being rude. She stated Resident #1 did not like her. She was not aware of RN A not giving Resident #1 her medications when she was his charge nurse and having other nurses administer his medications. She stated Resident #1 was admitted to the hospital on [DATE]. She stated Resident #1 had a history of DVT in a previous hospitalization. Interview on 06/05/25 at 9:33 AM with Resident #1's MD revealed he could not recall if he was notified about Resident #1 being sent to the hospital on [DATE]. He stated he expected the nurse to assess the resident including taking vitals and listening to lungs. He expected the nurse to find out more information of why Resident #1 wanted to be sent to the hospital. Resident #1's MD stated should call the on-call physician to notify of Resident #1 symptoms and change of condition. He stated Resident #1 had a history of calling Uber to go to hospital. He stated if resident wanted to go to the hospital, the nurse will contact EMS for transportation. He stated the risk to the resident could be potential risk of pulmonary embolism or heart attack. Interview on 06/05/25 at 10:17 AM with LVN D revealed Resident #1 told her he needed to talk to RN A but did not tell him what was going on. She reported to RN A at shift change which was 6:00 PM on 05/31/25 that Resident #1 wanted to talk to him. LVN D stated she was not informed Resident #1 wanted to go to the hospital and was not aware of any change of condition. Interview on 06/07/25 at 11:18 AM with RN A revealed LVN D reported to her Resident #1 wanted him to go see him at beginning of her shift at 6 PM. She stated she found it odd he wanted to talk to her because she stated she stayed out of his room, she did not like to deal with him and if he walking down the hall I go the other way. She stated when she entered Resident #1's room. RN A stated he told he needed to go to the hospital and she told him you can go. RN A stated Resident #1 started yelling at her, told her to get the hell out of his room. She stated she left his room and he followed her down the hall saying who the hell are you, I am going to destroy you. RN A stated she did not know what Resident #1 was complaining of and did not have a chance to ask any questions. She stated she did not have a chance to assess him or ask him more questions to find out what he wanted to go to the hospital. LVN D stated she went to shelter on the secure unit and called the police to inform of Resident #1's aggression towards her. She stated she needed to administer her medications to the residents on his hall and was afraid he might attack me so she called the police. RN A stated she called the police after she sheltered on the secure unit and it took like 20 to 30 minutes for them to arrive. She stated she did not inform the police about Resident #1 wanting to go to the hospital. She did not inform anyone about Resident #1 wanting to go to the hospital. She stated the police called for Resident #1 to be sent out to the hospital. She stated she had 2 incidents with Resident #1 when giving him his medications prior to 05/31/25 and Resident #1 got upset at her for opening the door and waking him up for his medications. She stated Resident #1 followed her and yelled at her by cussing her out. She stated she gave the other nurse on her shift to have the other nurse administer his medications. She stated she would follow-up with other nurse to see if it was given and documented it was given. She stated the DON called me on 05/31/25 to find out why I called the police. She stated she did not inform anyone about Resident #1 going to the hospital. She stated Resident #1 did have chronic DVT history. She stated when she was contacted by the facility on 06/02/25 she told them she quit because she knew Resident #1 would back at the facility. Interview on 06/05/25 at 12:10 PM with Administrator revealed Resident #1 did have past issues with nurses about wanting to get medications on time. He stated Resident #1 did have history of being verbally aggressive to staff. DON reported to him on 06/02/25 of Resident #1 reporting RN A refused to send him to the hospital and police had to call EMS to send him to the hospital. The Administrator stated this was an allegation of neglect and possibly abuse so he reported it to HHSC. He stated he initiated the investigation and contacted RN A to suspend her pending investigation. He stated RN A refused to give a witness statement for the incident on 05/31/25 and RN A told him F*** this facility and F*** those residents. He stated he was not aware of RN A not giving Resident #1 his medications on her shift as the charge nurse and having the other nurse give the medications to Resident #1. He stated CNA C should have immediately notified me as the abuse coordinator on 05/31/25 of RN A refusing to send Resident #1 to the hospital. He stated RN A should have assessed Resident #1 and/or tell other nurse about Resident #1 wanting to go to hospital. He stated the failure to immediately report abuse or neglect to me could place residents at risk for resident abuse/neglect to continue and not be aware of abuse/neglect. He stated this placed the residents at risk for further abuse and neglect with allowing RN A to continue to work and could possibly do it to someone else. Interview on 06/05/25 at 7:14 PM with Local Police Officer G revealed he did come out to the facility on [DATE]. He stated based on interviews with facility staff it seemed like Resident #1 did not seem to get along with RN A. He stated Resident #1 requested to the police to go to the hospital on [DATE] per a possible blood clot. He stated he called EMS and Resident #1 was sent out to the hospital. Review of RN A's timecard for 05/31/25 reflected RN A worked from 05/31/25 at 5:43 PM to 6:14 AM on 06/01/25. On 06/01/25 at 5:43 PM to 6:21 PM on 06/02/25. Review of facility's policy last revised September 2022 Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating reflected All reports of resident abuse (including injuries of unknown origin, neglect, exploitation or theft/misappropriation of property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management .Reporting allegations to the Administrator and Authorities 1. If resident abuse, neglect .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines .6. Upon receiving any allegations of abuse, neglect .the administrator is responsible for ensuring what actions (if any) are needed for the protection of residents .12. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete . On 06/05/25 at 5:10 PM, the Administrator and ADON were informed in person with DON and Regional VP on the phone of an IJ situation. The Administrator was provided the IJ template at this time. The facility's plan of removal was accepted on 06/06/25 at 10:44 AM and reflected the following: The facility failed to protect Resident #1's right to be free from neglect when RN A decided she would not provide care to resident #1 when she was assigned to the resident. This failure could place residents at risk for not having measures I place to protect them from serious harm, mental anguish, neglect or death. The facility medical director was notified of the Immediate Jeopardy by the Facility Administrator on 06/05/2025. Resident #1 was sent to the ER for evaluation and treatment on 5/31/25 and returned to the facility on [DATE]. RN A was suspended, pending investigation, by the DON and Facility Administrator on 6/2/25 and terminated from her position by the DON and Administrator on 6/3/25. All staff were in-serviced on Abuse, Neglect, and Exploitation, Patient care assignments, resident change in condition, resident rights, and reporting Abuse and Neglect to the abuse coordinator/facility administrator immediately, beginning on June 2nd, 2025, and were completed on 06/05/2025. In-services were completed per the Director of Nursing. No staff or agency staff will be allowed in the facility until they are in-serviced by the ADON/ADMIN on Abuse, Neglect, and Exploitation and all other in-service requirements. Staff were in-serviced that it is a resident right to go to the hospital when they want. Staff were also in-serviced that they must assess patients prior to send them out. Staff were in-serviced by ADON that the MD must be notified on any change of condition immediately. DON/ADON will monitor and be responsible moving forward. The facility DON began in-services for all nursing staff regarding resident care assignments and the responsibilities included in resident care assignments for nursing staff, notification to the physician if residents request to go to the hospital, notification to DON and Administrator if law enforcement are called to the facility, and resident assessment on 6/5/2025. All nursing staff will be in-serviced by the DON prior to the start of their next shift. DON and Administrator will interview 3 staff daily related to their understanding of the inservice education provided, for the next 4 weeks. Admin/ADON conducted safe surveys with alert residents on 6/3/25 An Ad Hoc QAPI was held by the Regional VP of Operations, Facility Administrator, Director of Nursing, Regional Nurse Consultant, (medical director), and Asst. Director of Nurses on 06/05/2025 to review the alleged deficiency and plan. Review of the IJ monitoring for the facility's plan of removal reflected the following: Review of RN A's termination dated 06/02/25 reflected RN A was placed on suspension for neglect allegation and said she wasn't going to do that and stated she quit .[RN A] was very antagonistic towards the residents and other staff. Interviews from 06/06/25 at 2:25 PM to 7:40 PM with four nurses from different shifts (LVN I, RN O, LVN Q and Agency LVN S) they had been in-serviced on abuse/neglect policy. All were knowledgeable of types of abuse/neglect and would report any allegations immediately to Administrator who was the abuse coordinator once the resident was safe. Interviews from 06/06/25 at 2:42 PM to 7:20 PM with eight CNAs from different shifts (CNA J, CNA K, CNA L, CNA M, CNA N, CNA P, CNA R, and CNA T) revealed they had been in-serviced on abuse/neglect policy, resident rights and patient care responsibility. All were knowledgeable of types of abuse/neglect and would report any allegations immediately to Administrator who was the abuse coordinator once the resident was safe. All CNAs were aware of resident rights including resident right to go to the hospital. All stated if CNA became aware of allegation of nurse not sending a resident to the hospital or assessing a resident for a change of condition they would immediately notify the Administrator of the allegation. The CNAs stated they would notify the DON and Administrator if resident rights were violated. They were all knowledgeable of where to find contact information for the abuse coordinator. Interviews from 06/06/25 at 3:40 PM to 7:26 PM with three facility staff (Activity Director, Dietary [NAME] U and Dietary Aide V) reflected they were in-serviced on abuse/neglect, reporting requirements of allegations and resident rights. All three staff were knowledgeable of types of abuse/neglect and would report any allegations immediately to Administrator who was the abuse coordinator once the resident was safe. They were aware of resident rights including resident right to go to the hospital. They stated they would notify the DON and Administrator if resident rights were violated. They were all knowledgeable of where to find contact information for the abuse coordinator. Interview on 06/06/25 at 3:53 PM with Administrator revealed staff have been in-serviced from different shifts on abuse/neglect policy and reporting requirements. He stated all staff who have been in-serviced should be aware to notify him immediately of any allegations of abuse/neglect. He stated CNA C and LVN B have been in-serviced on abuse/neglect and reporting requirements to immediately report any allegations to him. He stated any staff who have not been in-serviced will be unable to work until in-serviced. Interview on 06/06/25 at 4:41 PM with ADON revealed staff had been in-serviced on abuse/neglect. She was knowledgeable of types of abuse/neglect and would report any allegations to Administrator immediately once the resident was safe. She was knowledgeable of resident right. She stated LVN B had been in-serviced but she was unavailable to contact due to being on personal leave at this time. She stated LVN B would be in-serviced in person again to ensure her understanding of all the in-services when she returns back to work from her leave. Review of In-services for Abuse/Neglect dated 06/02/25 to 06/05/25 reflected staff were in-serviced on abuse/neglect policy and reporting requirements. Review of 2 of 2 resident clinical records (Resident #2 and #3) for change of condition and hospitalization revealed no concerns with abuse or neglect. Review revealed CNA C and LVN B were verbally counseled for not reporting an allegation of abuse/neglect signed by employees on 06/04/25. Review of Reporting of Abuse and Neglect dated 06/05/25 reflected if you feel, see or even think abuse or neglect is happening, immediately do the following: Get the resident or residents to safety. Immediately call the abuse coordinator [Administrator] with phone number provided. An IJ was identified on 06/05/25. The IJ template was provided to the Administrator and ADON on 06/05/25 at 5:10 PM. While the IJ was removed on 06/06/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm to ensure the effectiveness of the training and plan of removal components.

Based on observations, interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse and neglect 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 to the State Survey Agency in accordance with State law through established procedures for one, (Resident #1) of eight residents reviewed for resident neglect. The facility failed to report a potential allegation of neglect to the Abuse Coordinator when RN A failed to provide care and treatment for Resident # 1, who was in her care assignment. LVN B and CNA C were aware that RN A did not provide care to Resident #1. RN A was allowed to work on 05/31/25 to 06/02/25 after she failed to provide care and treatment when Resident # 1 requested to go the hospital on [DATE]. Police notified EMS of Resident #1's request to go to the hospital for a possible blood clot on 05/31/25. RN A was suspended on 06/02/25 by the Abuse Coordinator. An identification of an Immediate Jeopardy (IJ) on 06/05/25 at 5:10 PM. While the IJ was removed on 06/06/25 at 8:15 PM, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk for serious injuries, abuse, and serious harm. Findings included: Review of Resident #1's face sheet undated reflected Resident #1 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] from the hospital. Resident #1 had diagnoses of acute embolism and thrombosis of right femoral vein (presence of a blood clot in the femoral vein of the right leg), atrial fibrillation (irregular heartbeat), acute embolism and thrombosis of right lower extremity bilateral (presence of blood clots in the deep veins in both legs), chronic pulmonary edema (the buildup of fluid in your lungs), peripheral vascular disease (condition where blood vessels outside the heart and brain are affected, reducing blood flow to the limbs). Resident #1 was his own responsible party. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS of 15 indicating he was cognitively intact. Resident #1 required set up assistance to independent with ADLs. Review of Resident #1's Comprehensive Care Plan reflected the following: -dated 04/21/25 Resident will call [transportation] to go to the hospital wanting IV pain medication. Even when offering his pain medication he has on hand. -dated 06/02/25 high probability of [deep vein thrombosis] to lower extremities. Refuses to take any type of anticoagulant. Intervention included to notify provider and send resident to ER when [complaint of shortness of breath]. -dated 06/02/25 Risk for deep vein thrombosis. Interventions include evaluate legs for swelling and monitor legs for changes in skin color, temperature. Review of Resident #1's Nurse progress note by RN A dated 05/31/25 reflected the following: [LVN D] notified this nurse that resident wanted to talk. when this nurse arrived at resident room. resident stated, I said to that other nurse that when I need to go he hospital . I need to go. this nurse said, alright you can go then, resident interrupted nurse and stated, you know what get out of here. now! get the hell out of here. this nurse said OKAY and stared walking down the hall. Resident followed this nurse down the hall and became aggressive and started yelling at this nurse, you f****** bitch I will destroy you. I will ruin you. f*** you. resident waving hands in the air. This nurse left and went to shelter in 300 unit, then police were called. nurse asked the police to speak to resident because of the potential for scalation and that, he might physically attack this nurse later. this nurse also asked the police to request resident to delete the videos on his phone that he have been recording of this nurse on the previous morning in the lobby area of this facility. resident left facility via EMS. nurse was not notified of this. Review of local police call record dated 05/31/25 at 6:14 PM a call for a welfare check at the facility reflected patient is being aggressive towards staff with caller as the RN Nurse for night shift who is concerned for her safety. The caller reported patient verbally assaulted the caller. At 6:34 PM police arrived to the facility and 6:45 PM a request for EMS for patient transport possible blood clot. EMS notified. EMS transport one at 7:00 PM. Review of Resident #1's EMS record dated 05/31/25 reflected Patient was noted to be sitting on the edge of the bed with the left leg swollen. Patient stated that he was having some sudden trouble breathing with leg pain as well. Patient stated that he has history of blood clots and that today it was getting worse. Patient states that it's gotten even more unbearable for the last 45 minutes when his shortness of breath started. Patient stated that he tried telling the nurse staff but they would not take him seriously. Patient then stated he got irritated and raise his voice at the staff and law enforcement was called .Medic 2 transported one patient code [emergent] to [hospital] without incident. Review of Resident #1's hospital records reflected Resident #1 was admitted to the hospital on [DATE] from nursing home with a history of factor V Leiden deficiency (inherited disorder that increases the risk of developing blood clots) with a history of chronic bilateral lower extremity DVTs .who was brought to the [emergency department] from the nursing nurse via EMS with a chief complaint of worsening of his lower extremity edema with pain associated with worsening dyspnea over the last 2 days .He became concerned for new DVT probably [pulmonary embolism] because of his shortness of breath, requested EMS .In the [emergency department] venous dopplers currently ordered but are pending. CT angiogram of the chest revealed no pulmonary embolism .Labs include a CBC that revealed a mild normocytic anemia .Patient was initially on a heparin drip pending the venous doppler. He is being admitted for further management . Observation and Interview on 06/03/25 at 9:59 AM with Social Worker revealed Resident #1 was in his room sitting on his bed. Resident #1 stated he wanted the social worker to stay in the room. Resident #1 stated on 05/31/25 he asked to speak to RN A. He stated RN A came to his room and he told her he needed to go to the hospital for shortness of breath and leg pain. Resident #1 stated RN A refused to send him to the hospital on [DATE] at the beginning of her shift and RN A did not care what happened to me. He stated he did get upset yelled at RN A. He stated the police were called to the facility by staff. He stated the police called EMS for him noticing he was short of breath. He stated the EMTs took me to the hospital for possible blood clot. He stated he was complaining of shortness of breath and leg pain. He stated on 05/31/25 he told CNA C about RN A refusing to send him to the hospital. He stated RN A would not even print off his face sheet so he could have it when EMTs transporting him to the hospital. He stated he tried to do the right thing by letting RN A know he needed to go to the hospital. He stated he returned back to the facility from the hospital yesterday on 06/02/25. He stated the Administrator was aware of the allegation and he was told by Administrator that RN A would not be returning back to the facility. Interview on 06/03/25 at 10:35 AM with DON revealed she received a phone call on 05/31/25 from RN A about not wanting to take care of Resident #1 anymore because he was being verbally aggressive towards me and asked if LVN B could take care of him. DON stated she advised RN A to inform LVN B to take care of Resident #1 for the rest of the shift. DON stated it was not reported to her of Resident #1 wanting to go to the hospital. She stated at 6:38 pm she spoke to CNA C about RN A calling the police on Resident #1 but did not know why RN A called the police. DON stated she reached out to RN A who told her Resident #1 was being aggressive towards her and she was afraid of Resident #1. DON stated she was not notified about Resident #1 wanting to go to the hospital. She further stated she was not informed Resident #1 was sent to the hospital. She stated she should have been notified of Resident #1 being sent to the hospital. DON stated she did not find out Resident #1 had been sent to the hospital or in the hospital until 06/02/25 when she was at the facility. She stated she reached out to Resident #1 on 06/02/25 via telephone who reported to her about RN refusing to send him to the hospital on [DATE] when he reported having trouble breathing and needing to go to the hospital. She stated she immediately reported the neglect allegation to the Administrator. She stated Administrator reached out to RN A who was suspended pending investigation on 06/02/25. Interviews on 06/03/25 at 1:11 PM with CNA C revealed on 05/31/25 Resident #1 was concerned about leg pain and swollen leg thought he might have a blood clot. She stated Resident #1 reported to her he wanted to be sent to hospital CNA C stated Resident #1 told her that he tried to do it their way by notifying RN A of needing to go to the hospital so they can send him to hospital but Resident #1 stated RN A blew him off. CNA C stated she did not have an opportunity to report Resident #1 wanting to be send to the hospital to LVN B because she got distracted when the police arrived to the facility. She stated she contacted the DON via telephone on 05/31/25 about police in the facility and RN A had called the police on Resident #1. CNA C stated Resident #1 was walking slowly and was flustered with RN A. She stated Resident #1 went back to his room and police contacted EMT to send him to the hospital. She stated she did not know if LVN B was aware of Resident #1 wanting to go to the hospital. CNA C stated Resident #1 had issues with RN A but RN A was still Resident #1's nurse. She stated RN A would ask LVN B to give Resident #1 his medications. She stated her last in-service on abuse/neglect was about a couple weeks ago to maybe a month ago. She stated she had not been in-serviced on 05/31/25 or after on abuse/neglect policy including reporting. She stated she had not spoke to Administrator or DON to give them a statement about the incident on 05/31/25 with Resident #1. Interview on 06/04/25 at 8:09 PM with CNA C revealed she reported to the DON about RN A not sending Resident #1 to the hospital when she reported to DON about RN A calling the police on Resident #1. She stated she should have called the Administrator who is the abuse coordinator immediately to report the allegation of neglect of Resident #1 reporting RN A did not send him to the hospital. She stated she was verbally counseled for failure to report the allegation to the Administrator immediately yesterday. She stated RN A worked the rest of her shift on 05/31/25 and worked on 06/01/25 night shift until 6 AM on 06/02/25. She was knowledgeable of different types of abuse/neglect policy and reporting requirements and was in-serviced yesterday. Interview on 06/03/25 at 2:52 PM with Social Worker revealed Resident #1 reported on 05/31/25 to RN A he was short of breath and was concerned about a possible blood clot. She was not aware of RN A refusing to send him to the hospital until 06/03/25. Social Worker stated RN A had an attitude problem and Resident #1 reported to her RN A was mouthy to him. Interview on 06/04/25 at 11:05 AM with Police Officer H revealed the police officer who was dispatched to the facility on [DATE] worked the night shift. He stated he would leave a message to call surveyor. He stated based on his review of the report it reflected on 05/31/25 a nurse from the facility called to report Resident #1 having a verbal altercation with nurse. He reviewed the call details report reflecting Resident #1 complained of leg pain when police arrived at the facility and police notified EMTs to send Resident #1 to the hospital. Interview on 06/04/25 at 8:36 PM with CNA E revealed on 05/31/25 she did not know why Resident #1 was being sent to the hospital but saw him on the EMS stretcher. She stated the Administrator is the abuse coordinator. She stated RN A could be condescending and act like she is better than anyone else. Interview on 06/04/25 at 8:44 PM with LVN D revealed she had been administering Resident #1's medications to Resident #1 when RN A was assigned as his nurse for the last couple of weeks. She stated RN A told her that she could not administer medications to Resident #1 and DON was aware of it. She stated she did not follow up with DON or the Administrator about RN A not administering Resident #1's medications on her shifts and requesting her to give Resident #1 his medications. She stated she was not asked to be Resident #1's charge nurse on 05/31/25. She stated the police officer asked her to print off Resident #1's face sheet but did not understand why RN A was not more involved in Resident #1 being sent to the hospital. She stated she did not know why Resident #1 was sent to the hospital. She stated she did not make any notifications of Resident #1 going to the hospital since he was RN A's resident on 05/31/25. She stated she heard Resident #1 cussing right after shift change but she did not really think anything of it since it stopped. She stated Resident #1 did verbally cuss out staff. She stated as the charge nurse if a resident reports to her wanting to go to the hospital, she would assess, find out more information about what was going on with resident and take vitals. She stated residents have a right to go to the hospital if he or she wants to. She stated she would contact the physician to report her assessment of the resident and what was going on with resident. She stated if a resident wants to go to the hospital she would report it to physician and DON. Interview on 06/05/25 at 9:14 AM with DON revealed RN A called the police on Resident #1. She stated RN A told her Resident #1 was cussing and yelling at her. DON stated RN A told her she was in fear for her life so this is why she called the police. DON stated she expected the nurse to assess resident including head to toe, vital, and asking to find out more about resident's change of condition. She stated RN A should have notified the physician and if resident wanted to be sent out to the hospital to send resident out to the hospital. She stated Resident #1 was his own responsible party. She stated if she had known on 05/31/25 of RN A refusing to send Resident #1 to the hospital she would have reported an allegation of abuse/neglect to the Administrator immediately. She stated prior to this incident there had been customer service complaints of RN A's tone being rude. She stated Resident #1 did not like her. She was not aware of RN A not giving Resident #1 her medications when she was his charge nurse and having other nurses administer his medications. She stated Resident #1 was admitted to the hospital on [DATE]. She stated Resident #1 had a history of DVT in a previous hospitalization. Interview on 06/05/25 at 9:33 AM with Resident #1's MD revealed he could not recall if he was notified about Resident #1 being sent to the hospital on [DATE]. He stated he expected the nurse to assess the resident including taking vitals and listening to lungs. He expected the nurse to find out more information of why Resident #1 wanted to be sent to the hospital. Resident #1's MD stated should call the on-call physician to notify of Resident #1 symptoms and change of condition. He stated Resident #1 had a history of calling Uber to go to hospital. He stated if resident wanted to go to the hospital, the nurse will contact EMS for transportation. He stated the risk to the resident could be potential risk of pulmonary embolism or heart attack. Interview on 06/05/25 at 10:17 AM with LVN D revealed Resident #1 told her he needed to talk to RN A but did not tell him what was going on. She reported to RN A at shift change which was 6:00 PM on 05/31/25 that Resident #1 wanted to talk to him. LVN D stated she was not informed Resident #1 wanted to go to the hospital and was not aware of any change of condition. Interview on 06/07/25 at 11:18 AM with RN A revealed LVN D reported to her Resident #1 wanted him to go see him at beginning of her shift at 6 PM. She stated she found it odd he wanted to talk to her because she stated she stayed out of his room, she did not like to deal with him and if he walking down the hall I go the other way. She stated when she entered Resident #1's room. RN A stated he told he needed to go to the hospital and she told him you can go. RN A stated Resident #1 started yelling at her, told her to get the hell out of his room. She stated she left his room and he followed her down the hall saying who the hell are you, I am going to destroy you. RN A stated she did not know what Resident #1 was complaining of and did not have a chance to ask any questions. She stated she did not have a chance to assess him or ask him more questions to find out what he wanted to go to the hospital. LVN D stated she went to shelter on the secure unit and called the police to inform of Resident #1's aggression towards her. She stated she needed to administer her medications to the residents on his hall and was afraid he might attack me so she called the police. RN A stated she called the police after she sheltered on the secure unit and it took like 20 to 30 minutes for them to arrive. She stated she did not inform the police about Resident #1 wanting to go to the hospital. She did not inform anyone about Resident #1 wanting to go to the hospital. She stated the police called for Resident #1 to be sent out to the hospital. She stated she had 2 incidents with Resident #1 when giving him his medications prior to 05/31/25 and Resident #1 got upset at her for opening the door and waking him up for his medications. She stated Resident #1 followed her and yelled at her by cussing her out. She stated she gave the other nurse on her shift to have the other nurse administer his medications. She stated she would follow-up with other nurse to see if it was given and documented it was given. She stated the DON called me on 05/31/25 to find out why I called the police. She stated she did not inform anyone about Resident #1 going to the hospital. She stated Resident #1 did have chronic DVT history. She stated when she was contacted by the facility on 06/02/25 she told them she quit because she knew Resident #1 would back at the facility. Interview on 06/05/25 at 12:10 PM with Administrator revealed Resident #1 did have past issues with nurses about wanting to get medications on time. He stated Resident #1 did have history of being verbally aggressive to staff. DON reported to him on 06/02/25 of Resident #1 reporting RN A refused to send him to the hospital and police had to call EMS to send him to the hospital. The Administrator stated this was an allegation of neglect and possibly abuse so he reported it to HHSC. He stated he initiated the investigation and contacted RN A to suspend her pending investigation. He stated RN A refused to give a witness statement for the incident on 05/31/25 and RN told him Fuck this facility and Fuck those residents. He stated he was not aware of RN A not giving Resident #1 his medications on her shift as the charge nurse and having the other nurse give the medications to Resident #1. He stated CNA C should have immediately notified me as the abuse coordinator on 05/31/25 of RN A refusing to send Resident #1 to the hospital. He stated RN A should have assessed Resident #1 and/or tell other nurse about Resident #1 wanting to go to hospital. He stated the failure to immediately report abuse or neglect to me could place residents at risk for resident abuse/neglect to continue and not be aware of abuse/neglect. He stated this placed the residents at risk for further abuse and neglect with allowing RN A to continue to work and could possibly do it to someone else. Interview on 06/05/25 at 7:14 PM with Local Police Officer G revealed he did come out to the facility on [DATE]. He stated based on interviews with facility staff it seemed like Resident #1 did not seem to get along with RN A. He stated Resident #1 requested to the police to go to the hospital on [DATE] per a possible blood clot. He stated he called EMS and Resident #1 was sent out to the hospital. Review of RN A's timecard for 05/31/25 reflected RN A worked from 05/31/25 at 5:43 PM to 6:14 AM on 06/01/25. On 06/01/25 at 5:43 PM to 6:21 PM on 06/02/25. Review of facility's policy last revised September 2022 Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating reflected All reports of resident abuse (including injuries of unknown origin, neglect, exploitation or theft/misappropriation of property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management .Reporting allegations to the Administrator and Authorities 1. If resident abuse, neglect .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines .6. Upon receiving any allegations of abuse, neglect .the administrator is responsible for ensuring what actions (if any) are needed for the protection of residents .12. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete . On 06/05/25 at 5:10 PM, the Administrator and ADON were informed in person with DON and Regional VP on the phone of an IJ situation. The Administrator was provided the IJ template at this time. The facility's plan of removal was accepted on 06/06/25 at 10:44 AM. Review of facility's Plan of Removal for F609 reflected the following: The facility failed to report a potential allegation of neglect to the Abuse Coordinator when RN A failed to provide care and treatment for Resident #1, who was in her care assignment. The facility medical director was notified of the Immediate Jeopardy by the Facility Administrator on 06/05/2025. Resident #1 was sent to the ER for evaluation and treatment on 5/31/25 and returned to the facility on [DATE]. RN A was suspended on 06/02/2025 by the DON and Administrator and terminated from her position at the facility on 06/03/2025 by the DON and Facility Administrator/Abuse Coordinator. LVN B and CNA C were in-serviced by the DON and Administrator on 6/3/25 regarding immediately reporting potential Abuse, Neglect, and Misappropriation. Both employees were given written disciplinary action related to not reporting immediately, by the DON on 06/04/2025. All staff were in-serviced by ADON/DON on Abuse, Neglect, and Exploitation, and reporting Abuse and Neglect to the abuse coordinator/facility administrator immediately, beginning on June 2nd 2025 and were completed on 06/05/2025. ADMIN or designee will monitor and be responsible moving forward. In-services were completed per the Director of Nursing. Any new staff or agency staff will be in-serviced by the DON on Abuse, Neglect, and Exploitation policy before the start of their first shift. DON and Administrator will interview 3 staff daily related to their understanding of the in-service education provided, for the next 4 weeks. Admin and ADON conducted safe surveys with alert residents on 6/3/25. Review of the IJ monitoring for the facility's plan of removal reflected the following: Interviews from 06/06/25 at 2:25 PM to 7:40 PM with four nurses from different shifts (LVN I, RN O, LVN Q and Agency LVN S) they had been in-serviced on abuse/neglect policy,. All were knowledgeable of types of abuse/neglect and would report any allegations immediately to Administrator who was the abuse coordinator once the resident was safe. Interviews from 06/06/25 at 2:42 PM to 7:20 PM with eight CNAs from different shifts (CNA J, CNA K, CNA L, CNA M, CNA N, CNA P, CNA R, and CNA T) revealed they had been in-serviced on abuse/neglect policy,. All were knowledgeable of types of abuse/neglect and would report any allegations immediately to Administrator who was the abuse coordinator once the resident was safe. They were all knowledgeable of where to find contact information for the abuse coordinator. Interviews from 06/06/25 at 3:40 PM to 7:26 PM with three facility staff (Activity Director, Dietary [NAME] U and Dietary Aide V) reflected they were in-serviced on abuse/neglect, reporting requirements of allegations and resident rights. All three staff were knowledgeable of types of abuse/neglect and would report any allegations immediately to Administrator who is the abuse coordinator once the resident was safe. They were aware of resident rights including resident right to go to the hospital. They stated they would notify the DON and Administrator if resident rights were violated. They were all knowledgeable of where to find contact information for the abuse coordinator. Interview on 06/06/25 at 3:53 PM with Administrator revealed staff have been in-serviced from different shifts on abuse/neglect policy and reporting requirements. He stated all staff who have been in-serviced should be aware to notify him immediately of any allegations of abuse/neglect. He stated CNA C and LVN B have been in-serviced on abuse/neglect and reporting requirements to immediately report any allegations to him. He stated any staff who have not been in-serviced will be unable to work until in-serviced. Interview on 06/06/25 at 4:41 PM with ADON revealed staff had been in-serviced on abuse/neglect. She was knowledgeable of types of abuse/neglect and would report any allegations to Administrator immediately once the resident was safe. She stated LVN B had been in-serviced but she was unavailable to contact due to being on personal leave at this time. She stated LVN B would be in-serviced in person again to ensure her understanding of all the in-services when she returns back to work from her leave. Review of In-services for Abuse/Neglect dated 06/02/25 to 06/05/25 reflected staff were in-serviced on abuse/neglect policy and reporting requirements including CNA C and LVN B. Review of 2 of 2 resident clinical records (Resident #2 and #3) revealed no concerns with abuse or neglect. Review revealed CNA C and LVN B were verbally counseled for not reporting an allegation of abuse/neglect signed by employees on 06/04/25. Review of Reporting of Abuse and Neglect dated 06/05/25 reflected if you feel, see or even think abuse or neglect is happening, immediately do the following: Get the resident or residents to safety. Immediately call the abuse coordinator [Administrator] with phone number provided. An IJ was identified on 06/05/25. The IJ template was provided to the Administrator and ADON on 06/05/25 at 5:10 PM. While the IJ was removed on 06/06/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm to ensure the effectiveness of the training and plan of removal components.

Based on observation, interview and record review, the facility failed to ensure resident had a right to a dignified existence and self-determination that promotes enhancement of his or her quality of life, recognizing each resident's individuality for one of eight residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's right to go to the hospital on [DATE] was followed by RN A. Police had to contact EMS for Resident #1 requesting to go to the hospital for a possible blood clot. The failure could place residents at risk of a loss of self-determination and dignity. Findings included: Review of Resident #1's face sheet undated reflected Resident #1 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] from the hospital. Resident #1 had diagnoses of acute embolism and thrombosis of right femoral vein (presence of a blood clot in the femoral vein of the right leg), atrial fibrillation (irregular heartbeat), acute embolism and thrombosis of right lower extremity bilateral (presence of blood clots in the deep veins in both legs), chronic pulmonary edema (the buildup of fluid in your lungs), peripheral vascular disease (condition where blood vessels outside the heart and brain are affected, reducing blood flow to the limbs). Resident #1 was his own responsible party. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS of 15 indicating he was cognitively intact. Resident #1 required set up assistance to independent with ADLs. Review of Resident #1's Comprehensive Care Plan reflected the following: -dated 04/21/25 Resident will call [transportation] to go to the hospital wanting IV pain medication. Even when offering his pain medication he has on hand. -dated 06/02/25 high probability of [deep vein thrombosis] to lower extremities. Refuses to take any type of anticoagulant. Intervention included to notify provider and send resident to ER when [complaint of shortness of breath]. -dated 06/02/25 Risk for deep vein thrombosis. Interventions include evaluate legs for swelling and monitor legs for changes in skin color, temperature. Review of Resident #1's Nurse progress note by RN A dated 05/31/25 reflected the following: [LVN D] notified this nurse that resident wanted to talk. when this nurse arrived at resident room. resident stated, I said to that other nurse that when I need to go he hospital . I need to go. this nurse said, alright you can go then, resident interrupted nurse and stated, you know what get out of here. now! get the hell out of here. this nurse said OKAY and stared walking down the hall. Resident followed this nurse down the hall and became aggressive and started yelling at this nurse, you f****** bitch I will destroy you. I will ruin you. f*** you. resident waving hands in the air. This nurse left and went to shelter in 300 unit, then police were called. nurse asked the police to speak to resident because of the potential for scalation and that, he might physically attack this nurse later. this nurse also asked the police to request resident to delete the videos on his phone that he have been recording of this nurse on the previous morning in the lobby area of this facility. resident left facility via EMS. nurse was not notified of this. Review of local police call record dated 05/31/25 at 6:14 PM a call for a welfare check at the facility reflected patient is being aggressive towards staff with caller as the RN Nurse for night shift who is concerned for her safety. The caller reported patient verbally assaulted the caller. At 6:34 PM police arrived to the facility and 6:45 PM a request for EMS for patient transport possible blood clot. EMS notified. EMS transport one at 7:00 PM. Review of Resident #1's EMS record dated 05/31/25 reflected Patient was noted to be sitting on the edge of the bed with the left leg swollen. Patient stated that he was having some sudden trouble breathing with leg pain as well. Patient stated that he has history of blood clots and that today it was getting worse. Patient states that it's gotten even more unbearable for the last 45 minutes when his shortness of breath started. Patient stated that he tried telling the nurse staff but they would not take him seriously. Patient then stated he got irritated and raise his voice at the staff and law enforcement was called .Medic 2 transported one patient code [emergent] to [hospital] without incident. Review of Resident #1's hospital records reflected Resident #1 was admitted to the hospital on [DATE] from nursing home with diagnoses of bilateral leg pain, factor V Leiden deficiency (inherited disorder that increases the risk of developing blood clots) and chronic bilateral lower extremity DVTs. Resident #1 was brought to the [emergency department] from the nursing nurse via EMS with a chief complaint of worsening of his lower extremity edema with pain associated with worsening dyspnea over the last 2 days .He became concerned for new DVT probably [pulmonary embolism] because of his shortness of breath, requested EMS .In the [emergency department] venous dopplers currently ordered but are pending. CT angiogram of the chest revealed no pulmonary embolism .Labs include a CBC that revealed a mild normocytic anemia .Patient was initially on a heparin drip pending the venous doppler. He is being admitted for further management . Observation and Interview with Social Worker and Resident #1 on 06/03/25 at 9:59 AM revealed Resident #1 was in his room sitting on his bed. Resident #1 stated he wanted the social worker to stay in the room. Resident #1 stated on 05/31/25 he asked to speak to RN A. He stated RN A came to his room and he told her he needed to go to the hospital for shortness of breath and leg pain. Resident #1 stated RN A refused to send him to the hospital on [DATE] at the beginning of her shift and RN A did not care what happened to him. He stated the police were called to the facility by staff. He stated the police called EMS for him noticing he was short of breath. He stated the EMTs took me to the hospital for possible blood clot. He stated he was complaining of shortness of breath and leg pain. He stated RN A would not even print off his face sheet so he could have it when EMTs transporting him to the hospital. He stated he tried to do the right thing by letting RN A know he needed to go to the hospital. He stated he returned to the facility from the hospital yesterday on 06/02/25. Interview on 06/03/25 at 10:35 AM with DON revealed she received a phone call on 05/31/25 from RN A, but it was not reported to her of Resident #1 wanting to go to the hospital. She stated at 6:38 pm she spoke to CNA C about RN A calling the police on Resident #1 but did not know why RN A called the police. DON stated she reached out to RN A who told her Resident #1 was being aggressive towards her and she was afraid of Resident #1. DON stated she was not notified about Resident #1 wanting to go to the hospital. She further stated she was not informed Resident #1 was sent to the hospital. She stated she should have been notified of Resident #1 being sent to the hospital. DON stated she did not find out Resident #1 had been sent to the hospital or in the hospital until 06/02/25 when she was at the facility. She stated she reached out to Resident #1 on 06/02/25 via telephone who reported to her about RN A refusing to send him to the hospital on [DATE] when he reported having trouble breathing and needing to go to the hospital. Interviews on 06/03/25 at 1:11 PM with CNA C revealed on 05/31/25 Resident #1 was concerned about leg pain and swollen leg thought he might have a blood clot. She stated Resident #1 reported to her he wanted to be sent to hospital CNA C stated Resident #1 told her that he tried to do it their way by notifying RN A of needing to go to the hospital so they can send him to hospital but Resident #1 stated RN A blew him off. CNA C stated she did not have an opportunity to report Resident #1 wanting to be send to the hospital to LVN B because she got distracted when the police arrived to the facility. She stated Resident #1 went back to his room and police contacted EMT to send him to the hospital. She stated she did not know if LVN B was aware of Resident #1 wanting to go to the hospital. Interview on 06/04/25 at 11:05 AM with Police Officer H revealed the police officer who was dispatched to the facility on [DATE] worked the night shift. He stated he would leave a message to call surveyor. He stated based on his review of the report it reflected on 05/31/25 a nurse from the facility called to report Resident #1 having a verbal altercation with nurse. He reviewed the call details report reflecting Resident #1 complained of leg pain when police arrived at the facility and police notified EMTs to send Resident #1 to the hospital. Interview on 06/04/25 at 8:44 PM with LVN D revealed she was not asked to be Resident #1's charge nurse on 05/31/25. She stated the police officer asked her to print off Resident #1's face sheet but did not understand why RN A was not more involved in Resident #1 being sent to the hospital. She stated she did not know why Resident #1 was sent to the hospital on [DATE]. She stated she did not make any notifications of Resident #1 going to the hospital since he was RN A's resident on 05/31/25. She stated as the charge nurse if a resident reports to her wanting to go to the hospital, she would assess, find out more information about what was going on with resident and take vitals. She stated residents have a right to go to the hospital if he or she wants to. She stated she would contact the physician to report her assessment of the resident and what was going on with resident. She stated if a resident wants to go to the hospital she would report it to the physician and DON. Interview on 06/05/25 at 9:14 AM with DON revealed RN A should have notified the physician and if resident wanted to be sent out to the hospital to send resident out to the hospital. She stated Resident #1 was his own responsible party. She stated Resident #1 was admitted to the hospital on [DATE]. She stated Resident #1 had a history of DVT in a previous hospitalization. Interview on 06/05/25 at 9:33 AM with Resident #1's MD revealed if resident wanted to go to the hospital, the nurse will contact EMS for transportation. He stated the risk to the resident could be potential risk of pulmonary embolism or heart attack. He stated Resident #1 could have had complications but he was not discharged until 06/02/25 to rule out DVT and blood clot for Resident #1. Interview on 06/05/25 at 10:17 AM with LVN D revealed Resident #1 told her he needed to talk to RN A but did not tell him what was going on. She reported to RN A at shift change which was 6:00 PM on 05/31/25 that Resident #1 wanted to talk to him. LVN D stated she was not informed Resident #1 wanted to go to the hospital and was not aware of any change of condition for Resident #1. Interview on 06/07/25 at 11:18 AM with RN A revealed LVN D reported to her Resident #1 wanted him to go see him at beginning of her shift at 6 PM. She stated she found it odd he wanted to talk to her because she stated she stayed out of his room, she did not like to deal with him and if he walking down the hall. She went the other way. She stated when she entered Resident #1's room. RN A stated he told her he needed to go to the hospital and she told him you can go. RN A stated Resident #1 started yelling at her, told her to get the hell out of his room. She stated she left his room and he followed her down the hall saying who the hell are you, I am going to destroy you. RN A stated she did not know what Resident #1 was complaining of and did not have a chance to ask any questions. She stated she did not have a chance to assess him or ask him more questions to find out what he wanted to go to the hospital. LVN D stated she went to shelter on the secure unit and called the police to inform of Resident #1's aggression towards her. She stated she needed to administer her medications to the residents on his hall and was afraid he might attack her so she called the police. RN A stated she called the police after she sheltered on the secure unit and it took like 20 to 30 minutes for them to arrive. She stated she did not inform the police about Resident #1 wanting to go to the hospital. She did not inform anyone about Resident #1 wanting to go to the hospital. She stated the police called for Resident #1 to be sent out to the hospital. She stated the DON called me on 05/31/25 to find out why she called the police. She stated she did not inform anyone about Resident #1 going to the hospital. She stated Resident #1 did have chronic DVT history. She stated when she was contacted by the facility on 06/02/25 she told them she quit because she knew Resident #1 would be back at the facility. Review of facility's policy Resident Rights last revised February 2021 reflected employees shall treat all residents with kindness, respect and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; .e. self-determination .s .participate in decision-making regarding his or her care .

Based on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Residents #1) of six residents reviewed for pain management. 1. The facility failed to ensure Resident #1 was assessed, monitored and received effective pain management by LVN A after Resident #1 was found on the floor with indications of pain when mumbling and grumbling during transfer at time of unwitnessed fall on 02/24/24 at 12:17 AM. Resident #1 received no pain management from LVN A. 2. The facility failed to ensure Resident #1 received pain medication until after a 9 hour delay after the an unwitnessed fall. Resident #1 exhibited increasing signs of pain indicated by facial grimacing, moaning and holding her left hip. LVN B failed to follow Resident #1's prn physician order of administering Tylenol 500 mg before the 4 hours and failed to notify the physician of Resident #1's pain medication not being effective. 3. The facility failed to ensure effective pain management was provided to Resident #1 resulting in increased indicators of pain which resulted in 911 being called after Resident #1's POA intervention to contact Physician. Resident #1 was admitted to the hospital (19 hour delay since pain onset) for a left displaced hip fracture and had surgery to repair the fracture An Immediate Jeopardy (IJ) was identified on 07/17/24. The IJ Template was provided to the facility on [DATE] at 12:15 PM. While the IJ was removed on 07/19/24, the facility remained out of compliance at a scope of pattern and severity level of potential for more than minimal harm because all staff had not been trained on pain management. These failures placed residents at risk of experiencing significant pain, discomfort and hospitalization . Findings include: Review of Resident #1's face sheet dated 07/16/24 reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Review of Resident #1's Quarterly MDS dated [DATE] reflected Resident #1 had diagnoses of traumatic brain injury (form of acquired brain injury occurs when a sudden trauma causes damage to the brain), hypertension (high blood pressure), unsteadiness on feet, cognitive communication deficit, anxiety disorder (persistent feelings of worry or fear) and depression disorder (episodes of persistently sad moods) and a BIMS score of 00 (severely impaired cognition). Review of Resident #1's comprehensive care plan last revised on 06/11/24 revealed resident had experienced multiple falls and included a fall on 02/24/2024 but did not indicate injury of hip fracture. Interventions included floor mats next to bed when resident was in bed, ensure her nonskid socks are on, and check frequently to make sure resident was not self-transferring, and to monitor pain during task. Review of Event Report for Resident #1 by LVN A with an event date of 02/24/2024 at 12:17 AM, dated recorded 02/24/2024 at 06:18 AM and closed date of 02/26/2024 at 1:38 PM by the DON reflected an unwitnessed fall in resident room. Resident seen lying on her right side on the floor in her room. Resident confused, pacing around in hallway & room. Resident re-directed & repositioned back to bed several times but prove abortive. CNA called [Charge Nurse] that resident is on the floor, resident seen lying on her right side on the floor close to the door. When asked, resident unable to explain, Resident mumbling & grumbling during transfer. Vital signs Blood pressure: 129/73, Pulse :68, Respirations:18, 02:96% [room air], T:97.4. No skin tear noted. Stat xray to bilateral hip ordered. Resident's POA, Supervisor & MD notified. Neuro checks initiated. Resident's pain was noted to be a 1 out of 10 (mild) and had painful and/or limited range of motion in her lower extremities. She was responsive to her name and to pain and was able to perceive her environment clearly and responded appropriately to stimuli. Review of Post Fall Observation report with an observation date of 02/24/2024 at 12:21 AM and completed dated of 02/24/2024 at 6:24 AM by LVN A reflected Resident #1 was previously in her bed and had an unwitnessed fall and was seen lying on her left side in her room. LVN A documented that Resident #1 had an agitated and confused mental status prior to the fall, and a pain level of 3 of 10 at 06:26 AM. Review of Resident #1's nurse's progress note dated 02/24/2024 at 1:48 AM by LVN A revealed resident had an unwitnessed fall and the Physician, supervisor, and resident's representative were notified and a STAT x-ray to both hips were ordered. Review of Resident #1's nurse's progress note dated 02/24/2024 at 10:11 AM by LVN B reflected 9am Resident has facial grimacing and has been holding her left hip. [Physician C] notified ordered [Tylenol] 500mg tablet one q 4hrs prn pain.[Tylenol] 500mg tab one given for pain inital [sp] dose given for pain for pain level of 5. Repositioned in bed with both legs in straight alignment using pillows to keep legs straight align ment.10am good results from pain med.(1) 1011am Phone call made to [X-ray Company N] and they said he will be here shortly. Review of Resident #1's nurse's progress note dated 02/24/2024 at 12:27 PM by LVN B revealed at 12:24 PM [x-ray company N] had arrived to x-ray resident's hips and resident was observed moaning and holding her left hip and was given a Tylenol 500 mg for a pain level noted as a 4 and was turned and repositioned with pillows. Review of Resident #1's nurse's progress note date 02/24/2024 at 7:21 PM by LVN B revealed Resident #1's family had visited and were told the x-ray results were not in yet and staff had called x-ray services and they stated it would be awhile until results were ready. LVN B documented that the POA wanted Physician C called to ask for an order to transfer Resident #1 to the hospital via ambulance to be evaluated by the emergency room doctor. LVN B documented that Physician C gave orders to send Resident #1 to the hospital and Resident #1 was being transported via ambulance at 5:00 PM and DON notified at 5:09 PM. Review of Resident #1's Physician Orders for February 2024 reflected a physician order with a start date of 02/24/2024 and end date of 02/28/2024 for APAP [Tylenol] 500 MG one tablet, every 4 hours for pain. Record review of February 2024 MAR for 02/01/2024-02/29/2024 revealed an order for a pain evaluation every shift, 6:00 AM- 6:00 PM (day shift) and 6:00 PM to 6:00 AM shift (night shift). Review of resident pain level on the night shift of 02/23/2024 showed entry, initialed by LVN A, that noted resident's pain was a 0. The following morning shift on 02/24/2024 initialed by LVN B recorded a pain of 5. Review of Resident #1's MAR for February 2024 revealed a physician order with a start date of 02/24/2024 and end date of 02/28/2024 for APAP [Tylenol] 500 MG one tablet, every 4 hours for pain with blank spaces for 02/24/2024. Review of Hospital EMS record dated 02/24/24 reflected EMS received a phone call on 02/24/24 at 5:02 PM from facility. Resident #1 was transported from facility to local hospital for a possible hip fracture. Patient was having right hip pain secondary to a fall she sustained at 0100 this morning. Nursing staff stated they called for transport due to the patient not getting better. Patient was transported supine and immobilized the right hip area. Patient also has a history of [traumatic brain injury] due to a fall and hitting her head on a marble coffee table as stated by family in the room .Patient complains of pain on the left side during any movement .Lower extremities-patient had pain on left side with shortening of the left leg The EMS record reflected Resident #1 had chief complaint of hip hurting for 16 hour duration. Review of Hospital paperwork for Physician documentation dated 02/24/24 from Emergency Doctor reflected Resident #1 diagnosis of fracture of unspecified part of neck of left femur bone ( hip fracture). Resident #1 presented to ER with complaints of hip injury .coming into the emergency room with left hip pain after she had a fall at the nursing home patient denies any other injuries, she does have deformity on the left hip.X-ray shows a femoral neck fracture on the left side. Review of Hospital paperwork of Admitting History and Physical dated 02/24/24 reflected Resident #1 was a [AGE] year-old female nursing home resident with history of dementia, coronary artery disease, hypertension, type 2 diabetes and seizure disorder .She continued to have pain in left hip area after the fall at nursing home .Evaluation revealed left femoral neck (hip) fracture .It is relieved with oral hydrocodone .Pain with any movement of left hip .Plan.1. Left femoral neck fracture: Patient will be admitted to the hospital. IV morphine will be given as needed for pain control .orthopedic surgery was consulted. Plan to have surgical open reduction internal fixation tomorrow . Review of Hospital X-rays CR for pelvis and left hip with pain with traumas/injury dated 02/24/24 reflected Resident #1 had an acute left displaced subcapital femoral neck fracture (hip fracture). Review of Resident #1's X-ray by X-ray Company N of bilateral hips with pelvis dated 02/24/24 signed at 7:55 PM reflected an acute transverse fracture of the left of the neck femur (hip fracture). Review of Email dated 02/24/24 at 7:59 PM reflected DON and ADON were emailed to indicate a critical finding was flagged for patient [Resident #1], service date 02/24/24. Observation on 07/16/2024 at 9:40 AM of Resident #1 revealed she was asleep in bed on low position and with floor mats and interview with resident revealed she was confused, pleasant, and did not remember falling. Interview on 07/16/24 at 2:09 PM with resident's POA revealed on 02/24/2024 she was notified by the night nurse (LVN A) in the middle of the night that Resident #1 had a fall and was found on the floor with her blankets tangled around her legs and x-ray was ordered for Resident #1. She had another call later in the morning by LVN B about Resident #1 had been in bed all day and had a little discomfort and crying and was given Tylenol for pain and were awaiting x-ray to come. The POA and another family member visited Resident #1 on 02/24/24 in the late afternoon and resident was in bed with a pillow propped under her knee. POA said it seemed like the resident could not get comfortable because when she would make any movement with the left leg she would cry and grab it. She stated Resident #1 did not typically have pain and she was concerned that the fall had occurred in the middle of the night but there were still no x-ray results and resident was crying with any little movement and said it hurt. The POA stated she told the nurse (LVN B) that she was going to call 911 and have resident transported to ER and nurse said they needed to call the doctor to get an order and that the nurse would call. The POA checked a few minutes later and the nurse was helping a different resident and the POA and family member stated they would call 911 and nurse said no, she would do it immediately. The POA stated that she was frustrated that it seemed to take another 45 minutes before they had the call from Physician C to send resident to hospital via ambulance. The POA stated that the resident ended up having a fracture and had hip surgery. The POA stated she called the Administrator the following day and expressed her frustration about the delay in getting the resident to the hospital and x-ray results. The POA stated that the Administrator stated she knew and understood and had turned it in [to HHSC]. Interview on 07/16/2024 at 2:42 PM via phone with Physician C revealed he was notified in the middle of the night on 02/24/2024 that Resident #1 had a fall with some pain with movement and he ordered a STAT x-ray. He stated he thought he was called again later in the morning about the resident having some pain and he ordered Tylenol 500 mg every 4 hours as needed and asked about the status of the x-ray and was told they were waiting for x-ray to arrive. He stated he did not know Resident #1 was experiencing increasing pain until later into the evening when he was contacted by facility and informed that the family requested Resident #1 be sent to the emergency room (ER) due to her pain levels. He instructed that Resident #1 be sent to the hospital for an evaluation due to the level of pain resident had and the results of the x-ray were still pending. Physician C stated he reviewed the nurse's progress notes and did not know why Resident #1 received Tylenol 500 mg on 02/24/2024 at 9 am and then at 12:24 pm because it was too soon for another dose that if contacted he would have ordered a Tylenol #3 which is slightly stronger to manage the pain. Physician C stated that his expectation was if a resident's pain was not controlled then he would be called and he would either order stronger pain medication or send the resident to the hospital. Physician C stated that he expected the nurses to use their judgement and if a resident fell , and there was a suspicion of injury or the resident had uncontrolled pain, then they can send her to the ER themselves. He stated Resident #1 had injury of hip fracture. Interview on 07/16/2024 at 3:12 PM via phone with LVN A revealed on 02/24/24 resident was up and pacing the halls that evening which was typical for her and she was put back to bed a number of times. LVN A stated the CNA alerted LVN A that Resident #1 had fallen and she observed the resident lying on right side on the floor in her room next to her bed. LVN A stated that she assessed Resident #1 and she didn't seem to be in much pain but only mumbled and grumbled during transfer back into bed. She states she notified the doctor and the POA and an x-ray was ordered STAT by physician due to resident having some pain. LVN A stated she did not remember giving any pain medication to Resident #1 on her shift. LVN A stated she noticed later into her shift that Resident #1 was having more pain and discomfort when moving her lower extremities. She stated she contacted x-ray company about the STAT x-ray by phone but could not recall when she called the STAT x-ray in. LVN A stated she notified LVN B at shift change of Resident #1 had a fall and x-ray ordered for Resident #1. She stated she was not in-serviced on pain management or x-ray services since incident. Interview on 07/17/2024 at 5:09 PM via phone with LVN B revealed she was familiar with Resident #1 and that she had falls in the past but never had a serious injury until February 2024. She stated Resident #1 typically walked up and down the halls and it was common for her to cry, ask for family members, to lash out and throw things, hit or kick. LVN B stated that Resident #1 was able to indicate that she had pain verbally and would point to the area or say hurt. LVN B stated that on 02/24/2024 during the night to day shift change, LVN A informed her that Resident #1 had experienced a fall around the middle of the night- the POA and physician had been contacted, and an order for a STAT X-ray had been ordered. LVN B stated that during her shift Resident #1 did not display her typical behavior, she was in bed, displayed signs of pain such as facial grimacing and holding her left leg which appeared slightly turned out and was painful to touch. LVN B stated she thought Resident #1 had broken her hip. LVN B stated that she called Physician C around 9:00 AM to ask for pain medication because the resident did not have any orders pain medication and he prescribed Tylenol 500 mg as needed every 4 hours for pain and asked if the x-ray results were in yet. LVN A stated she told him they were not in yet and she would call about the x-ray status. LVN B stated that she gave Resident #1 Tylenol 500 mg and called the x-ray company at 10:11 AM and they stated they would be there soon. LVN B stated she must have forgotten to document she gave the Tylenol to Resident #1 in the Medication Administration Record (MAR) because there was a lot going on and Resident #1 ended up going back to sleep but was restless. LVN B stated that she did her best to make Resident #1 as comfortable as possible while waiting for x-ray to arrive and repositioned resident with legs in straight alignment using pillows to keep the legs straight based on her nursing experience that if a resident has a broken hip then you want to keep the legs straight. LVN B stated that around 12:24 PM the x-ray arrived and resident was observed to be moaning and crying during the x-ray and she repositioned the resident with straight legs and gave her another Tylenol 500 mg. LVN B stated Resident #1 was restless and with any little movement, expressed pain verbally, said she was hurting, had facial grimacing, and was pointing and holding at both sides of her hip but mostly the left side. LVN B stated that around 4:00 PM on 02/24/2024 the POA arrived and was concerned about the resident. LVN B stated Resident #1 had facial grimacing, grabbed at both of her hips, cried with any movement and said she was in pain. She stated at the POA's request she contacted Physician C and received an order to transfer resident to the emergency room around 5:00 PM. She stated she was not in-serviced on pain management or x-ray services since incident. Interview on 07/19/24 at 2:36 PM with CNA G revealed she worked the day shift on 02/24/24 when Resident #1 was grunting. She stated she overheard LVN A tell LVN B about Resident #1 having a fall on the night shift. She stated at breakfast Resident #1 did not want to get up and eat breakfast. She recalled during her shift Resident #1 was crying constantly and looked to be in pain by holding and gesturing to left side. She stated LVN B gave Resident #1 pain medication not sure what time sometime after breakfast. CNA G stated she used gait belt to transfer Resident #1 into wheelchair and put her back in bed with gait belt. She stated Resident #1 was showing signs of pain of moaning and crying along with holding and guarding her left side. She stated LVN B did not give her any instruction about transferring or positioning resident. She stated Resident #1 stayed in the bed for the rest of the shift after noticing Resident #1 was in pain with transfer. She stated sometime after lunch before supper Resident #1's family came and were upset the x-ray results were not in yet for Resident #1 asking for her to be sent to hospital due to her being in pain. She stated LVN B sent Resident #1 to the hospital. Interview on 07/16/2024 at 12:58 PM with the DON revealed if a resident falls they are assessed by a nurse for pain and injury and if a resident could not speak, the PAINAD (pain assessmnt scale) should be used. The DON stated she expected mobile STAT x-ray can take anywhere up to 4-6 hours to be completed. The DON stated that she expected staff to document any medication given in the MAR. She was not able to find documentation of pain medication given in the February 2024 MAR for Resident #1. Interview on 07/16/2024 at 1:26 PM with the Corporate Nurse, revealed her expectations for staff documentation of medication administration were the same as the DON mentioned and expected it to be documented in the MAR to show pain medication administered. Interview on 07/17/2024 at 10:56 AM with LVN F revealed she was familiar with Resident #1 and was not working on the day of her fall on 02/24/2024. LVN F stated Resident #1 did not typically display pain indicators before her fall on 02/24/2024 and she was able to point to or tell you where the pain was and cried if in pain. She stated she could not recall an in-service on pain management she received. Interview on 07/17/24 at 11:01 AM with LVN I revealed she had not received an in-service or training on x-ray services or pain management within the last year that she could recall. Interview on 07/17/24 at 11:12 AM with CNA H revealed Resident #1 yelled out when in pain after she sustained hip fracture but she did not work on 02/24/24. She stated Resident #1 grumbling or mumbling during movements was not normal it would tell me she was hurting and in pain. She states she would tell the nurse of any indicators of pain for residents immediately. Review of Email received from X-ray Company N dated 07/16/24 at 4:38 PM sent to ADON revealed the X-ray Company N notes indicated received phone call from [LVN A] at 4:01 AM who took the order. It was originally placed as routine. [LVN B] called at 10:21 AM and the order was changed to a STAT. [X-ray tech] called facility at 10:40 am and spoke to [LVN A] with ETA. [X-ray tech] arrived at 12:15 PM . Interviews on 07/16/24 at 5:32 and 5:56 PM with ADON revealed Resident #1 was sent out via 911 by LVN B after LVN B notified Physician C and physician ordered Resident #1 to be sent out to hospital for further evaluation. She stated she expected stat x-ray results to be completed within 4 to 6 hours. She was not sure what time stat x-ray results had come to the facility and Resident #1 was sent to the hospital prior to receiving stat x-ray results. She stated she was not working on 02/24/24 and did not read her email to indicate Resident #1 had critical finding for her x-ray. She stated she was aware of Resident #1 being sent to the hospital and having a fracture on 02/25/24 when she was at work. Interview on 07/17/24 at 9:05 AM with DON revealed she expected charge nurse to document what time she contacted x-ray company to order stat x-ray and when she notified Physician C. She stated the stat x-ray order should have been put in the electronic record as a telephone order after getting the order from Physician C. She stated she was unable to find documentation of telephone physician order by LVN A. She stated LVN B should have documented the administration of the prn Tylenol order on 02/24/24 but stated at least it was in the progress notes when Resident #1 received Tylenol. She stated Resident #1 was sent out to the hospital on 02/24/24 at 5:09 PM and facility had not received the stat x-ray results. The DON stated Resident #1 should have been sent out to the hospital prior to 5 pm if Resident #1 was exhibiting increasing signs of pain as indicated by the progress notes. She stated LVN A should have reached out to the physician for a pain medication order and to give a report of Resident #1's pain to the physician. The DON stated a delay in pain management placed Resident #1 at risk for increased pain and suffering. She stated she did not review Resident #1's stat x-ray results until 02/25/24 and she did receive an email in the evening about a critical x-ray result but she did not review it until the next morning. She stated Resident #1's stat x-ray results were not received until after Resident #1 was sent to the hospital. She stated the facility had not in-serviced on pain management or x-ray services since 02/24/24. Interview on 07/19/2024 at 3:20 PM with ADON revealed Resident #1 did not usually have pain and when she did she would be able to say she is in pain by gesturing to area she was hurting. She stated Resident #1 would display pain indicators with facial grimaces, crying, or sweating. The ADON stated that if a resident is nonverbal then they would display signs of pain such as grimacing, breathing changes, guarding of the site, crying; and for residents with dementia the PAINAD scale should be used to assess pain. She stated based on reviewing Resident #1's progress notes on 02/24/24 by LVN A and LVN B there were indicators of pain displayed by Resident #1 including grumbling during transfer, grimacing, crying, moaning and holding onto her hip. Review of facility's in-service dated 10/21/23 to Nurses and CNA reflected Acute Condition Changes - Clinical Protocol policy was reviewed which included Nurse shall assess and document/report the following baseline information .c. Current level of pain, and any recent changes in pain level . It reflected LVN B attended in-service but LVN A did not attend in-service. Review of facility's policy titled Pain Assessment and Management, dated 2001 and revised March 2015, reflected to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Under general guidelines . 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. 'Pain management' is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. assessing the potential for pain; b. effectively recognizing the presence of pain; c. Identifying the characteristics of pain; d. addressing the underlying causes of the pain; e. developing and implementing approaches to pain management; f. identifying and using specific strategies for different levels and sources of pain; g. monitoring for effectiveness of interventions; and h. modifying approaches as necessary . 5. Conduct a comprehensive pain assessment .whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain . Under Recognizing Pain, it reflected .2. Possible Behavioral signs of pain a. Verbal expressions such as groaning, crying, screaming; b. Facial expressions such as grimacing .d. Behavior such as .decreased participation in usual activities; e. Limitations in his or her level of activity due to the presence of pain; f. Guarding, rubbing or favoring a particular part of the body . Under Assessing pain it reflected During the comprehensive pain assessment gather the following as indicated from the resident .Characteristics of pain (1) Intensity of Pain, (2) Descriptors of pain (3) Pattern of pain (4) Location and radiation of pain and (5) Frequency, timing and duration of pain . An Immediate Jeopardy was identified on 07/17/24. The Administrator and the DON were notified on 07/17/24 at 12:15 PM of the Immediate Jeopardy. IJ template provided at this time and plan of removal was requested. The facility's plan of removal was accepted on 07/18/24 at 3:49 PM. The accepted plan of removal for the Immediate Jeopardy included the following: Problem: Pain (F697) The facility failed to treat residents' pain in a timely manner. Plan: 1. [Physician C] Medical Director has been notified of the Immediate Jeopardy by the Administrator on 07/17/2024. QAPI was conducted with the medical director. 2. Administrator/Designee initiated in-service on abuse and neglect on 07/17/24. 3. Regional Nurse to educate DON regarding assessing residents for pain after an incident and of sending the resident to the ER for evaluation if inhouse Xray cannot be obtained timely. DON educated on assessing pain in the moderate to severely cognitively impaired. Completion: 07/18/24 4. DON/designee will initiate assessing residents who have fallen from July 1, 2024, to current for indicators of pain i.e., verbal/non-verbal on 07/17/24. Completion date: 07/17/24. 5. DON/designee initiated in-service on 07/17/24 with charge nurses/agency nurses on the following: o Pain Management verbal and non-verbal indicators following a fall. o Pain Assessment observation form completion following a fall. o Notification to physician when pain medication is ineffective. o Assessing pain using a consistent approach and a standardized pain assessment (PAINAD) instrument appropriate to the resident's cognitive level (moderate to severe cognitive impairment). Completion: 07/18/24 and ongoing 6. DON/designee initiated in-service with nurse aides, medication aides and managers on duty/agency staff on reporting indicators of pain i.e., verbal or non-verbal to the charge nurse. Completion: 7/18/24 and ongoing 7. Charge nurses, agency nurses, aides, certified staff not working during the in-services on Pain, will be in-service prior to their next scheduled shift. Staff will not be allowed to work until in-service is complete. Newly hired staff will receive the in-services during their orientation period. Agency nurses will be in-service prior to beginning their shift. 8. Licensed and certified nursing staff/agency staff will be given a competency-based quiz on pain. Completion: 7/18/24 9. Monitoring will occur during the clinical morning meeting Monday through Friday; weekend supervisor will review the Facility Activity Report for resident falls and new orders. If concerns are noted by weekend supervisor the DON will be contacted. The DON will be responsible and monitor residents' post fall pain management. 10. Weekend supervisor was in-serviced on monitoring the Facility Activity Report and follow-up on orders i.e., X-ray, and residents with pain. Completed: 07/18/24 The facility's implementation of the IJ Plan of Removal was verified through the following: Review of facility's in-service initiated for 07/17/24 reflected CNAs, nursing and nursing administration (ADON, Weekend RN Supervisor and DON) were in-serviced on pain management, nursing documentation about pain assessment, notification to physician when exhibit change of condition of pain onset, physician orders for pain medication and x-ray orders, and laboratory, diagnostic and radiology services On 07/19/24 between 10:55 AM and 6:51 PM revealed four (4) licensed vocational nurses were interviewed, from different shifts, on training and new system to ensure compliance for pain management. All nursing staff were able to verbalize understanding of how to assess for pain for residents with nonverbal indicators to use painad scale and give examples of pain indicators for nonverbal residents. Nursing was in-serviced on training regarding stat x-rays to be completed in timely manner and to follow up to get results in a timely manner. They were knowledgeable of expectation of physician's orders for x-rays that they needed to obtain x-ray orders and contact x-ray company to follow the physician x-ray orders. Nursing was knowledgeable on inputting physician orders for x-rays and to notify physician if there is a delay in stat x-ray services. Nursing stated if resident showed increasing signs of pain since unwitnessed fall and/or pain during movements they would send resident out to hospital for further evaluation. They would contact ADON, DON or weekend RN supervisor if having issues with x-ray services. Nursing aware of time for completion of stat x-rays to be with 4 to 6 hours and to follow up if results of stat x-ray have not been received. On 07/19/24 between 2:36 PM to 6:15 PM revealed four (4) CNAs were interviewed, from different shifts on training and notifying nurses of indicators of resident pain. All CNAs could give examples of verbal and nonverbal indicators of pain and would immediately notify charge nurse of any concerns with resident pain. If CNAs felt like nurse was not following up with resident about pain, then they would notify the ADON or DON. Review of Resident #2 and Resident #6's clinical record reflected no concerns with physician orders for pain medication and MAR documentation for pain management. Interview on 07/19/24 with ADON at 4:45 PM revealed LVN B is currently on leave and she will be in-serviced 1:1 about pain management and x-ray services timeliness. She stated she was responsible to ensure new nurses were in-serviced going forward prior to working the floor on pain management and x-ray services. She stated her and the DON have incorporate a tool of auditing residents sent to hospital and x-ray services to ensure timeliness of stat x-rays ordered. She stated they have not in-serviced LVN A yet and will be doing a 1:1 inservice with her a[TRUNCATED]

Based on interview and record review the facility failed to provide radiology or other diagnostic services to meet the needs of its residents in a timely manner for one (Resident #1) of six residents reviewed for radiology services. 1. The facility failed to ensure that a stat x-ray was completed in a timely manner for Resident #1 on 02/24/24. 2. The facility failed to follow up to get Resident #1's stat x-ray results in a timely manner on 02/24/24. Resident #1 had an unwitnessed fall on 02/24/24 at 12:17 AM and sustained an injury. LVN A failed to ensure x-ray physician order was placed stat and not routine 12 hours after the unwitnessed fall, X-ray tech was at facility to complete stat x-ray for Resident #1. 17 hours after unwitnessed incident, Resident was sent to hospital for increasing pain and x-ray results had not been received. As a result, Resident #1 was admitted to the hospital (19 hour delay) since pain onset and unwitnessed fall for a left displaced hip fracture and had surgery to repair the fracture. An Immediate Jeopardy (IJ) was identified on 07/17/24. The IJ Template was provided to the facility on [DATE] at 12:15 PM. While the IJ was removed on 07/19/24, the facility remained out of compliance at a scope of pattern and severity level of potential for more than minimal harm because all staff had not been trained on x-ray services. These failures could place resident at risk of results in delayed diagnosis, medical treatment, and hospitalization . Findings include: Review of Resident #1's face sheet dated 07/16/24 reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Review of Resident #1's Quarterly MDS dated [DATE] reflected Resident #1 had diagnoses of traumatic brain injury (form of acquired brain injury occurs when a sudden trauma causes damage to the brain), hypertension (high blood pressure), unsteadiness on feet, cognitive communication deficit, anxiety disorder (persistent feelings of worry or fear) and depression disorder (episodes of persistently sad moods) and a BIMS score of 00 (severely impaired cognition). Review of Resident #1's comprehensive care plan last revised on 06/11/24 revealed resident had experienced multiple falls included a fall on 02/24/2024 but did not indicate injury of hip fracture. Interventions included floor mats next to bed when resident was in bed, ensure her nonskid socks are on, and check frequently to make sure resident was not self-transferring, and to monitor pain during task. Review of Event Report for Resident #1 by LVN A with an event date of 02/24/2024 at 12:17 AM, dated recorded 02/24/2024 at 06:18 AM and closed date of 02/26/2024 at 1:38 PM by the DON reflected an unwitnessed fall in resident room. Resident seen lying on her right side on the floor in her room. Resident confused, pacing around in hallway & room. Resident re-directed & repositioned back to bed several times but prove abortive. CNA called [Charge Nurse] that resident is on the floor, resident seen lying on her right side on the floor close to the door. When asked, resident unable to explain, Resident mumbling & grumbling during transfer. Vital signs Blood pressure: 129/73, Pulse :68, Respiratoins:18, 02:96% [room air], T:97.4. No skin tear noted. Stat xray to bilateral hip ordered. Resident's POA, Supervisor & MD notified. Neuro checks initiated. Resident's pain was noted to be a 1 out of 10 (mild) and had painful and/or limited range of motion in her lower extremities. She was responsive to her name and to pain and was able to perceive her environment clearly and responded appropriately to stimuli. Review of Post Fall Observation report with an observation date of 02/24/2024 at 12:21 AM and completed dated of 02/24/2024 at 6:24 AM by LVN A reflected Resident #1 was previously in her bed and had an unwitnessed fall and was seen lying on her left side in her room. LVN A documented that Resident #1 had an agitated and confused mental status prior to the fall, and a pain level of 3 of 10 at 06:26 AM. Review of Resident #1's nurse's progress note dated 02/24/2024 at 1:48 AM by LVN A revealed resident had an unwitnessed fall and the Physician, supervisor, and resident's representative were notified and a STAT x-ray to both hips were ordered. Review of Resident #1's nurse's progress note dated 02/24/2024 at 10:11 AM by LVN B reflected 9am Resident has facial grimacing and has been holding her left hip. [Physician C] notified ordered [Tylenol] 500mg tablet one q 4hrs prn pain.[Tylenol] 500mg tab one given for pain inital [sp] dose given for pain for pain level of 5. Repositioned in bed with both legs in straight alignment using pillows to keep legs straight align ment.10am good results from pain med.(1) 1011am Phone call made to [X-ray Company N] and they said he will be here shortly. Review of Resident #1's nurse's progress note dated 02/24/2024 at 12:27 PM by LVN B revealed at 12:24 PM [x-ray company N] had arrived to x-ray resident's hips and resident was observed moaning and holding her left hip and was given a Tylenol 500 mg for a pain level noted as a 4 and was turned and repositioned with pillows. Review of Resident #1's nurse's progress note date 02/24/2024 at 7:21 PM by LVN B revealed Resident #1's family had visited and were told the x-ray results were not in yet and staff had called x-ray services and they stated it would be awhile until results were ready. LVN B documented that the POA wanted Physician C called to ask for an order to transfer Resident #1 to the hospital via ambulance to be evaluated by the emergency room doctor. LVN B documented that Physician C gave orders to send Resident #1 to the hospital and Resident #1 was being transported via ambulance at 5:00 PM and DON notified at 5:09 PM. Review of Resident #1's Physician Orders for February 2024 reflected a physician order with a start date of 02/24/2024 and end date of 02/28/2024 for APAP [Tylenol] 500 MG one tablet, every 4 hours for pain. Review of Hospital EMS record dated 02/24/24 reflected EMS received a phone call on 02/24/24 at 5:02 PM from facility. Resident #1 was transported from facility to local hospital for a possible hip fracture. Patient was having right hip pain secondary to a fall she sustained at 0100 this morning. Nursing staff stated they called for transport due to the patient not getting better. Patient was transported supine and immobilized the right hip area. Patient also has a history of [traumatic brain injury] due to a fall and hitting her head on a marble coffee table as stated by family in the room .Patient complains of pain on the left side during any movement .Lower extremities-patient had pain on left side with shortening of the left leg The EMS record reflected Resident #1 had chief complaint of hip hurting for 16 hour duration. Review of Hospital paperwork for Physician documentation dated 02/24/24 from Emergency Doctor reflected Resident #1 diagnosis of fracture of unspecified part of neck of left femur. Resident #1 presented to ER with complaints of hip injury .coming into the emergency room with left hip pain after she had a fall at the nursing home patient denies any other injuries, she does have deformity on the left hip X-ray shows a femoral neck fracture on the left side. Review of Hospital paperwork of Admitting History and Physical dated 02/24/24 reflected Resident #1 was a [AGE] year-old female nursing home resident with history of dementia, coronary artery disease, hypertension, type 2 diabetes and seizure disorder .She continued to have pain in left hip area after the fall at nursing home .Evaluation revealed left femoral neck (hip) fracture .It is relieved with oral hydrocodone .Pain with any movement of left hip .Plan.1. Left femoral neck fracture: Patient will be admitted to the hospital. IV morphine will be given as needed for pain control .orthopedic surgery was consulted. Plan to have surgical open reduction internal fixation tomorrow . Review of Hospital X-rays CR for pelvis and left hip with pain with traumas/injury dated 02/24/24 reflected Resident #1 had an acute left displaced subcapital femoral neck fracture (hip). Review of Resident #1's X-ray by X-ray Company N of bilateral hips with pelvis dated 02/24/24 signed at 7:55 PM reflected an acute transverse fracture of the left of the neck femur (hip). Review of Email dated 02/24/24 at 7:59 PM reflected DON and ADON were emailed to indicate a critical finding (findings/results require immediate or urgent communication with the provider) was flagged for patient [Resident #1], service date 02/24/24. Observation on 07/16/2024 at 9:40 AM of Resident #1 revealed she was asleep in bed on low position and with floor mats and interview with resident revealed she was confused, pleasant, and did not remember falling. Interview on 07/16/24 at 2:09 PM with resident's POA revealed on 02/24/2024 she was notified by the night nurse (LVN A) in the middle night that Resident #1 had a fall and was found on the floor with her blankets tangled around her legs and x-ray was ordered for Resident #1. She had another call later in the morning by LVN B about Resident #1 had been in bed all day and had a little discomfort and crying and was given Tylenol for pain and were awaiting x-ray to come. The POA and another family member visited Resident #1 on 02/24/24 in the late afternoon and resident was in bed with a pillow propped under her knee. POA seemed like the resident could not get comfortable because when she would make any movement with left leg she would cry and grab it. She stated Resident #1 did not typically have pain and she was concerned that the fall had occurred in the middle of the night but there were still no x-ray results and resident was crying with any little movement and said it hurt. The POA stated she told the nurse (LVN B) that she was going to call 911 and have resident transported to ER and nurse said they needed to call the doctor to get an order and that the nurse would call. The POA checked a few minutes later and the nurse was helping a different resident and the POA and family member stated they would call 911 and nurse said no, she would do it immediately. The POA stated that she was frustrated that it seemed to take another 45 minutes before they had the call from Physician C to send resident to hospital via ambulance. The POA stated that the resident ended up having a fracture and had hip surgery. The POA stated she called the Administrator the following day and expressed her frustration about the delay in getting the resident to the hospital and x-ray results. The POA stated that the Administrator stated she knew and understood and had turned it in [to HHSC]. Interview on 07/16/2024 at 2:42 PM via phone with Physician C revealed he was notified in the middle of the night on 02/24/2024 that Resident #1 had a fall with some pain with movement and he ordered a STAT x-ray. He stated he thought he was called again later in the morning about the resident having some pain and he ordered Tylenol 500 mg every 4 hours as needed and asked about the status of the x-ray and was told they were waiting for x-ray to arrive. He stated he did not know Resident #1 was experiencing increasing pain until later into the evening when he was contacted by facility and informed that the family requested Resident #1 be sent to the emergency room (ER) due to her pain levels. He instructed that Resident #1 be sent to the hospital for an evaluation due to the level of pain resident had and the results of the x-ray were still pending. Physician C stated he reviewed the nurse's progress notes and did not know why Resident #1 received Tylenol 500 mg on 02/24/2024 at 9 am and then at 12:24 pm because it was too soon for another dose that if contacted he would have ordered a Tylenol #3 which is slightly stronger to manage the pain. Physician C stated that his expectation was if a resident's pain was not controlled then he would be called and he would either order stronger pain medication or send the resident to the hospital. Physician C stated that he expected the nurses to use their judgement and if a resident fell , and there was a suspicion of injury or the resident had uncontrolled pain, then they can send her to the ER themselves. He stated Resident #1 had injury of hip fracture. Interview on 07/16/2024 at 3:12 PM via phone with LVN A revealed on 02/24/24 resident was up and pacing the halls that evening which was typical for her and she was put back to bed a number of times. LVN A stated the CNA alerted LVN that Resident #1 had fallen and she observed the resident lying on right side on the floor in her room next to her bed. LVN A stated that she assessed Resident #1 and she didn't seem to be in much pain but only mumbled and grumbled during transfer back into bed. She states she notified the doctor and the POA and an x-ray was ordered STAT by physician due to resident having some pain. LVN A stated she did not remember giving any pain medication to Resident #1 on her shift. LVN A stated she noticed later into her shift that Resident #1 was having more pain and discomfort when moving her lower extremities. She stated she contacted x-ray company about the STAT x-ray by phone but could not recall when she called the STAT x-ray in. LVN A stated she notified LVN B at shift change of Resident #1 had a fall and x-ray ordered for Resident #1. She stated she was not in-serviced on pain management or x-ray services since incident. Interview on 07/17/2024 at 5:09 PM via phone with LVN B revealed she was familiar with Resident #1 and that she had falls in the past but never had a serious injury until February 2024. She stated Resident #1 typically walked up and down the halls and it was common for her to cry, ask for family members, to lash out and throw things, hit or kick. LVN B stated that Resident #1 was able to indicate that she had pain verbally and would point to the area or say hurt. LVN B stated that on 02/24/2024 during the night to day shift change, LVN A informed her that Resident #1 had experienced a fall around the middle of the night- the POA and physician had been contacted, and an order for a STAT X-ray had been ordered. LVN B stated that during her shift Resident #1 did not display her typical behavior, she was in bed, displayed signs of pain such as facial grimacing and holding her left leg which appeared slightly turned out and was painful to touch. LVN B stated she thought Resident #1 had broken her hip. LVN B stated that she called Physician C around 9:00 AM to ask for pain medication because the resident did not have any orders pain medication and he prescribed Tylenol 500 mg as needed every 4 hours for pain and asked if the x-ray results were in yet. LVN A stated she told him they were not in yet and she would call about the x-ray status. LVN B stated that she gave Resident #1 Tylenol 500 mg and called the x-ray company at 10:11 AM and they stated they would be there soon. LVN B stated she must have forgotten to document she gave the Tylenol to Resident #1 in the Medication Administration Record (MAR) because there was a lot going on and Resident #1 ended up going back to sleep but was restless. LVN B stated that she did her best to make Resident #1 as comfortable as possible while waiting for x-ray to arrive and repositioned resident with legs in straight alignment using pillows to keep the legs straight based on her nursing experience that if a resident has a broken hip then you want to keep the legs straight. LVN B stated that around 12:24 PM the x-ray arrived and resident was observed to be moaning and crying during the x-ray and she repositioned the resident with straight legs and gave her another Tylenol 500 mg. LVN B stated Resident #1 was restless and with any little movement, expressed pain verbally, said she was hurting, had facial grimacing, and was pointing and holding at both sides of her hip but mostly the left side. LVN B stated that around 4:00 PM on 02/24/2024 the POA arrived and was concerned about the resident. LVN B stated Resident #1 had facial grimacing, grabbed at both of her hips, cried with any movement and said she was in pain. She stated at the POA's request she contacted Physician C and received an order to transfer resident to the emergency room around 5:00 PM. She stated she was not in-serviced on pain management or x-ray services since incident. Interview on 07/19/24 at 2:36 PM with CNA G revealed she worked the day shift on 02/24/24 when Resident #1 was grunting. She stated she overheard LVN A tell LVN B about Resident #1 having a fall on the night shift. She stated at breakfast Resident #1 did not want to get up and eat breakfast. She recalled during her shift Resident #1 was crying constantly and looked to be in pain by holding and gesturing to left side. She stated LVN B gave Resident #1 pain medication not sure what time sometime after breakfast. CNA G stated she used gait belt to transfer Resident #1 into wheelchair and put her back in bed with gait belt. She stated Resident #1 was showing signs of pain of moaning and crying along with holding and guarding her left side. She stated LVN B did not give her any instruction about transferring or positioning resident. She stated Resident #1 stayed in the bed for the rest of the shift after noticing Resident #1 was in pain with transfer. She stated sometime after lunch before supper Resident #1's family came and were upset the x-ray results were not in yet for Resident #1 asking for her to be sent to hospital due to her being in pain. She stated LVN B sent Resident #1 to the hospital. Interview on 07/16/2024 at 12:58 PM with the DON revealed if a resident falls they are assessed by a nurse for pain and injury and if a resident could not speak, the PAINAD should be used. The DON stated she expected mobile STAT x-ray can take anywhere up to 4-6 hours to be completed. The DON stated charge nurse was responsible for calling X-ray company N by phone after obtaining a physician order for x-ray orders including stat x-ray orders. Interview on 07/17/2024 at 10:56 AM with LVN F revealed she could not recall an in-service on pain management she received and was unaware of any in-service for X-ray services Interview on 07/17/24 at 11:01 AM with LVN I revealed she had not received an in-service or training on x-ray services or pain management within the last year that she could recall. Review of Email received from X-ray Company N dated 07/16/24 at 4:38 PM sent to ADON revealed the X-ray Company N notes indicated received phone call from [LVN A] at 4:01 AM who took the order. It was originally placed as routine. [LVN B] called at 10:21 AM and the order was changed to a STAT. [X-ray tech] called facility at 10:40 am and spoke to [LVN A] with ETA. [X-ray tech] arrived at 12:15 PM . Interviews on 07/16/24 at 5:32 and 5:56 PM with ADON revealed Resident #1 was sent out via 911 by LVN B after LVN B notified Physician C and physician ordered Resident #1 to be sent out to hospital for further evaluation. She stated she expected stat x-ray results to be completed within 4 to 6 hours. She stated X-ray company N reported according to their records Resident #1's x-ray was called in as routine at 4:01 by LVN A on 02/24/24 but was changed to stat by LVN B when she reached out to them. She was not sure what time stat x-ray results had come to the facility and Resident #1 was sent to the hospital prior to receiving x-ray results. She stated she was not working on 02/24/24 and did not read her email to indicate Resident #1 had critical finding for her x-ray. She stated she was aware of Resident #1 being sent to the hospital and having a fracture on 02/25/24 when she was at work. Interview on 07/17/24 at 9:05 AM with DON revealed she expected charge nurse to document what time she contacted x-ray company to order stat x-ray and when she notified Physician C. She stated the stat x-ray order should have been put in the electronic record as a telephone order after getting the order from Physician C. She stated she was unable to find documentation of telephone physician order by LVN A. She stated LVN A should have documented and inputted x-ray order into the electronic record as a physician telephone order. She stated Resident #1 was sent out to the hospital on 02/24/24 at 5:09 PM and facility had not received the stat x-ray results. The DON stated Resident #1 should have been sent out to the hospital prior to 5 pm if Resident #1 was exhibiting increasing signs of pain and x-ray results had not been received as indicated by the progress notes. The DON stated a delay in receiving stat x-ray results could place Resident #1 at risk for increased pain and suffering. She stated she did not review Resident #1's stat x-ray results until 02/25/24 and she did receive an email in the evening about a critical x-ray result but she did not review it until the next morning. She stated Resident #1's stat x-ray results were not received until after Resident #1 was sent to the hospital. She stated the facility had not in-serviced on pain management or x-ray services since 02/24/24. Facility was unable to provide any in-service on X-ray services per DON on 07/16/24. Review of X-ray Company N's Contract with Facility effective 12/01/19 reflected C. Provider shall perform the service required hereunder in accordance with: I. All applicable federal, state, and local laws, rules and regulations. II. All applicable standards of all relevant accrediting organizations, and III. All applicable policies, rules and regulations. The facility did not have a policy for X-ray services per DON on 07/16/24. An Immediate Jeopardy was identified on 07/17/24. The Administrator and the DON were notified on 07/17/24 at 12:15 PM of the Immediate Jeopardy. IJ template provided at this time and plan of removal was requested. The facility's plan of removal was accepted on 07/18/24 at 3:49 PM. The accepted plan of removal for the Immediate Jeopardy included the following: Problem: Radiology (F776) The facility failed to ensure an x-ray was completed in a timely manner for a resident who sustained an injury/pain from a fall. The facility failed to follow up to get the results for a stat x-ray for a resident who sustained injury/pain from a fall in a timely manner. The facility failed to follow their policy for x-rays with residents who sustain an injury/pain with a fall. Plan: 11. [Physician C], Medical Director has been notified of the Immediate Jeopardy by the Administrator on 07/17/2024. QAPI was conducted with the medical director. 12. Administrator/Designee initiated in-service on abuse and neglect on 07/17/24. 13. Regional Nurse to educate DON regarding assessing residents for pain after an incident, ordering STAT X-ray, completion, and follow-up of X-ray. Education includes obtaining order for X-ray, entering order in EHR/Matrix, sending the resident to the ER for evaluation if in-house X-ray cannot be obtained timely. Completion: 7/17/2024 14. DON/Designee initiated in-services on 07/17/24 with charge nurses/agency nurses on how to order a STAT X-ray, timely follow-up on X-rays related to X-ray completion and results which should be obtained within four hours when related to injury/pain, if longer than four hours resident(s) need to be transported to emergency room per physician's order. 15. In-service charge nurses/agency nurses on notification to the DON/designee after hours and on weekends related to resident falls and results of pending X-rays initiated on 07/17/24. Completion: 07/17/24 16. Audit was completed on X-rays ordered in the last 30 days. Completion: 07/17/2024 17. Charge nurses, agency nurse/aides, and certified staff not working during the in-services on X-rays, will be in-service prior to their next scheduled shift. Staff will not be allowed to work until in-service is complete. Newly hired staff will receive the in-services during their orientation period. 18. The weekend supervisor was in-service monitoring the Facility Activity Report and follow-up on orders i.e, X-ray, and residents with pain. Completed: 07/17/24 19. Monitoring will occur during the clinical morning meeting Monday through Friday; weekend supervisor will review the Facility Activity Report for resident falls and new orders. If concerns are noted by the weekend supervisor the DON will be contacted. The DON will be responsible and monitor residents' post fall with major injury for timely completion of X-ray and results. 20. Facility charge nurses and agency nurses will be given a competency-based quiz on following physician orders. Completion: 7/18/24 The facility's implementation of the IJ Plan of Removal was verified through the following: Review of facility's in-service initiated for 07/17/24 reflected CNAs, nursing and nursing administration (ADON, Weekend RN Supervisor and DON) were in-serviced on pain management, nursing documentation about pain assessment, notification to physician when exhibit change of condition of pain onset, following physician orders for pain medication and x-ray orders, and laboratory, diagnostic and radiology services timeliness. On 07/19/24 between 10:55 AM and 6:51 PM revealed four (4) licensed vocational nurses were interviewed, from different shifts, on training and new system to ensure compliance for pain management. All nursing staff were able to verbalize understanding of how to assess for pain for residents with nonverbal indicators to use painad scale and give examples of pain indicators for nonverbal residents. Nursing was in-serviced on training regarding stat x-rays to be completed in timely manner and to follow up to get results in a timely manner. They were knowledgeable of expectation of physician's orders for x-rays that they needed to obtain x-ray orders and contact x-ray company to follow the physician x-ray orders. Nursing were knowledgeable on inputting physician orders for x-rays and to notify physician if there is a delay in stat x-ray services. Nursing stated if resident showed increasing signs of pain since unwitnessed fall and/or pain during movements they would send resident out to hospital for further evaluation. They would contact ADON, DON or weekend RN supervisor if having issues with x-ray services. Nursing aware of time for completion of stat x-rays to be with 4 to 6 hours and to follow up if results of stat x-ray have not been received. Interview on 07/19/24 with ADON at 4:45 PM revealed LVN B is currently on leave and she will be in-serviced 1:1 about pain management and x-ray services timeliness. She stated she was responsible to ensure new nurses were in-serviced going forward prior to working the floor on pain management and x-ray services. She stated her and the DON have incorporate a tool of auditing residents sent to hospital and x-ray services to ensure timeliness of stat x-rays ordered. She stated they have not in-serviced LVN A yet and will be doing a 1:1 inservice with her about pain management, documentation and x-ray services timeliness. She stated all current staff have been in-serviced and she will be working this weekend to ensure all nursing are in-serviced. She stated at morning meeting they will discuss any residents sent to the hospital, any concerns with pain management and x-ray services. She stated RN weekend supervisor will be overseeing on the weekends to ensure pain management and x-ray services are addressed. She stated the DON is out today due to personal leave. She stated her and the DON will be notified of any critical x-ray lab results and will look at them immediately then they will contact the charge nurse to follow up to ensure nursing is addressing resident needs. On 07/19/24 at 7:03 PM, the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a scope of pattern that is not immediate jeopardy and severity level of potential for more than minimal harm. The facility needs to ensure in-service training and evaluate the effectiveness of the corrective systems for diagnostic services. 49427