Every finding on record at Avir at Kerrville

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 8 residents (Residents #31, #45, #3) reviewed for medications in that:1.Resident #31's ordered Tizanidine HCI, Baclofen, and Levetiracetam medications were late on 8/25/2026 2.Resident #45's ordered Sodium Chloride, Gabapentin, Bupropion HCI ER medications were late on 8/25/20263. Resident #3's ordered Baclofen medications were late for 8/25/2026.This failure could affect all residents' orders for medications and could result in missed doses and harm. The Findings: 1.Record review of Resident #31's admission record dated 8/28/2026 revealed he was admitted [DATE] with diagnoses of chronic pain syndrome, cramp and spasm and epilepsy (chronic neurological brain disorder characterized by recurring, unproked seizures caused by sudden burst of abnormal electrical activity in the brain). Record review of Resident #31's consolidated orders for August 2026 reflected he had the following orders for 8/25/2026:a. Tizindine HCI oral tablet 4 mg, give 1 tablet by mouth two times a day related to chronic pain syndrome. b. Baclofen oral tablet 10 mg, give 1 tablet by mouth three times a day related to cramp and spasm.c. Levetiracetam oral tablet 100 mg, give 1 tablet by mouth two times a day related to epilepsy.Record review of Resident #31's Medication Administration Audit Report dated 8/25/2026 reflected: a. Tizindine HCI oral tablet 4 mg, give 1 tablet by mouth two times a day related to chronic pain syndrome order for 7:30AM and did not administer until 1:48 PM.b. Baclofen oral tablet 10 mg, give 1 tablet by mouth three times a day related to cramp and spasm was ordered to administer at 8 AM, and he was not administered the medications until 1:48 PM.c. Levetiracetam oral tablet 100 mg, give 1 tablet by mouth two times a day related to epilepsy. Ordered to administer at 9:30 am, and he was not administered the medication until 1:48 PM.Interview on 8/27/2026 at 11:27 AM with Resident #31 stated his medications were late today, he notified the charge nurse (but was not sure of name). Resident #31 did not have any negative effects. 2. Record review of Resident #45's admission Record dated 8/28/2026 revealed, she was admitted on [DATE] with diagnoses of hypothyroidism (a common medical condition where your thyroid gland does not produce enough thyroid hormones to meet your body's needs, chronic pain syndrome, anxiety disorder and depression (a common and serious mood disorder that causes a persistent feeling of sadness, emptiness, and a loss of interest or pleasure in daily activities).Record review of Resident #45's consolidated orders for August 2026 reflected she had the following orders for 8/25/2026:a. Sodium Chloride oral tablet, give 1 gram by mouth two times a day for low sodium level related to hypothyroidism.b. Gabapentin oral tablet 600 mg, give 1 tablet by mouth three times a day related to chronic pain syndrome.c. Bupropion HCI ER oral tablet extended release 12 hour 150 mg, give 1 tablet orally two times a day related to anxiety disorder and depression. Record review of Resident #45's Medication Administration Audit Report dated 8/25/2026 reflected. Sodium Chloride oral tablet, give 1 gram by mouth two times a day for low sodium level related to hypothyroidism, this medication was ordered for 7:30 AM, it was administered at 11:29 AM.Gabapentin oral tablet 600 mg, give 1 tablet by mouth three times a day related to chronic pain syndrome, this medication was ordered for 7:30 AM, it was administered at 11:26 AM.Bupropion HCI ER oral tablet extended release 12 hour 150 mg, give 1 tablet orally two times a day related to anxiety disorder and depression, this medication was ordered for 8:00 AM, it was administered at 11:35 AM.Interview on 8/25/2026 at 11:15 AM with Resident #45 stated her medications were late, and she did talk to staff. Resident #45 stated she did not have any negative effects. 3.Record review of Resident #3's admission Record dated 8/28/2026 reflected he was [AGE] year-old, with diagnosis of muscle spasms.Record review of Resident #3's consolidated orders for August 2026 reflected what she had orders for 8/25/2026:Baclofen oral tablet 20 mg, give 20 mg by mouth three times a day related muscle spasms. Record review of Resident #3's Medication Administration Audit Report dated 8/25/2026 reflected: a. Baclofen oral tablet 20 mg, give 20 mg by mouth three times a day related muscle spasms, this medication was ordered for 8:00 AM, it was administered at 12:24 PM. Interview on 8/25/2026 at 11:26 AM, the RN stated the residents #31, #45, #3 medications should be administered at 9:00 am. The RN stated a nurse did not show up for work today. Interview on 8/27/2026 at 5:01 PM with the DON stated she was aware that Resident #31, # 45, #3's medications were administered late. The DON stated the nurse called in sick and had to be replaced. The DON stated she was responsible for all the nursing task in the facility. The DON stated residents #31, #45, and #3 did not have any adverse effects. The DON stated this could affect residents by not feeling well and potential negative side effect. The DON had no other comments. The DON stated the physician was notified and residents were reassessed with no negative side effects. No other comments. No policy was provided.

Based on interviews and record reviews, the facility failed to ensure comprehensive care plans were developed within 7 days after completion of the comprehensive assessment for 4 of 8 (Residents #12, #31, #48, #66) residents in that:Residents #12, # 31, 48, and #66 did not have a care plan conference. This failure could affect all residents and could result in a decrease in resident care.The Findings: 1.Record review of Resident #12's admission Record dated 8/28/2026 revealed she was [AGE] years old. She was admitted on [DATE]. Resident #12 had diagnoses of muscle weakness, abnormal gait and mobility, need for assistance with personal care, depression and chronic pain.Record review of Resident #12's care plan was dated 6/1/2026. Record review of Resident #12's chart did not have a care plan conference. Record review of Resident #12's Quarterly MDS dated [DATE] revealed she had corrective lenses; she mobilized with a wheelchair and was dependent with ADLs.2. Record review of Resident #31's admission record dated 8/28/2026 revealed he was admitted , 4/10/2024 with diagnoses of lack of coordination, morbid obesity, cognitive communication deficit, anemia, retention of urine, ostomy, indwelling catheter and hand contracture. Record review of Resident #31's Quarterly MDS stated 7/25/2026 revealed he had a BIMS score of 12/15 (moderately cognitive impairment), ADLs he was dependent on for staff care, ostomy and indwelling catheter. Record review of Resident #31's care plan was dated 7/8/2026.Record review of Resident #31's last care plan conference was dated 3/11/2025. In an interview on 8/27/2026 at 11:26 AM, the SW stated she had not scheduled a care plan conference for Resident #31 at this time. The SW was new and was not sure when the last care plan conferences were dated. In an interview on 8/27/2026 at 4:01 PM, the Corporate MDS stated resident care plans were due quarterly and was not sure why Residents #12, #31, #48, #66 had not been completed for residents. The Corporate MDS staff stated this facility had struggled with keeping staff. 3.Record review of Resident #48's admission Record dated 8/28/2026 reflected 81year old female, was admitted on [DATE] with diagnoses of cognitive communication deficit and bipolar disorder (a lifelong mental health condition that causes extreme shifts in mood, energy, activity level and the ability to focus) Record review of Resident #48's Quarterly MDS dated [DATE] reflected her BIMS score was 10/15, moderate cognitive impairment. The Quarterly MDS reflected in section I Active Diagnoses: Bipolar Disorder.Record review of Resident #48's Care plan dated 8/31/2026 reflected diagnoses of cognitive communication deficit. No care plan for bipolar disorder, and personal refrigerator. Record review of Resident #48's chart had no documentation of care plan meetings. In an interview on 8/27/2026 at 10:58 AM with Resident #48 stated she had maybe 2 meetings, but was not sure, since she has been admitted to facility. Resident #48 stated she was not invited to the care plan meeting every 3 months. In an interview on 8/27/2026 at 3:31 PM the SW confirmed Resident #48 had no care plan conferences in her chart. 4.Record review of Resident #66's admission Record dated 8/28/2026 revealed the resident was admitted on [DATE] with diagnoses of spinal stenosis (narrowing of open spaces within the spine that puts pressure on the spinal cord and nerves), major depressive disorder (is a serious mood disorder that causes persistent feeling of sadness, emptiness, and a loss of interest in activities), acute bronchitis, need for assistance with personal care, Diabetes II, and cognitive communication.Record review of Resident #66's PPS MDS dated [DATE] reflected he had lower extremity impairment on one side and required partial supervision for his ADLs.Record review of Resident #66's care plan dated 7/1/2026.Record review of Resident #66's chart last care plan conference was dated 3/4/2026.In an interview on 08/27/2026 at 3:28 PM the SW stated she was new to the facility and was responsible for putting the care plan together. She said she does type out summaries of care plan meetings in the resident charts. The SW stated she had not had a chance to audit all residents for care planning meetings. The SW was documenting care plan meeting as the resident MDS/Care plan were due. The SW confirmed she could not find care plan conferences documented for Residents #12, # 31,#48, and #66.In an interview on 8/27/2026 at 4:06 PM the corporate MDS LVN stated she was not able to find care plan conference for Residents #12, #31,#48, and #66. The care plan conferences should be completed quarterly. Interview on 8/28/2026 at 2:34 PM the ADM stated he was not aware the residents were not offered care plan conferences. The ADM stated if the residents were not offered care plan conferences that could affect resident care and direction the facility should proceed. Record review of the policy for Care Plans, Comprehensive Person-Centered dated 2001 reflected for A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the residents' physical, psychosocial and functional needs is developed and implemented for each resident. 1 a comprehensive, person centered care plan is developed within seven days of the completion of the required MGS assessment and no more than 21 days after admission.4. Each residence comprehensive person centered care plan is consistent with the residents rights to participate in the development and implementation of his or her care plan of care, including the right to; Participate in the planning process, identify individuals or goals to be included., request meetings, request revisions to the plan of care, participate in establishing the expected goals and outcomes of care, participate in determining the type, amount, frequency and duration of care, receive the services and or items included in the plan of care and see the care plan & sign after significant changes are made. 12. The disciplinary team reviews and updates the care plan; When there has been a significant change in the residence condition; at least quarterly, in conjunction with required for the MBS assessment.

Based on interviews and record reviews the facility failed to ensure facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 2 of 8 (Residents #48,#11) resident with possible PASARR diagnoses, in that:1. The facility failed to submit an accurate PASARR level 1 for Resident #11.2. The facility failed to submit an accurate PASARR level 1 for Resident #48.This failure could affect all residents and could result in a decrease of potential services. The Finding: 1. Record review of Resident #11 Face Sheet, dated 08/25/2026, revealed an admission date of 08/29/2025 and diagnosis including Post-Traumatic Stress Disorder(a mental health condition that can develop after you experience or witness a life-threatening or deeply stressful traumatic event), Depression (a common, serious mood disorder that causes a persistent feeling of sadness and loss of interest in life), Anxiety (Chronic, exaggerated worry about everyday events and activities), and Diabetes Mellitus (a chronic health condition where your body cannot properly process sugar from the food you eat because it either does not make enough insulin or cannot use insulin correctly). Record review of Resident #11 Quarterly MDS, dated [DATE], revealed a BIMS score of 99, indicating that the BIMS test was not completed or the patient chose not to participate. Record review of Resident #11 Care Plan, dated 07/01/2026, revealed cognitive deficits, self-care deficits, resistance to care, risk for falls, and mood disturbances related to post-traumatic stress disorder. Record review of Resident #11 Level 1 PASRR screening that was completed by the referring entity on 08/29/2025 indicated in section C0100 there was no evidence of this individual having mental illness. During an interview on 08/29/2026 at 11:49 AM, the Regional Reimbursement Nurse (RRN) revealed that Resident #11 should have had a positive PASRR due to the diagnosis of Post-Traumatic Stress Disorder. RRN revealed that a PASRR Evaluation should have been completed to see if Resident #11 qualified for additional services. PASRR guidelines for Health and Human Services dated June 2023 state that if a resident has a diagnosis for mental illness, a PASRR level II must be completed by appropriate entity. PASRR guidelines list post-traumatic stress disorder as a qualifying diagnosis to initiate this next step. 2.Record review of Resident #48's admission Record, dated 8/28/2026, reflected an 81year old female, was admitted on [DATE] with diagnoses of cognitive communication deficit and bipolar disorder (a lifelong mental health condition that causes extreme shifts in mood, energy, activity level and the ability to focus). Record review of Resident #48's consolidated orders for August 2026 reflected she was ordered lamotrigine oral tablet for bipolar disorder. Record review of Resident #48's Quarterly MDS dated [DATE] reflected that her BIMS score was 10/15 indicating moderate cognitive impairment. The Quarterly MDS reflected in section I Active Diagnoses: Bipolar Disorder. Record review of Resident #48's Care plan dated 8/31/2026 reflected diagnoses of cognitive communication deficit. There was no care plan for bipolar disorder. Record review of Resident #48's PASARR level 1 was dated 11/14/25 was negative, this form was filled by a hospital. No other PASARR was in Resident #48's chart. In an interview on 8/27/2026 11:12 AM, the corporate MDS nurse stated Resident #48's diagnosis was Bipolar. The Corporate MDS nurse stated when Resident #48 was admitted on [DATE] the PASARR level 1 was negative, this was filled out by a hospital, before admitting to this facility. The corporate MDS nurse stated it should have been positive on PASARR 1 due to Resident #48's diagnosis of bipolar disorder. Interview on 8/28/2026 at 2:34 PM the ADM stated Resident #48's diagnosis was missed for PASARR level 1. No staff looked at PASARR when Resident #48 was admitted to check her diagnoses, to see if she was a candidate for PASARR services. The ADM stated he was not aware of the missed PASARR level 1 for Resident #48. The ADM stated he would make sure care was given to residents according to their needs. Record review of PASRR guidelines for Health and Human Services dated June 2023 state that if a resident has a diagnosis for mental illness, a PASRR level II must be completed by appropriate entity. PASRR guidelines list post-traumatic stress disorder as a qualifying diagnosis to initiate this next step.

Based on observation, interview, and record review, the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 1 of 8 (Resident #48) personal refrigerator in that: The facility failed to ensure Resident #48's personal refrigerator's ice box was no frozen with a chunk of ice around it on 8/25/2026 and 8/27/2026.This could place residents at risk to get sick with food borne illnesses.Findings included:Record review of Resident #48's admission Record, dated 8/28/2026, reflected an 81year old female, admitted on [DATE], with diagnose of cognitive communication deficit.Record review of Resident #48's Quarterly MDS Assessment, dated 6/19/2026, reflected her BIMS score was 10/15, indicating moderate cognitive impairment. Record review of Resident #48's Care plan, dated 8/31/2026, reflected diagnose of cognitive communication deficit.Observation on 8/25/2026 at 10:59 AM in Resident #48's room revealed she had a personal refrigerator and the ice box was frozen with a chunk of ice around it. Observation on 8/27/2026 at 10:42 AM, Resident #48's personal refrigerator's ice box was frozen with a chunk of ice around it. In an interview on 8/25/2026 at 11:00 AM, Resident #48 stated this was her personal refrigerator that she kept snacks in. Resident #48 stated the ice box had been frozen over for a while and she was not sure who was responsible for cleaning the refrigerator. Resident #48 stated she tried to clean it out but was not able to clean the frozen chunk of ice due to decrease in physical ability. Resident #48 was not able to use the freezer department due to a chunk of ice blocking the ice box shelf.In an interview on 08/26/2026 at 3:01 PM, the ADM stated staff were responsible for keeping residents' personal refrigerators clean and defrosted. The ADM stated staff needed to maintain a quality environment for residents. The ADM stated there were 7 total resident personal refrigerators. Record review of the facility policy, Refrigerators and Freezers, dated November 2022, reflected, This facility will ensure safe refrigerator and freezer maintenance, and sanitation and will observe food expiration guidelines. 10. Supervisors inspect refrigerators and freezers monthly for guest additions, bad condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately. Maintenance schedules per manufacturing guidelines are scheduled and followed. 11. Refrigerators are kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more often as necessary. Record review of the facility policy entitled, Food Receiving and Storage, dated 2001, revealed foods shall be received and stored in a manner that complies with safe food handling practices and that foods were covered, labeled, dated and monitored to ensure safe food handling practices.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed for food safety requirements. The facility failed to store food in accordance with professional standards for food service safety. This failure could place residents at risk for the spread of food borne illness.The findings included:Based on observation on 08/25/2026 at 10:12am, the refrigerator's in the facility kitchen revealed that no dates were present on a container of yogurt, lemon juice, package of ham, container of relish and a container of sour cream.Based on observation on 08/25/2026 at 10:25am, the freezer's in the facility kitchen revealed that no dates were present on a package of turkey breast, and 3 containers of pesto sauce. The observation of the freezer also revealed that a container of mixed vegetables, a container of corn, a container of biscuits, a container of sausage links and a container of dough were not sealed correctly and left open within the freezer.Based on observation on 08/25/2026 at 10:35am, the facility's dry storage room revealed no dates present on a container of icing, fry oil, pancake syrup, a container of organic protein and potato pearls. The observation of the dry storage room also revealed the scoop for the container of flour was left in the flour, versus stored in container or bag outside of the flour.During an interview on 08/25/2026 at 10:35am, the DM stated that all food items in the kitchen should have an expiration or use by date on them. The DM stated that not having the expiration or use by date could lead to food borne illness amongst the residents. The DM also stated that all food items should be sealed appropriately.During an interview on 08/26/2026 at 1:45pm, the ADMIN stated that items in the kitchen were to be labeled, dated and sealed per regulation to prevent food borne illnesses.During an interview on 08/27/2026 at 7:05am, [NAME] A stated that all items in the kitchen needed proper labeling and dates and this prevented residents from getting expired food and getting sick.Record review of the facility policy entitled, Food Receiving and Storage. dated 2001, revealed foods shall be received and stored in a manner that complies with safe food handling practices and that foods were covered, labeled, dated and monitored to ensure safe food handling practices.

Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 3 of 16 residents (Resident #48, Resident #45, and Resident #78), and 1 of 1 meal reviewed for palatability and attractiveness. The facility failed to provide food that was palatable and attractive for residents.This failure could place residents at risk of a decrease in food intake, hunger, and unwanted weight loss. The findings included: Record review of Resident #78's Face Sheet, dated 08/27/2026, revealed an [AGE] year-old female that admitted on [DATE] with diagnosis including Gastro-esophageal Reflux Disease (a chronic digestive condition where stomach acid frequently flows back into the tube connecting your mouth and stomach, known as the esophagus), Polyneuropathy (a medical condition where many peripheral nerves throughout the body malfunction at the same time), and Dysphagia following Cerebral Infarction (trouble swallowing after a stroke). Record review of Resident #78's Quarterly MDS Assessment, dated 08/27/2026, revealed a BIMS score of 14, indicating normal thinking and memory skills with little to no cognitive impairment. Record review of Resident #78's Care Plan, date 08/23/2026, revealed monitoring for swallowing, fall risk, and pain management. Record review of Resident #78's Physician Order Summary Report, dated 08/26/2026, revealed Resident #78 was ordered a regular diet, oxygen as needed, and dietician consult. During an observation on 08/26/2026 at 12:33pm, mixed vegetables and okra were served in the dining room for lunch, and a sample tray was requested from kitchen. The sample of vegetables served on 08/26/2026 at lunch revealed a mixed combination of vegetables, to include corn, green beans, peas and lima beans. The mixed vegetables did not have any seasoning or flavor added to them. Upon sampling the mixed vegetables, they tasted as though there was no salt, pepper, or any additional seasoning added during it's cooking. Sample of okra revealed, when the lid was removed, a clear, viscous fluid that stretched from the top of the okra in the bowl to the lid as it was removed, in multiple strands. The lid was placed back on the okra container and shook to assess if this helped with the fluid sitting on top of the okra. When lid removed from okra bowl again, the clear, viscous fluid was still present and stretching from top of okra in bowl to the lid. During an interview on 08/26/2026 at 9:0am, Resident #78 revealed that there was an issue with the food from the kitchen. Resident #78 revealed that the vegetables were either over- or undercooked and that the okra specifically was slimy when they received it. Resident #78 revealed that other than the vegetables the food is okay. Resident #78 stated that they had shared these concerns with management previously. During an interview on 8/27/2026 at 10:42 AM with Resident #48 stated the food does not look appealing, does not look appetizing, smells really bad, and vegetables are way overcooked. The vegetables are mushy, its not pleasant to eat and saturated with water. During an interview on 8/27/2026 at 10:37 AM with Resident #45 stated the food does not look palatable or attractive enough to eat and family brings her food. During an interview on 8/27/2026 at 3:41 PM with the SW stated resident complaints that the food is not good, SW talks to the dietary manager, and had gotten those complaints from residents. During record review on 08/27/2026 revealed that facility's policy titled Food and Nutrition Services, dated 2001, stated that each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

Based on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater. A total of 6 errors out of 25 opportunities were observed, resulting in a 24% error rate for 1 of 4 residents (Resident #66) reviewed during medication pass, in that: LVN D failed to administer Resident #66's medications at the correct time. This failure could place residents at risk for not receiving the intended therapeutic benefits of their medications and exacerbation of their medical conditions. Findings included:Record review of Resident #66's Face Sheet dated 08/28/2026, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included spinal stenosis (narrowing of space within the spinal canal), major depressive disorder (a mood disorder characterized by persistent feelings of sadness and loss of interest), gastro-esophageal reflux disease (when stomach acid flows back up into the tube connecting the mouth and stomach), age-related osteoporosis (bones become weak and brittle), and allergic rhinitis (inflammation or irritation of mucous membranes that line the nose).Record review of Resident #66's BIMS Evaluation, dated 5/15/2026, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition.Observation of medication pass with LVN D on 08/26/2026 which began at 9:30 a.m. and record review of Medication Admin Audit Report dated 8/27/2026 revealed 6 medications were administered for Resident #66 more than two hours after ordered time of 7:30 a.m. 1. Buspirone HCL oral Tablet 5mg. Give 1 tablet by mouth two times a day related to Major Depressive Disorder. Schedule date: 08/26/2026 at 07:30, Administration date: 08/26/2026 at 09:37. 2. Protonix Oral Tablet Delayed Release 40mg. Give 1 tablet by mouth two times a day for GERD. Schedule date: 08/26/2026 at 07:30, Administration time: 08/26/2026 at 09:37. 3. Calcium 600+D3 Oral Tablet 600-5mg-mcg. Give 1 tablet by mouth two times a day for supplement. Schedule date: 08/26/2026 at 07:30, Administration time: 08/26/2026 at 09:37. 4. Vascazan Oral Capsule 1GM. Give 2 capsule by mouth two times a day for supplement. Schedule date: 08/26/2026 at 07:30, Administration time: 08/26/2026 at 09:37. 5. Mucinex Oral Tablet Extended Release 12-hour 600mg. Give 1 tablet by mouth two times a day for mucus. Schedule date: 08/26/2026 at 07:30, Administration time: 08/26/2026 at 09:37. 6. Azelastine HCL Nasal Solution 137mcg/spray. Schedule Date 08/26/2026 at 07:30, Administration date: 08/26/2026 at 09:37. During an interview with LVN D on 08/26/2026 at 9:45 a.m. she stated the reason the 7:30 a.m. medications for Resident #66 were late and showing as red on the eMAR was because she arrived at the facility late and this was her first time working in this facility. LVN D stated the consequences of medications being administered late were that the medication was not being administered when the doctor ordered it and the resident could end up getting meds too close together or at the same time. During an interview with Resident #66 on 08/26/2026 at 9:40 a.m., the resident stated that unfortunately, his medications were sometimes given to him late, but he has not suffered any adverse effects because of it. Resident #66 stated he was on his way out to an appointment and wanted his 7:30 a.m. medications before he left, even though they were late.During an interview with the DON on 08/27/2026 at 1:40 p.m., she stated that medications administered late were a medication error and her expectation was that medications are administered on time according to physician orders. Record review of the facility policy titled Administering Medication, dated April 2019, revealed, 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medication are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview, and record review the facility failed to ensure residents who need respiratory care were provided with such care, consistent with professional standards of practice for 2 (Residents #2 and #65) of 3 residents reviewed for respiratory care.1. Resident #2 was receiving oxygen therapy without a physician's order.2. Resident #65's oxygen tubing and nasal cannula were not covered in a plastic bag when it was not being used on 8/25/2026.This failure could place residents receiving oxygen at risk for incorrect oxygen administration and infection.The findings included:1. Record review of Resident #2's Face Sheet dated 8/26/2026, reflected a [AGE] year-old female admitted on [DATE]. Diagnoses included atherosclerotic heart disease of native coronary artery (caused by plaque buildup in arterial walls).Record review of Resident #2's admission MDS assessment, dated 7/16/2026, revealed the resident's BIMS score was 13 out of 15 which indicated the resident's cognitive was intact. The use of oxygen was not identified on the admission MDS.Observation and interview of Resident #2 on 08/25/2026 at 10:30 a.m., revealed resident receiving oxygen via nasal cannula at 2L/min. Resident stated she has been on oxygen for a few weeks now to help her breathe.Record review of Resident 2's Order Summary Report dated 8/26/2026, revealed there was no active order for oxygen administration.During an interview with the DON on 8/27/2026 at 1:40 p.m., she was unable to locate an order for oxygen for Resident #2. The DON stated she does not know when or why the resident began using oxygen.During interview with LVN C on 8/27/2026 at 1:49 p.m., she stated she did not know the resident did not have an active order for oxygen administration. LVN C stated Resident #2 had been receiving oxygen since she began working at facility several weeks ago. 2. Record review of Resident #65's Face Sheet dated 8/27/2026 reflected an [AGE] year-old male originally admitted on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia(low levels of oxygen in body tissues), and chronic obstructive pulmonary disease (lung and airway diseases that restrict breathing).Record review of Resident #65's quarterly MDS dated [DATE], revealed the resident's BIMS score of 15 out of 15 indicating intact cognition and Section O-Special Treatment, Procedures, and Programs, Respiratory Treatments: C1 Oxygen therapy indicated resident was receiving oxygen.Record review of Resident #65's Order Summary Report dated 8/27/2026, reflected an active order Oxygen at 2 LPM via N/C every shift for SOB and to maintain pulse ox >90% dated 6/12/2026.Observation on 8/25/2026 at 10:15 a.m., Resident #65 had an oxygen concentrator next to the bed with oxygen tubing and nasal cannula lying on top of concentrator. No bag was observed to store oxygen in when not in use.During an interview with LVN C on 8/25/2026 at 12:10 p.m., the LVN stated the oxygen tubing, and nasal cannula should be in a bag, and she does not know why it wasn't. LVN C stated she was responsible for making sure it was bagged when not in use because she was the charge nurse on the hall. The LVN stated if tubing and nasal cannula were left out, there was risk of contamination and possible infection.Observation and interview with Resident #65 on 8/26/2026 at 8:00 a.m., a plastic bag was observed on top of the oxygen concentrator. The resident stated he did not know what the bag was for, and nobody explained it to him, someone just left it there and he has never had one before. During an interview with the DON on 8/28/2026 at 11:15 a.m., the DON stated her expectation was that oxygen tubing and nasal cannula are bagged when not in use. The DON stated night shift nurses were responsible for replacing oxygen tubing and bags and Angel Rounds were conducted each day so that missing equipment can be identified and concerns brought to the morning meeting.Record review of the policy titled Oxygen Administration dated October 2010, Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders, facility protocol for oxygen administration.

Based on interviews and record reviews, the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents (Resident #2) reviewed for pressure ulcers. The facility failed to implement treatment orders for Resident #2's wound to left heel. This failure could hinder the healing of the residents' existing pressure ulcer.The findings included:Record review of Resident #2's Face Sheet dated 8/26/2026, reflected a [AGE] year-old female admitted on [DATE]. Diagnoses included unspecified open wound, left lower leg.Record review of Resident #2's admission MDS assessment, dated 7/16/2026, revealed the resident's BIMS score was 13 out of 15 which indicated the resident's cognitive was intact. Record review of Resident #2's Wound Assessment Report dated 8/20/2026, reflected a left heel unstageable pressure ulcer present upon admission on [DATE]. Description of the left heel pressure ulcer: Length 4.00cm, width: 4.00cm, depth 0.10cm, 100% stable eschar (thick layer of dead tissue that adheres to wounds). Treatment: cleanse with wound cleanser, apply Betadine, leave open to air daily and PRN.Record review of Resident #2's Order Summary Report dated 8/26/2026 revealed no active order for treatment to the left heel unstageable pressure ulcer.Record review of Resident #2's Treatment Administration Record dated 8/27/2026, revealed no order for treatment to the left heel nor documented treatment having been administered.During interview with Resident #2 on 8/25/2026 at 10:30 a.m., the resident stated she has wounds to her left leg and foot and the nurse comes to provide care every day.During interview with the Wound Care NP on 8/27/2026 at 1:25 p.m., the NP stated she comes weekly to assess Resident #2's wounds including the unstageable pressure ulcer to her left heel. The NP stated the resident's wound was stable and the facility nurses wrap the resident's left leg and foot wounds leaving the pressure wound on the left heel exposed to air. The NP stated she believes the facility was performing treatment on the wound because when she comes to assess it, it was orange in color from Betadine. The NP stated she has no concerns about care provided at the facility and that Resident #2's wound was not declining or showing signs of infection at this time.During interview with the DON on 8/27/2026 at 1:40 p.m., the DON was unable to locate an active order for wound care to Resident #2's left heel unstageable pressure ulcer. The DON stated it was the responsibility of the wound care nurse to communicate orders from the wound care NP and enter those orders which were then checked by the nurse managers the following morning, however; the wound care nurse recently left the position. The DON stated they were currently training a new wound care nurse.Record review of the policy titled Wound Care dated October 2010, Preparation: #1. Verify that there is a physician's order for this procedure.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 3 residents (Residents #4 and #13) reviewed for infection control.The facility failed to ensure staff performed proper hand-hygiene and glove changes when providing personal care for Resident #4.The facility failed to ensure staff performed proper hand-hygiene when providing personal care for Resident #13.This failure could place residents at risk for the spread of infection. The findings included:1. Record review of Resident #4's Face Sheet, dated 8/27/2026, reflected an [AGE] year-old male readmitted to the facility on [DATE] with an initial admission date of 08/20/2024. Diagnoses included neuromuscular dysfunction of bladder (a condition where nerve or muscle damage that control the bladder prevents it from properly storing or emptying urine).Record review of Resident #4's Care Plan Report, reflected focus: The resident has Foley Catheter, initiated 04/21/2026 and goal: The resident will show no s/sx of urinary infection through the review date.Record review of Resident #4's Order Summary Report, dated 8/28/2026, reflected the following physician's order dated 4/29/2026: Foley cath care q shift and PRN.During an observation of catheter and incontinence care for Resident #4 on 8/26/2026 at 10:30 a.m., CNA A cleaned the resident's peri area and buttocks, but failed to remove soiled gloves, perform hand hygiene and apply clean gloves before applying a clean brief and adjusting the linens.During an interview with CNA A, on 08/26/2026 at 10:45 a.m., she stated she forgot to remove her gloves and perform hand hygiene before applying the clean brief to resident during care and that could cause the spread of infection.2. Record review of Resident #13's Face Sheet, dated 8/26/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease (a progressive brain disorder that destroys memory, thinking skills and the ability to carry out simple tasks).Record review of Resident #13's admission MDS Assessment, dated 8/03/2026, reflected section H. Bowel and Bladder, Urinary Continence: 2. frequently incontinent and Bowel Continence: 2. frequently incontinent.During an observation of incontinence care for Resident #13 on 8/26/2026 at 10:50 a.m., CNA B cleaned the resident's peri area and buttocks, removed soiled brief, removed soiled gloves, but failed to perform hand hygiene before applying clean gloves.During an interview with CNA B on 8/26/2026 at 11:10 a.m., she stated she forgot to wash her hands before putting on clean gloves and that could result in cross-contamination and it was infection control.During an interview with DON on 8/28/2026 at 12:45 p.m., the DON stated it was her expectation that staff perform hand hygiene and change their gloves during incontinence care and catheter care at the appropriate times to prevent UTIs.Record review of the facility policy titled, Standard Precautions, dated September 2022, indicated, 1. Hand hygiene b. Hand hygiene is performed with ABHR or soap and water: (3) before moving from work on a soiled body site to a clean body site on the same resident.

Based on interviews and record reviews, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 8 (Residents#3, #48) residents reviewed in that: 1.Resident #3 did not have a care plan for hospice services.2. Resident #48 did not have a care plan for her diagnosis of Bipolar and having personal refrigerator. This failure could affect all residents and could result in residents not being provided with care. The Findings:1. Record review of Resident #3's admission Record dated 7/22/2025 reflected he was a [AGE] year-old, with diagnoses of Parkinson's Disease (is a movement disorder of the nervous system that worsens over time. The nervous system is a network of nerve cells that controls many parts of the body, including movement.) and personal history of traumatic brain injury. Record review of Resident #3's consolidated orders for August 2026 reflected he had an order for hospice services for diagnoses of Parkinson's disease, with an admit date of 7/15/2026. Record review of Resident #3's Comprehensive MDS dated [DATE] reflected he was on hospice service. No other MDS was submitted for a significant change. Record review of Resident #3's care plan dated 7/23/2026 did not address hospice services. In an interview on 8/27/2026 at 4:24 PM, the MDS corporate staff, (no MDS staff working at facility), stated she was not able to find a significant MDS that was completed for Resident #3. The MDS corporate staff stated this could affect care that was provided and Resident #3 should have a significant change MDS when he was admitted to hospice. The MDS corporate staff a significant MDS should be submitted within 14 days.Interview on 8/28/2026 at 2:34 PM, the ADM stated the MDS nurse should submit a significant MDS for residents that were provided with hospice services. The ADM stated there was not an MDS nurse employed at the facility and the corporate nurse was filling in. The ADM stated that with no significant MDS, this could affect resident care. The ADM stated they follow the RAI. 2.Record review of Resident #48's admission Record dated 8/28/2026 reflected 81year old female, was admitted on [DATE] with diagnoses of cognitive communication deficit and bipolar disorder (a lifelong mental health condition that causes extreme shifts in mood, energy, activity level and the ability to focus). Record review of Resident #48's consolidated orders for August 2026 reflected she was ordered lamotrigine oral tablet for bipolar disorder. Record review of Resident #48's Quarterly MDS dated [DATE] reflected her BIMS score was 10/15, moderate cognitive impairment. The Quarterly MDS reflected in section I Active Diagnoses: Bipolar Disorder. Record review of Resident #48's Care plan dated 8/31/2026 reflected no care plan for bipolar disorder, and use of personal refrigerator. In an interview on 8/25/2026 at 11:00 AM, Resident #48 stated this was her personal refrigerator that she kept snacks in. In an interview on 8/27/2026 11:12 AM, the corporate MDS nurse stated Residents #3 and#48's care plan was not accurate. No other comments Record review of the policy for Care Plans, Comprehensive Person-Centered dated 2001 reflected for A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the residents' physical, psychosocial and functional needs is developed and implemented for each resident. 1 a comprehensive, person centered care plan is developed within seven days of the completion of the required MGS assessment and no more than 21 days after admission.4. Each residence comprehensive person centered care plan is consistent with the residents rights to participate in the development and implementation of his or her care plan of care, including the right to; Participate in the planning process, identify individuals or goals to be included., request meetings, request revisions to the plan of care, participate in establishing the expected goals and outcomes of care, participate in determining the type, amount, frequency and duration of care, receive the services and or items included in the plan of care and see the care plan & sign after significant changes are made. 12. The disciplinary team reviews and updates the care plan; When there has been a significant change in the residence condition; at least quarterly, in conjunction with required for the MBS assessment.

Based on observations, interviews and record reviews, the facility failed to ensure the Nurse Staffing Information contained resident census and maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater for 1 of 1 nursing home in that:The Nurse Staffing posting did not have the correct census for 3 days. The Facility failed to ensure they retained 10 months of Nurse Staffing posting.These failures could affect all residents and visitors and could result in not having who was working for the day, was not available to public to view.The Finding: Observation on 8/25/2026 at 10:56 AM the Nurse staffing posting did not have the correct census for the day Observation on 8/26/2026 at 12:30 PM the Nurse staffing posting had a census of 192.Observation on 8/27/2026 at 1:42 PM the Nurse staffing posting had a census of 174.In an interview on 8/27/2026 at 5:01 PM, the DON stated the staffing coordinator was responsible for posting the Nurse staffing data for the day. The DON confirmed the Nurse staffing postings had the incorrect census. DON and ADM was responsible for overseeing the staffing coordinator.In an interview on 8/27/2026 at 5:10 PM, the staffing coordinator stated she was new at posting daily Nurse staffing date and she only had this week's Nurse staffing posting. In an interview on 8/28/2026 at 2:34 PM, the ADM stated that he was not aware of the Nurse staffing posting census. The ADM stated the nurse staffing postings would make sure residents are aware of staffing. No other comments. The ADM stated no policy for Nurse Staffing Postings. Record review of resident list with census on 8/25/2026, and 8/27/2026 and 8/27/2026 was 64. Record review of Nurse Staffing postings reflected these dates 8/18/2026- 8/28/2026 for the 18 month retention.

Based on interviews and record review the facility failed to ensure that each resident had upon admission physician orders for the resident's immediate care, for 1 of 5 residents (Resident #1) reviewed for enteral feeding orders. LVN A failed to get a feeding order for Resident #1, who had a gastronomy tube, upon admission on [DATE], until the next afternoon, 7/28/2026. This failure could place residents at risk for delayed orders and care.The findings included: A record review of Resident #1's admission record dated 8/13/2026 revealed an admission date of 7/27/2026 with diagnoses which included cerebral infarction (stroke), dysphagia (medical term for difficulty or discomfort when swallowing foods, liquids, or saliva). A record review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted for activities of daily life and support with a gastronomy tube (a soft medical tube placed through the skin of the abdomen directly into the stomach. It delivers liquid food, fluids, and medicines when a person cannot safely or adequately eat by mouth). A record review of Resident #1's discharge orders, dated 7/20/2026, from the previous skilled nursing facility revealed gastronomy feeding orders which indicated Resident #1 was to receive a diabetic formula via a feeding pump continuously, Start continuous enteral feeding at 1200pm. Glucerna 1.2 @ [at] 70ml/hr with 200ml of h20 q4 hours. Feeding down time 4 hours. Feeding down time 0800-1200 sic[AM] one time a day related to cerebral infarction. Stop continuous enteral feeding at 0800am. Glucerna 1.2 @ 70ml/hr with 200ml of h20 q4 hours. Feeding down time 4 hours. Feeding down time 0800-1200 one time a day related to cerebral infarction. A record review of Resident #1's physician's orders dated 8/12/2026 revealed on 7/28/2026 the physician ordered Resident #1 to be fed by her gastronomy tube with a diabetic formula via a feeding pump; every shift for continuous enteral feeding (means giving food, liquids, or medicine directly into your digestive system [the stomach or intestines]). During an interview on 8/12/2026 at 5:02 PM LVN A Stated she was the admitting charge nurse for Resident #1 when she was admitted from another skilled nursing facility on the evening of 7/27/2026. LVN A Stated Resident #1 had a gastronomy tube and had a need to receive her hydration and nutrition through the tube. LVN A stated Resident #1 could not eat or drink normally because she had a swallowing problem and materials could go down her lungs from her throat. LVN A stated on the evening of 7/27/2026 she failed to get an order from the physician for Resident #1's feeding with a feeding pump. LVN A stated she recognized the failure on the morning of 7/28/2026 and asked LVN B for details of Resident #1's need for feeding, since LVN B was the admissions coordinator. During an interview on 8/12/2026 at 5:31 PM LVN B stated she was the admissions coordinator and on 7/28/2026 and around 8 AM LVN A approached her to inform her that Resident #1 had no feeding order. LVN B stated she assisted LVN A to call the physician and secure the order. LVN B stated she then notified the Administrator and the DON that Resident #1 had a need for a diabetic formula which the facility did not have in stock. LVN B stated the Administrator delivered the formula to LVN A. LVN B stated she assisted LVN A to set up the feeding pump for Resident #1 around 2 PM on 7/28/2026. During a joint interview on 8/13/2026 at 4:00 PM the Administrator and the DON stated on 7/28/2026 around 8:00 AM, they received a report from LVN A and LVN B that Resident #1 had an order for a diabetic enteral feeding via a feeding pump, however the facility did not have the diabetic formula in stock. The Administrator stated he partnered with a sister skilled nursing facility and purchased the diabetic formula and delivered the formula to LVN A within a couple of hours. The DON stated her expectation was for LVN B to have secured the diabetic formula prior to Resident #1's admission and they could have coordinated the formula delivery with LVN C who also had access to ordering supplies. The DON stated her expectation was for LVN A, upon admission of Resident #1 on the evening of 7/27/2026, to have secured an enteral feeding order for Resident #1 immediately upon admission. The DON stated the potential negative outcome for residents who did not receive immediate orders for their immediate needs upon admission was residents may not receive immediate care. The Administrator and the DON stated the facility follows HHSC guidelines. A record review of the facility's Physicians Orders policy dated November 2014, revealed, PurposeThe purpose of this procedure is to establish uniform guidelines in the receiving and recording of physician orders to ensure the resident receives the necessary care and services.Supervision by a Physician . Recording Orders . 11. admission orders- the licensed nurse will verify admission or readmission order with the physician or physician extender for all residents admitting or readmitting.

Based on observation, interviews, and record review the facility failed to ensure the assessment accurately reflected the resident's status for one (1) of five (5) residents (Resident #1) reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded on her Quarterly MDS assessment, dated 04/30/2026, for having had weight loss of 18.2%, ten percent (10%) or more in the last six (6) months. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: Record review of Resident #1's Face Sheet, dated 06/30/2026, revealed an [AGE] year-old female. She was admitted on [DATE] and readmitted on [DATE]. Record review of Resident #1's Diagnosis Report, dated 06/30/2026 revealed diagnoses included severe protein-calorie malnutrition (not eating enough protein and calories in the diet to meet the body's needs), dysphagia (difficulty swallowing), and muscle wasting and atrophy (the shrinking of muscle or nerve tissue). Record review of Resident #1's Quarterly MDS Assessment, dated 04/30/2026, revealed the assessment reference date and observation end date was 04/30/2026. The resident was rarely/never understood and had severe cognitive impairment with a memory problem. Under Section K - Swallowing/Nutritional Status of the MDS Assessment, Resident #1 was noted to have weighed 80 pounds on the most recent measure in the last 30 days. She was documented has having not lost or gained weight of 5% or more in the last month or 10% or more in the last 6 months. LPN A was noted to have completed Section K on 05/01/2026. The DON was noted to have signed the assessment as complete on 05/26/2026. Record review of Resident #1's Weight Summary, undated accessed 06/30/2026 at 12:01 p.m., revealed Resident #1 had a weight of 80.0 pounds on 04/09/2026. She did not have another weight on the record until 05/04/2026, after Resident #1's Quarterly MDS Assessment observation end date. She did not have a weight on record within one (1) month prior to 04/09/2026 with the closed weight recorded on 02/22/2026 (46 days prior). She had a weight of 97.8 pounds on 10/09/2025, indicating a 17.8 pound or 18.2% weight loss in six (6) months (10/09/2025 to 04/09/2026). During an observation and attempted interview with Resident #1 on 07/01/2026 at 09:37 a.m., Resident #1 was observed lying in bed with a sheet up to her shoulders. She appeared thin but weight status observation was obstructed by bed sheet. Resident #1 was uninterviewable. She nodded her head upon entry to her room but did not vocalize a response or nod her head in relation to the attempted conversation. During an interview on 07/01/2026 at 11:06 a.m., Resident #1's family member stated Resident #1 was placed on hospice care partially due to her declining weight status. During an interview on 07/01/2026 at 05:02 p.m., the DON stated the MDS was completed by a remote (a person who works in a different location) worker. The DON stated she did not know how the staff member, who was completing the MDS Assessments, was assessing the residents for weight changes. She stated an error in documenting a resident's weight change in the MDS would not impact the resident's care. She stated the documentation in the MDS Assessment was for facility revenue purposes. During an interview on 07/01/2026 at 05:42 p.m., LPN A stated she worked as a remote MDS nurse. She stated when reviewing resident weight changes, she would look for a five percent (5%) weight change in one (1) month or a ten percent (10%) weight change in six (6) months. She stated the error (not noting Resident #1 had significant weight loss) might have been due to oversight. She stated the information might have been entered into the MDS Assessment by another staff member and she might not have had all the information to review prior to having signed the section. She stated the error was an oversight for the resident's weight to not have been coded correctly prior to the assessment's submission. She stated it was the responsibility of the person submitting the information and the registered nurse that reviewed and signed the assessment as complete to ensure accuracy. She stated the error would not impact the resident's care but might impact the facility's reimbursement for Resident #1's care since the weight change might result in Resident #1 having been coded for a higher level of care need. During an interview on 07/01/2026 at 06:07 p.m., the ADMIN stated he did not believe an error in a resident's MDS Assessment for weight status could impact a resident's care but stated it might impact the facility's reimbursement for care. He stated the staff did quality of care meetings which would ensure the resident's care was addressed clinically. Record review of facility policy Weight Assessment and Intervention, date updated 11/25/2024, revealed: Policy StatementResident weights are monitored for undesirable or unintended weight loss or gain.Policy Interpretation and ImplementationWeight Assessment .5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight)/(usual weight) x 100]: . c. 6 months - 10% weight loss is significant; greater than 10% is severe. Record review of facility policy Change in a Resident's Condition or Status, date revised April 2025, revealed: .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual.

Based on observation, interview, and record review, the facility failed to post on a daily basis information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for two (2) of two (2) days (06/30/2026 and 07/01/2026) reviewed for posting of required information. The facility failed to post the required current nurse staffing and census information at the beginning of each shift on 06/30/2026 and 07/01/2026. These failures could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census. The findings included: During an observation on 06/30/2026 at 10:49 a.m. and 12:27 p.m., a document with the daily census and nurse staffing information was not observed during a facility tour. During an observation on 07/01/2026 at 09:50 a.m. and 12:50 p.m., a document with the daily census and nurse staffing information was not observed during a facility tour. During an interview on 07/01/2026 at 05:02 p.m., the DON stated the document with the daily census and nurse staffing information should be posted and had to verify that the task was not overlooked. She stated the staff member in the scheduler position should be responsible for posting the document; however, the scheduler position recently changed to an as needed position and was working primarily remote (a person who works in a different location). She stated the task had not been reappointed since the change in the Scheduler position. She stated she did not believe there would be an impact on resident care if the document was not posted because the nursing staff had their own assignment sheets and dining room assignment sheets. During an interview on 07/01/2026 at 06:07 p.m., the ADMIN stated the daily census and nurse staffing document was typically posted after the morning meeting. He stated the prior Staffing Coordinator used to be responsible, but that position was currently empty, and the task was reassigned to him. He stated the task seemed to have been missed for the past two days, 06/30/2026 and 07/01/2026. He stated the lack of posting the document would not have impacted the residents, facility guests, or staff because the staffing had been per the facility's normal staffing schedule. Record review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, dated revised August 2022, revealed, Policy StatementOur facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents.Policy Interpretation and Implementation1. Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs and NAs) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions and were stored in accordance with currently accepted professional principles for 1 of 4 medication/treatment carts reviewed for storage of drugs. The facility failed to ensure the treatment cart was locked and secured when it was left unattended. This failure could place residents at risk of medication misuse and diversion.The findings included: Observation on 6/19/2026 at 10:36 am unlocked treatment cart on the 400 hall, which contained prescribed medications for resident treatments. During an interview on 6/19/2026 at 10:38 am - staff LVN C, stated the cart is a treatment cart and it should have been locked for resident safety, so residents could not access medications.Record review of the facility policy titled Medication Labeling and Storage, revealed, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 residents (Resident #2) reviewed for indwelling urinary catheter care. The facility failed to ensure Resident #2's indwelling urinary catheter drainage bag was not lying on the floor. This failure could place residents with indwelling urinary catheter devices at risk for the development of new or worsening urinary tract infections.The findings included: Record review of Resident #2's face sheet, dated 6/19/2026, revealed he was , admitted on [DATE] and re-admitted on [DATE] diagnosis included: uninhibited neuropathic bladder (nerve damage to the bladder), retention of urine (bladder does not empty completely), and quadriplegia, c5-c7 incomplete (partial spinal cord injury in the neck). Record review of Resident #2's MDS assessment, dated 5/13/2026, revealed the resident's BIMS score was 13, which indicated cognitive intact. Record review of Resident #2's care plan revealed Resident #2 Ensure staff aware of correct placement of catheter gravity drainage bag and tubing. During an observation on 6/18/2026 at 10:30 am -Resident #2's catheter bag was lying on the floor During an interview on 6/18/2026 at 10:33 am - Resident #2 stated he did not know why the catheter bag was on the floor. During an observation and interview on 6/18/2026 at 3:30 pm Nurse A observed the catheter bag lying on the floor. She stated it should be secured to the bed below the bladder to prevent a possible infection. During an interview on 6/18/2026 at 3:33 pm CNA B stated the catheter bag should not have been on the floor due to possible infection. Record review of the facility's policy and procedure titled Catheter Care, Urinary, dated 7/2024, revealed, Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview and record review, the facility failed to ensure residents received services in the facility, 1 of 6 residents (Resident #2), reviewed for reasonable accommodation. The facility failed to ensure the call light was within reach for Resident #2, on 6/18/2026. This failure could place residents at risk of not being able to call for help as needed, not receiving care and services in a timely manner.Findings included: Record review of Resident #2's face sheet, dated 6/19/2026, revealed he was a [AGE] year old male, admitted on [DATE] and re-admitted on [DATE] diagnosis included: uninhibited neuropathic bladder (nerve damage to the bladder), retention of urine (bladder does not empty completely), and quadriplegia, C5-C7 incomplete (partial spinal cord injury in the neck). Record review of Resident #2's MDS assessment, dated 5/13/2026, revealed the resident's BIMS score was 13, which indicated cognitive intact. MDS Section GG showed resident was dependent for assistance with ADL's. MDS Section I showed diagnosis of quadriplegia. Record review of Resident #2's care plan revealed Resident #2 .call light for resident, keepcall light in reach at all times, visible to resident, and the resident is informed of its location and use. During an observation on 6/18/2026 at 10:30 am -Resident #2's call light was wrapped around the head of the bed frame, out of sight and out of reach of the resident. During an interview on 6/18/2026 at 10:33 am - Resident #2 stated he could not reach the call light nor could he see it. During an observation and interview on 6/18/2026 at 3:30 pm Nurse A observed the call light wrapped around the residents' bed frame and she stated it was out of the residents' sight and reach. She stated if the resident could not reach the call light, then he could not call for help, which may put the resident at risk for care. During an interview on 6/18/2026 at 3:33 pm CNA B stated the call light should be within residents reach so the resident could call for help. He stated it may impact the residents' care if the call light was not within reach. Record review of the facility's policy titled Call System, Residents showed Residents are provided with a means to call staff for assistance. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on interviews and record reviews, the facility failed to have evidence all allegations of abuse, neglect or mistreatment were thoroughly investigated and documented for 1 of 5 residents (Resident #2) reviewed for abuse. The facility failed to have evidence that a thorough investigation was conducted following the allegation regarding staff blew cigarette smoke in front of Resident #2. These failures could place residents at risk for abuse and neglect by not investigating allegations of abuse, neglect, exploitation, or mistreatment. The findings were: Record review of Resident # 2's face sheet, dated 04/24/2026, revealed the resident was an [AGE] year-old female and admitted to the facility on [DATE] with diagnoses of age-related osteoporosis with current pathological fracture (fracture due to declining bone mass and strength), Alzheimer's disease (a neurodegenerative disease that destroys cells in your brain, causing loss of some brain functions, including memory and language), and Anxiety ( a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). Further record review of the face sheet revealed the resident was discharged to the home on [DATE]. Record review of Resident #2's admission MDS assessment, dated 02/14/2026, revealed the resident's BIMS score was 5 out of 15, which indicated severe cognitive impairment. The admission MDS assessment further revealed Resident #2 required Partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to chair to bed and toilet transfer. Record review of Resident #2's Incident Investigation Worksheet, received 02/19/2026, revealed the facility administrator reported to Texas HHSC regarding It was alleged that staff members blew smoke in the direction of resident and family out in the designated smoking area while family visiting with loved one. Record review of the facility's Provider Investigation Report 3613-A's revealed that Resident #2's allegation there was no Provider Investigation Report 3613-A in the facility records Record review of Texas Unified Licensure Information Portal (TULIP) accessed (date) indicated there was no report of Resident #2's allegation. Record review of Resident #2's nursing progress note by LVN-D, dated 02/19/2026, revealed that Resident #2 and family member denied staff blew cigarette smoke in front of Resident #2 on 02/19/2026 at the smoking area. Interview on 04/23/2026 at 4:45 p.m. with LVN-D said she did not work at the facility anymore and could not recall who CNAs smoked cigarettes, but she performed interviews with Resident #2 and family, and they denied CNAs blew cigarette smoke in front of the resident. Interview on 04/23/2026 at 4:15 p.m., the Administrator said he did not work on 02/19/2026 because he started working on March 2026 at the facility, so he could not know what happened to Resident #2 on 02/19/2026. The Administrator said he searched all records, computers that previous administrator used, and files but could not find the facility provider investigation report 3613-A regarding Resident #2's allegation. Further interview with the Administrator said there was also no evidence that the previous administrator submitted Provider Investigation Report 3613-A to Texas HHSC within 5 days, and he said the facility administrator should have conducted thorough investigation regarding Resident #2's allegation and submitted provider investigation report 3613-A to Texas HHSC within 5 days to prevent possible abuse or neglect. Record review of the facility policy, titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 09/2022, revealed . 7. All allegations are thoroughly investigated. The administrator initiates investigations. Follow-Up Report. 1. Within five (5) days of the incident, the administrator will provide a follow-up investigation report. 2. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified.

Based on observation, interview and record review the facility failed to manage the personal funds of the residents deposited with the facility for 1 (Resident #3) of 5 residents reviewed for access to personal funds. The facility failed to provide Resident with personal funds upon request for at least 2 months. This deficient practice could place residents at risk for not having money to purchase personal items to meet their needs. The findings were:Review of Resident #3's face sheet, dated 4/24/26, revealed he was admitted to the facility on [DATE] with diagnoses including unspecified Dementia, unspecified severity with other behavioral disturbance and bipolar disorder unspecified. Review of Resident #3's quarterly MDS assessment, dated 3/11/26, revealed Resident #3's BIMS score was 15 reflected he did not have cognitive impairment. Review of Resident #3's Care Plan, dated 9/30/26, revealed Resident #3 was at risk of low self-esteem and interventions included encourage Resident/Representative participation in decision process regarding treatment program. Review of Resident #3's Resident Fund Management Service, revealed the account was opened on 9/10/25 and the current balance was $3965.39 as of 4/21/26. Further review revealed $6320 was deposited into Resident #3's trust fund account on 1/27/26. He was provided with $150. on 2/24/26. Interview on 4/23/26 at 3:40 PM with Resident #3 revealed he was in his room sitting in a chair next to the bed. Resident #3 presented as being alert and oriented to person, place and time. He reported he was admitted to the facility during September 2025 and during October 2026 he requested $600 dollars from his trust fund to buy clothes and silk pillowcases. Resident #3 stated some of his clothes were damaged while being laundered and he liked the silk pillowcases because they kept him cool and from sweating. Resident #3 stated he did not understand why he had not received any of his monies because the trust fund balance from his previous placement had been deposited into his account at the nursing facility. Resident #3 stated he talked with the previous BOM, but since then she left and another person took over the position. He stated he talked with the new BOM and requested monies since at least October 2025 and stated he received 150 dollars but not the amount he requested. Again, Resident #3 expressed frustration and commented staff did not seem to care. Interview on 4/24/26 at 2:10 PM, the BOM revealed Resident #3 request $350 early January or February 2026. He stated he assumed his position as BOM not long ago and was still learning his position. The BOM stated he talked with Resident #3 several times about his request for funds but stated providing funds to him was delayed because there had been high staff turnover including the ADM. The previous ADM was the person who cashed their petty checks which was where he withdrew monies for residents upon their request. He stated the current ADM started his position about 2 weeks ago and at that time he discussed Resident #3's request to withdraw $300 with the ADM and his regional support. The BOM stated he was provided with $300 in petty cash every month from which he disbursed monies to residents from their trust fund upon their request. He stated Resident #3 received $75 every month from MCD and he requested a lump sum accumulated amount since his admission on [DATE]. The BOM stated Resident #3's family member assisted Resident #3 in withdrawing Resident #3's trust fund balance from the previous facility where Resident #3 resided. The balance of the trust fund balance was deposited into Resident #3's account at the facility. The BOM stated he provided Resident #3 with $150 on 2/23/26 but Resident #3 had been requesting the entire balance he was owed in a lump sum so he could buy clothes. The BOM stated at this point Resident #3 was owed $375. He stated corporate office provided him with $300 monthly in petty cash. He stated he told Resident #3 that he would not be able to provide him with the entire amount because of the petty cash limitations, but Resident #3 insisted on the entire amount. The BOM stated he spoke with his regional support and was advised he would have to split the amount into 2 withdrawals. The BOM stated the ADM told him a couple of weeks ago he was waiting for permission to cash the petty cash checks provided from their corporate office. He stated the ADM had not said anything to him since that time. The BOM stated he understood Resident #3 had a right to have access to his funds and Resident #3 expressed his frustration every time they met. Interview on 4/24/26 at 3L46 PM, the ADM revealed the BOM talked with him on Tuesday or Wednesday of this week (4/21/26 or 4/22/26) about Resident #3's request to withdraw monies from his account. The ADM stated Resident #3 had a right to access to his personal funds and was waiting for approval from corporate office to cash the petty cash checks. The ADM stated he had not talked with Resident #3 but according to the BOM Resident #3 requested funds since the end of February. He stated he understood Resident #3 was frustrated because he had been waiting for monies. The ADM stated not providing residents with access to their funds could lead to feelings of helplessness. Review of facility policy, Resident Rights, dated February 2021, read in relevant part,1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to:e. self-determination; h. be supported by the facility in exercising his or her rights; r. manage his or her personal funds, or have the facility manage his or her funds (if he or she wishes).

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 3 residents (Resident #1) reviewed for drug administration in that:Resident #1 was administered one tablet of Donepezil HCL Oral Tablet 10 MG (Donepezil Hydrochloride) twice a day from 11/14/2025 to 11/26/2025. The physician order was 1 tablet of Donepezil HCL Oral Tablet 10 MG (Donepezil Hydrochloride) once a day.The noncompliance was identified as PNC. The facility had corrected the noncompliance before the survey began.This deficient practice could affect residents who receive medications by administering an incorrect dose which could cause injury to the residents.The findings were: Review of Resident #1's face sheet, dated 10/24/25, revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (brain dysfunction caused by systemic metabolic disturbances) and muscle weakness. Review of Resident #1's quarterly MDS assessment, dated 10/24/25, revealed her BIMS score was 12 out of 15 reflective of moderate cognitive impairment. Review of Resident #1's Care Plan, revised 8/1/25, revealed:She was at risk for falls related to an acute medical condition with impaired mobility requiring encouragement to stay in common areas to promote more supervision.She had a nutritional problem related to swallowing problems that required encouragement and assistance with alternating small bites with thorough chewing and sips of a beverage. Observation and reporting of choking, coughing, and not swallowing food to the nurse.She had impaired coping required evaluation of the cause of fear or anxiety.She was at risk of harm: self-directed or other-directed requiring medication and contacting the provider if the resident posed a potential threat to injure herself or others.Record review of Resident #1's TAR record for September of 2025 and October of 2025 revealed that wound care for the left ankle was to be performed once a day with an order start date of 8.14.2025. Wound care for the lower left buttocks was to be performed once a day with an order start date of 8.27.2025. Review of hospital report dated 11/28/25 revealed Resident #1 is an [AGE] year-old Caucasian female with past medical history of advanced dementia who presents with worsening mental status over the last few days, Apparently her donepezil was increased from 10 mg to 20 mg daily accidentally and since then has had worsening in her mentation. On my evaluation she is alert to person only. I do not know what her baseline mental status is so we will need to discuss with her son when he is available. Workup is otherwise negative for any source of infection. Record review of Resident #1s orders on the EMR revealed: A starting dose of Donepezil (dementia medication) HCL Oral Tablet 5 MG (Donepezil Hydrochloride) to be given once per day on 7/1/2025 with an end date of 8/11/2025. The dose was increased on 8/11/2025 to two 5 MG tablets given once per day with an end date of 8/13/25. A replacement order of two 5 MG tablets was placed on 8/14/2025 with an end date of 11/13/25. A replacement order of Donepezil HCL Oral Tablet 10 MG (Donepezil Hydrochloride) given two times a day was started on 11/14/25 and ended with the 0800 dose on 11/27/25 following the residents worsening mental status and discovery that the resident was receiving twice the recommended dose per a dose warning next to the order which stated The frequency of 2 times per day exceeds the usual frequency of daily. The ordered dose of Donepezil HCL Oral Tablet 10 MG (Donepezil Hydrochloride) given one time a day was started on 12/1/25 when the resident returned from the hospital on [DATE] with an end date of 12/10/2025. The identical proceeding dose was ordered for the dates of 12/10/25 with an end date of 12/24/25. Record review of the MAR for the month of November revealed that Resident #1 was administered Donepezil HCL Oral Tablet 10 MG (Donepezil Hydrochloride) twice a day starting on 11/14/2025 through 11/26/2025. Observation and interview on 12/11/25 at 11:07 AM revealed Resident #1 was sitting in her wheelchair in the entrance common area alone reading a magazine. Resident #1 easily engaged in conversation and stated that her stay was going beautifully. Resident #1 did not always provide answers to this surveyor's questions that made sense. She spoke about her family in detail. The interview was concluded early because answers did not align with the questions. Interview on 12/12/25 at 1:03 PM with the ADON revealed that the ordered Donepezil dose for Resident #1 was 10 MG one time per day. She stated Resident #1 received a larger dose of Donepezil 10 MG twice a day for roughly 2 weeks. She stated that the error was realized after the daughter communicated to the facility that the insurance would not cover the administration of more than one Donepezil 10 mg tablet per day. She stated that the injury to Resident #1 that she was aware of was an altered mental state. Interview on 9/23/25 at 12:20 PM with the ADMIN revealed that a medication error report was created after the Donepezil 10 MG dose given two times a day was administered to Resident #1. He stated that the steps that were taken for Resident #1 was to send her to the hospital for evaluation. He stated the MD and pharmacy were notified of the incident. He revealed that a reeducation on verifying physicians orders and the accuracy of orders was provided to the nursing staff responsible for entering orders into the EMR. Record review of a facility policy, Abuse/Neglect revised April 2021, read in the relevant part The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation ofresident property.9. Investigate and report any allegations within timeframes required by federal requirements. Record review of a facility policy, Administering Medications revised April 2019, read in the relevant part: Policy Medications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions.4. Medications are administered in accordance with prescriber orders, including any required time frame.6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training.8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. Interview with the Administrator on 12/12/2025 at 10:55 AM, confirmed that a QAPI meeting was held with the Medical Director and DON to address the medication error. He provided the investigation file of the medication error. Record review of a facility document titled Record Of Employee Counseling revealed the ADON was issued a verbal counseling on 12/5/2025 for failure to notify physician of medication notification of dosage frequency exceeding the recommended daily dose. The Expectations/Outcomes stated Nurse was educated on proper medication alerts. The record was signed by the ADON and the DON on 12/5/2025. Record review of a facility in-service training, dated 12/5/2025, and titled, Accuracy of Medication Orders; Physician Notification on all medication alerts; admission orders must be confirmed/review with physician group on admission. The in-service reviewed clarifying unclear orders with the physician, multiple checks on the accuracy of the order entered into the EMR by reviewing the written order or repeating the verbal order to the physician with confirmation of accuracy, and contacting the physician immediately when a Dose Warning is received which stated that This order is outside of the recommended dose or frequency. The in-service was signed by 18 direct care staff members. Interviews with 4 direct care staff on 12/12/2025 regarding the 12/5/2025 in-service training roster revealed that they had been trained on the Accuracy of Medication Orders; Physician Notification on all medication alerts; admission orders must be confirmed/review with physician group on admission. Direct care staff revealed that orders must be checked more that once or accuracy with the physician's orders, warnings triggered on the orders page require a call to the physician to verify the accuracy of the order, and missing order information requires a follow-up call to the physician to obtain the corrected order information. Record review of Resident #8's medication orders on 12/12/2025 revealed that the 17 medication orders received by the nursing facility from the discharging entity had been correctly entered into the EMR including updated orders from the facility's physician/NP. Observation at approximately 7:00 PM on 12/12/2025 of LVN B passing Resident #8's evening medication, Pregabalin 150mg, to the resident matched the MAR dose and was administered. Record review of Resident #9's residents' medication orders on 12/12/2025 revealed that the 11 medication orders received by the nursing facility from the discharging entity had been correctly entered into the EMR including updated orders from the facility's physician/NP.

Based on interviews, and record reviews the facility failed to ensure personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 4 (#1) residents in that: Resident #1 was administered CPR, 2 compressions which caused Resident #1 to moan in pain, by LVN A after found unresponsive. Resident #1 was a DNR. Resident #1 had an OOH-DNR. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 6 PM. While the IJ was removed on [DATE] at 1:26 PM. The facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to evaluate the plan of removal. This facility failure could place residents at risk of not having their rights honored; experiencing worsening of condition; severe injury, and hospitalization. The findings included: A record review of complaint investigation #546794, dated [DATE], revealed Resident #1 had to go to the emergency room, the addendum stated Resident #1 was unresponsive and 911 was called. The complainant stated RN A said she was sorry; I was completely unaware that Resident #1 had a DNR and I administered CPR. The complainant, not realizing that Resident #1 had no pulse and wasn't breathing which complainant took to mean unconscious, sat speechless. complainant then said, You mean she (Resident #1) didn't have a pulse? The RN A replied No. She wasn't breathing, and she did not have a pulse. When I got in there, I assessed for breath and pulse, didn't find either one, and jumped on her and yelled Starting CPR and gave her 2 compressions. At that point her chest came off the bed and she made a loud groaning sound. The nurse went on to explain that she never checked the binder on the crash cart and that there is no protocol for the order things should be done when the crash cart is needed. RN A told complainant she only knew about the DNR because the Dr called over from the hospital to discuss what happened and when the nurse got to the part about the CPR, he stated to her You realize she has a DNR. The nurse said it was after that phone call that she went and checked the binder and saw the non-hospital DNR was in there. The RN A stated that she had called her Director of Nursing, but she wanted us to hear it from her what had happened. A record review of Resident #1's admission Record dated [DATE] was documented, a [AGE] year-old, she was admitted on [DATE] with diagnoses of multiple rib fractures, dementia) (a decline in mental ability severe enough to interfere with daily life), Parkinson's disease (a progressive neurological disorder that affects movement, primarily due to a decline in dopamine-producing brain cells, leading to symptoms like tremors, stiffness, and slow movement, but also impacting non-motor functions like sleep and mood.) and cognitive communication deficit. Resident #1 was at facility for 24 days and was discharged on [DATE]. A record review of Resident #1's electronic chart was documented an OOH-DNR dated [DATE]. A record review of Resident #1's consolidated physician orders for [DATE] revealed she had a code status order for DNR. A record review of Resident #1 admission MDS dated [DATE] was documented her BIMs score was 8/15 (moderate cognitive impairment), she had impairment on lower extremity on both sides, she used a walker/wheelchair to mobilize, she required supervision for self-care for eating, oral hygiene, persona hygiene, and maximum/moderate assistance with toileting, showers, and dressing. Resident #1 was incontinent of bowel/bladder, she had diagnoses of fractures, dementia, and Parkinson's. A record review of Resident #1 baseline care plan dated [DATE] was documented her code status was DNR. A record review of Resident #1's care plan conference dated [DATE] was documented her code status was OOH-DNR. A record review of Resident #1's Transfer/Discharge Report dated [DATE] at 5:15 PM was documented she was unresponsive and was transferred to hospital. A record review of Resident #1's progress note dated [DATE] by MD was documented Admitting Diagnosis: Right sided rib fractures Chief Complaint: Impaired mobility and self-care. Medical coverage provided by: MD. Interval History: The patient is undergoing rehabilitation at the skilled nursing facility and since the last visit, the patient is participating well in the therapy program. The patient is reporting any pain. New issues since last visit: The patient was assessed while sitting up in the chair with [family member] at her side. The patient reports moderate pain but tolerable with Tylenol and Lidoderm patches, per [family member] Oxycodone attempted and made the patient nauseous requiring Zofran. Patient's [family member] requesting continuation of Zofran PRN with nursing. A record review of Resident #1's progress note dated [DATE] at 4:41 PM was documented Resident #1 presents with weakness and tremors. Request labs for UTI, UA and were ordered. A record review of Resident #1's progress notes dated [DATE] at 4:48 PM Zofran ODT Tablet Dispersible 4 MG, give 1 tablet by mouth every 8 hours as needed for nausea. A record review of Resident #1's progress notes dated [DATE] at 5:43 PM was documented Zofran ODT Tablet Dispersible 4 MG, give 1 tablet by mouth every 8 hours as needed for nausea. PRN Administration was: Effective. A record review of Resident #1's progress note dated [DATE] at 6:13 PM by RN A, was documented, resident was last seen well at 1630 (4:30 PM) when I administered her evening medications. I was notified at 1705 (5:05 PM) that resident was unresponsive. when assessed resident was not breathing and did not respond to sternal chest rub. 911 was called, CPR was initiated after 1 pump of CPR resident moaned out and was now breathing. vitals where 139/78 02 88 heart rate 52. resident still would not open eyes and would not verbally respond. EMS arrived and resident was sent to hospital for further evaluation. A record of Resident #1's hospital record dated [DATE] was documented Resident #1 had an unresponsive episode at her nursing home. Resident #1 was fond by nurse the started 1 chest compression and Resident #1 started moaning so compressions were stopped. Resident #1 was more responsive and CT scan to chest showed a large pleural effusion. Resident #1 had been able to answer questions, began to moan and moving and these were stopped, EMS administer Narcan per report Resident #1 was on narcotics. Resident #1 was at her baseline status and was weaned off oxygen. CT scan was negative and was stable and read for discharge to another facility. During an interview on [DATE] at 4:47 PM, via email, the complainant stated She (LVN A) was also the one who told me she did CPR without knowing there was a DNR in place. She spoke directly to the hospital and was in charge of the ambulance upon its arrival. The last stay at hospital was a severe UTI. Attempted interview on [DATE] at 12:30 PM, [DATE] at 1:26 PM, [DATE] at 12:02 PM with RN A left a voicemail and did not return call before the exit. During an interview on [DATE] at 1:07 PM with CNA B stated that day, she was not sure of exact date, Resident #1 was not breathing, called CNA C on phone and asked her to get nurse, RN A. CNA B stated she automatically grabbed the crash cart, with code status book and went to tell RN A to go to Resident #1's room. CNA B stated RN A started CPR and did 2 compressions, and Resident #1 opened her eye. CNA B stated during the compression, she had opened the code book to Resident #1's code status and told RN A that Resident #1 was a DNR. CNA B stated she had stepped out on the hall to return to her hall, saw EMS and let them know Resident #1's room number, and she left on the stretcher awake. CNA B stated later that day, RN A stated she had looked at Resident #1's admission record and her code status was a DNR. CNA B had stated to RN A that she had told her Resident #1 was a DNR, but she did not listen. CNA B stated that RN A did not hear her. CNA B stated RN A, CNA C were in Resident #1's, but was not sure of the other staff. CNA B stated she was trained for CPR at hospital that she worked at and not at the facility. During an interview on [DATE] at 1:47 PM with LVN AE stated Resident #1 was fine and did not have a change of condition, the night before the incident with the code status. LVN AE stated she worked nights and was not involved with the code status incident with Resident #1. LVN AE stated she knew Resident #1 was a DNR. LVN AE stated she would look at the crash cart, on top had a code status log of all residents with their code states. LVN AE stated the code status was printed out every night. LVN AE stated she was not sure if she was trained at facility for code status. During interview on [DATE] at 2:56 PM with MD stated she was not aware that a CNA, had told LVN A Resident #1 was a DNR, and the LVN A continued to do compressions. During an interview on [DATE] at 11:52 AM with the current DON stated her expectations of nursing would be to document more, document a change of condition, and notify the state agency. The current DON stated the MD had access to resident labs via software system. The current ADON started working after this incident. During an interview on [DATE] at 12:23 PM with ADON stated she was not present for the incident with Resident #1. ADON stated the family had not shared any complaints and Resident #1 family member visited her daily. The ADON stated every night the residents code status's get printed by night staff and placed in a binder, on top of crash cart. The ADON stated RN A should have looked at the code status binder. The ADON stated the previous DON did educate her on the code status incident but had no documentation and she did not remember signing anything for code status training. The ADON stated she was not the boss and did not report this incident to the state agency. During an interview/observation on [DATE] at 10:51 AM with the DON showed the surveyor where they kept the code status of residents in binder, on top of the crash cart near the nurse's station. During an interview on [DATE] at 12:01 PM with the previous DON stated she worked from [DATE] through [DATE]. The previous DON stated she did not remember Resident #1 at this time. The previous DON stated she would expect a nurse to respond to an unresponsive resident, by looking at the binder with all resident code status, call 911. The previous DON stated if resident was a DNR, do not do CPR on resident and call 911. If resident a full code she would expect the nurse to start CPR until EMS came. In regard to this incident, she as a DON would train on code status and what to do, and report to the state agency. During an interview on [DATE] at 2:15 PM with Resident #1's family member/ MPOA stated he was in the room the day Resident #1 went to the hospital. Resident #1's spouse stated he was with Resident #1 in the morning, and at lunch. Family member stated Resident #1 went to lay down and she was unresponsive to him, he called out for a staff, staff grabbed the crash cart, and did see the nurse doing compressions, and went outside room, so staff can care for Resident #1. Family member of Resident #1 stated at the time it happened so fast he did not think about the code status of DNR. Family member stated EMS was able to get Resident #1 stabilized and Resident #1 went to hospital. Family member of Resident #1 stated at the hospital Resident #1 did not have any broken bones and changed her blood pressure medications due to low blood pressure. Family member stated Resident #1 was well and was taking a nap at the time. During an interview on [DATE] at 2:18 PM the previous DON stated she was the DON at the facility until mid-[DATE] when she resigned. The previous DON stated she was unaware of Resident #1's CPR event and could not recall any details of the incident. The DON stated she was employed as the DON during the month of [DATE] but was not the DON effectively stating the administrator and the ADON had cut her out of the loop and the ADON was as a result the DON. The DON stated had she known of the incident she would have reported the incident and investigated the incident. The DON stated if Resident #1 had wished to be a DNR status they should have not provided CPR. During an interview on [DATE] at 2:25 PM with CNA C stated RN A did do compressions, she was not sure who found Resident #1. CNA C stated she did not recall if Resident #1 was in pain. CNA C stated the resident code status were in a binder on the crash cart. CNA C stated she was following the nurses' instructions, and she was not sure of Resident #1's code status. During an interview on [DATE] at 5:59 PM the SW stated the residents last right/choice was to have their code status honored and staff should respect a resident choice. During interview in [DATE] at 4:17 PM with LVN L stated she was the overnight nurse that maintained the DNR binder and ensured the binder was accurate nightly and last night [DATE] at 1 AM, he printed out a new page for the binder and placed on crash cart. During an interview on [DATE] at 5:02 PM the Administrator stated he was not the administrator at the time of the allegation on behalf of Residents #1 and the previous Administrator was responsible for ensuring those allegations were heard, documented, and satisfactorily resolved for Residents #1. The Administrator stated he was the current abuse, neglect, and exploitation prevention coordinator. The Administrator stated the failure to recognize and report allegations of ANE could place residents at risk for not having their allegations of ANE reported. The Administrator stated he had begun training for his team and all the staff to ensure they all understood the ANE prevention recognizing and reporting process and expected increased documentation and recognition of allegations of ANE with reports to the state agency. Record review of Policy, Communication of Code Status dated 7/22 was documented, It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. 4. The resident's code status should be entered into the resident physician orders in the EMR. 5. Additional means of communication of code status include: Code status will appear at the top of the resident home screen in EMR. 9. The resident's code status will be reviewed at least quarterly and documented in the medical record. The Administrator was notified of an IJ on [DATE] at 6 PM and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on [DATE] at 1:26 PM and included the following: Plan of Removal (POR) for Immediate Jeopardy, dated [DATE] was documented: To Whom it may concern, Summary of Details which lead to outcomes. On [DATE], an abbreviated survey was initiated at 10 am. On [DATE], A surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the facility constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F678 The facility failed to implement a resident's advance directive on Resident #1. Identify residents who could be affected. All Residents with an advance directive have the potential to be affected. Facility census on [DATE]. Identify responsible staff/ what action taken: . Regional VPO and Regional Nurse Consultant provided education on CPR and Advance Directives honoring resident rights to Administrator and Director of Nursing on [DATE]. Director of Nursing and Assistant Director of Nursing conducted education on CPR and Advance Directives for all nurses. A mock code was performed for am and pm shifts on [DATE], with documentation on a Mock Code form. Advance Directive Binder on the crash cart was reviewed and verified to ensure residents code status were listed and correct on [DATE], by the DON. The Regional VPO educated the Administrator and Director of Nursing on reporting guidelines per PL 2014-14 dated [DATE], on [DATE]. Social Worker/designee will be responsible for updating the Advance Directive binder when there is a change in code status. New staff and agency staff (if applicable) will be educated in Advance Directives and the location of the code status binder which is located on the emergency cart by the DON/designee prior to starting their shift. Implementation of Changes Nurses can easily identify and locate the code status for residents, as the advanced directive binder is clearly marked and located on the crash cart. The location of the advance directive binder is documented in the in-service provided to the nursing staff. Nurses will only perform CPR if the resident is designated as a Full Code. Training initiated and completed on [DATE], and after the education sessions, nurses will have a better understanding of code status and the situations in which CPR should or should not be performed. Any new hires and or agency staff (if applicable) will be educated prior to the start of their shift. The Director of Nursing will conduct monthly mock code scenarios for 3 months. Monitoring Administrator, Director of Nursing, or designated staff will monitor the code status of residents daily for 4 weeks, including any changes upon admission and thereafter. Social Worker/designee will be responsible for updating the Advance Directive binder when there is a change in code status. Any negative outcomes will be reported to the QAPI Committee. Involvement of Medical Director Ad hoc QAPI held at 7:35 pm on [DATE], with the Medical Director, Director of Nursing and Administrator for discussion of Immediate Jeopardy and the plan of removal. The Medical Director, 6:28 pm was notified about the immediate Jeopardy on [DATE]. Who is responsible for the implementation of the process? Director of Nursing and/or Designee. POR verification was started on [DATE] was documented: Identify residents who could be affected. Record review of Resident list revealed 71 residents in the building During an interview on [DATE] at 1:13 PM on [DATE] the DON stated prior to [DATE] the entire census of 71 had the potential for their code statuses not being reviewed if a potential event of a resident being discovered unresponsive. Identify responsible staff/ what action taken: Record Review of CPR/Advanced Directive in-service training dated [DATE] was documented the Regional VPO and Regional Nurse Consultant provided education on CPR and Advance Directives to the Administrator and DON. During an interview on [DATE] at 1:18 PM Regional VPO stated he provided education on CPR and Advance Directives honoring resident rights to the Administrator and the Director of Nursing on [DATE],[DATE] and that the Director of Nursing and the Assistant Director of Nursing conducted education on CPR and Advance Directives for all nurses. A mock code was performed for am and pm shifts on [DATE],[DATE] with documentation on a Mock Code form. Record review of in-service training CPR code status mock code, summary: in the event of code blue, immediately delegate for a staff member to retrieve resident code status form binder on crash cart before beginning CPR. Code status binder is updated nightly by nursing staff. (mock code initiated) dated [DATE] included, LVN H, LVN P, CNA Q, PT R, CNA S, CNA T, CNA U, CNA V, and CNA W. The following staff LVN H, LVN P, CNA Q, PT R, CNA S, CNA T, CNA U, CNA V, and CNA W, who received training for supporting a residents' wishes for a code status and participated in the facility's initial Mock Code event on [DATE] training were interviewed as follows: During an interview on [DATE] at 1:46 PM LVN H stated on [DATE] she was trained by the DON for a Mock Code event designed to augment the staffs' in-service regarding a potential CPR event if a Resident was discovered unresponsive. LVN H stated the protocol in the training would have a focus in the training for the staff to identify the Resident in the DNR Binder which was maintained accurately on the cart, and to communicate the information to one and another to specify if the Resident had wishes to receive or not to receive CPR. During interviews on [DATE] from 5:45 PM to 6:33 PM LVN P, CNA Q, PT R, CNA S, CNA T, CNA U, CNA V and CNA W stated she they had received Resident code status for DNR versus CPR training via a Mock Code event on the afternoon on [DATE] when LVN H in general called out in the facility to unaware staff that a Resident #1'sSmith was discovered on the 100-hall unresponsive to which numerus staff reacted and ran down the 100- hall. LVN PThey stated she arrived to discover CNA Q was on her way with the crash cart and upon arrival of the crash cart the training was for a focus on the Code Status Binder which contained a current accurate list of all residents and their wishes to receive CPR or not. LVN PThey stated if it were a real CPR event she they would not provide CPR if the Resident had wished for a DNR Status and would communicate the residents wishes to all the staff present. During an interview on [DATE] at 5:56 PM CNA Q stated she had received Resident code status for DNR versus CPR training via a Mock Code event on the afternoon on [DATE] when LVN H in general called out in the facility to unaware staff that a Resident Smith was discovered on the 100-hall unresponsive to which numerus staff reacted and ran down the 100- hall. CNA Q stated she arrived at the 100-hall with the crash cart and upon arrival of the crash cart the training was for a focus on the Code Status Binder which contained a current accurate list of all residents and their wishes to receive CPR or not. CNA Q stated if it were a real CPR event she would not provide CPR if the Resident had wished for a DNR Status and would communicate the residents wishes to all the staff present. During an interview on [DATE] at 6:33 PM PT R stated he had received Resident code status for DNR versus CPR training via a Mock Code event on the afternoon on [DATE] when LVN H in general called out in the facility to unaware staff that a Resident Smith was discovered on the 100-hall unresponsive to which numerus staff reacted and ran down the 100- hall. PT R stated he arrived to discover CNA Q was on her way with the crash cart and upon arrival of the crash cart the training was for a focus on the Code Status Binder which contained a current accurate list of all residents and their wishes to receive CPR or not. PT R stated if it were a real CPR event he would not provide CPR if the Resident had wished for a DNR Status and would communicate the residents wishes to all the staff present. During an interview on [DATE] at 5:49 PM CNA S stated she had received Resident code status for DNR versus CPR training via a Mock Code event on the afternoon on [DATE] when LVN H in general called out in the facility to unaware staff that a Resident Smith was discovered on the 100-hall unresponsive to which numerus staff reacted and ran down the 100- hall. CNA S stated she arrived to discover CNA Q was on her way with the crash cart and upon arrival of the crash cart the training was for a focus on the Code Status Binder which contained a current accurate list of all residents and their wishes to receive CPR or not. CNA S stated if it were a real CPR event she would not provide CPR if the Resident had wished for a DNR Status and would communicate the residents wishes to all the staff present. During an interview on [DATE] at 5:50 PM CNA T stated she had received Resident code status for DNR versus CPR training via a Mock Code event on the afternoon on [DATE] when LVN H in general called out in the facility to unaware staff that a Resident Smith was discovered on the 100-hall unresponsive to which numerus staff reacted and ran down the 100- hall. CNA T stated she arrived to discover CNA Q was on her way with the crash cart and upon arrival of the crash cart the training was for a focus on the Code Status Binder which contained a current accurate list of all residents and their wishes to receive CPR or not. CNA T stated if it were a real CPR event she would not provide CPR if the Resident had wished for a DNR Status and would communicate the residents wishes to all the staff present. During an interview on [DATE] at 5:47 PM CNA U stated she had received Resident code status for DNR versus CPR training via a Mock Code event on the afternoon on [DATE] when LVN H in general called out in the facility to unaware staff that a Resident Smith was discovered on the 100-hall unresponsive to which numerus staff reacted and ran down the 100- hall. CNA U stated she arrived to discover CNA Q was on her way with the crash cart and upon arrival of the crash cart the training was for a focus on the Code Status Binder which contained a current accurate list of all residents and their wishes to receive CPR or not. CNA U stated if it were a real CPR event she would not provide CPR if the Resident had wished for a DNR Status and would communicate the residents wishes to all the staff present. During an interview on [DATE] at 5:45 PM CNA V stated she had received Resident code status for DNR versus CPR training via a Mock Code event on the afternoon on [DATE] when LVN H in general called out in the facility to unaware staff that a Resident Smith was discovered on the 100-hall unresponsive to which numerus staff reacted and ran down the 100- hall. CNA V stated she arrived to discover CNA Q was on her way with the crash cart and upon arrival of the crash cart the training was for a focus on the Code Status Binder which contained a current accurate list of all residents and their wishes to receive CPR or not. CNA V stated if it were a real CPR event she would not provide CPR if the Resident had wished for a DNR Status and would communicate the residents wishes to all the staff present. During an interview on [DATE] at 5:47 PM CNA W stated she had received Resident code status for DNR versus CPR training via a Mock Code event on the afternoon on [DATE] when LVN H in general called out in the facility to unaware staff that a Resident Smith was discovered on the 100-hall unresponsive to which numerus staff reacted and ran down the 100- hall. CNA W stated she arrived to discover CNA Q was on her way with the crash cart and upon arrival of the crash cart the training was for a focus on the Code Status Binder which contained a current accurate list of all residents and their wishes to receive CPR or not. CNA W stated if it were a real CPR event she would not provide CPR if the Resident had wished for a DNR Status and would communicate the residents wishes to all the staff present. Record review of list of nurses provided by the DON revealed at total of 10 nursing staff working in the facility. Interview on [DATE] at 12:15 PM with ADM/DON/Regional nurse stated they had 10 full time nurses working at facility with no agency staff. Record of staffing schedule for [DATE] was documented 7 nursing staff that worked on the AM and PM schedule. The Advance Directive Binder on the crash cart was reviewed and verified to ensure residents code status were listed and correct on [DATE]/4/25, by the DON. Record review of statement from DON dated [DATE] was documented, Reviewed and verified advanced directrices binder on crash cart to ensure all code status were correct. Record review of the Advance Directive Binder on the crash cart was reviewed and verified to and included 71 residents. The Regional VPO educated the Administrator and Director of Nursing on reporting guidelines per PL 2014-14 dated [DATE], on [DATE]. Record review of In-service training dated [DATE] by the Regional VPO was documented ADM and or DON will enforce state/Federal guidelines on state reporting. In addition, the ADM and/or DON will report all significant events to the Regional [NAME] President which included signatures of DON/RN, ADM and ADON. Record review of the LTC provider letter, dated [DATE]. 2024 (PL 2014-14) was attached to in-service. Social Worker/designee will be responsible for updating the Advance Directive binder when there is a change in code status. Record review of statement dated [DATE] was documented I, SW understand that it is my responsibility to update advanced directive binder when there are changes in code status. Upon each admission it will be explained to family and residents their right to make medical decisions, including the right to formulate and have respected advance directives that may be updated and changed anytime at their request, signed and dated by SW. New staff and agency staff (if applicable) will be educated in Advance Directives and the location of the code status binder which is located on the emergency cart by the DON/designee prior to starting their shift. During an interview on [DATE] at 1:13 PM the DON stated new staff and agency staff (if applicable) will be educated about Advance Directives and the location of the code status binder which was located on the emergency cart, prior to starting their shift. Implementation of Changes Record review of in-service training on Code Status/Advanced Directive, where and how do you know what code status they have, and Binder is located on the crash cart with list of resident code status dated [DATE] which included 13 nursing staff. A record review of the facility's full time nursing roster revealed 11 nurses: 1. The DON 2. LVN D 3. ADON LVN E 4. LVN F 5. LVN G 6. LVN H 7. LVN I 8. LVN J 9. LVN K 10. LVN L 11. LVN O A record review of the facility's PRN nursing roster revealed 3 nurses: 1. LVN M 2. RN N Of the facility's' 13[TRUNCATED]

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 residents (Resident #1, #3, #4) of 4 residents reviewed for care plans. 1. Facility failed to develop a person-centered care plan that addressed Resident #1's risk for fall to with interventions to prevent further injury when he was admitted to the facility on [DATE] with a broken neck from a fall at home and when he had a fall at the facility on 6/05/2024 (date of admission), 6/09/2024, two falls on 6/12/2024 and a fall on 6/24/2024 which resulted in a subdural hemorrhage (a pool of blood between the brain and its outermost covering) which required hospitalization in the ICU. An IJ was identified on 06/26/2024 at 3:50 PM. The IJ template was provided to the facility on [DATE] at 3:50 PM. While the IJ was removed on 06/28/2024 at 7:58 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because of the facility's need to monitor the implementation of the plan of removal. 2. The facility failed to develop a person-centered care plan with interventions that addressed Resident #4's assessment which indicated a high fall risk or when the resident had an actual fall on 6/17/2024 3. The facility failed to develop a person centered care plan that addressed Resident #3's moderate risk for falls or any of his admitting diagnoses. These deficient practices could affect all residents and place them at risk for accidents and falls with injury and missed care. The findings included: 1. Record review of Resident #1's face sheet, dated 6/25/2024 revealed an admitted [DATE] with diagnoses which included: unspecified fracture of fifth lumbar vertebra sequela (6/04/2024 - a fracture that occured after initial encounter), parkinsonism (movement disorder from deterioration of the brain which typically involves slowed movements, rigidity or stiffness and tremors), progressive supranuclear ophthalmoplegia [Steele-[NAME]-[NAME] syndrome] (Also known as PSP: a rare progressive brain disease which affects walking, balance, eye movements and swallowing. Damage of cells in the areas of brain that control body movement, coordination and thinking), abnormalities with gait and mobility, generalized muscle weakness (decrease in strength), glaucoma (damage to the optic nerve which provides information to the brain either with or without raised pressure in the eye and leads to vision loss) and insomnia (trouble falling or staying asleep). Record review of Resident #1's hospital discharge summary dated 6/04/2024 before admission to the facility on [DATE] revealed the resident had a fall on 5/11/2024 with fracture of spinous process of cervical vertebrae (break in the bones of the neck) (5/11/2024) with fusion of cervical spine on 5/17/2024 (surgical repair of the fracture). The hospital discharge stated Resident #1 had multiple falls in the past year. Record review of Resident #1's 5-day admission MDS assessment revealed a BIMS of 13 which indicated the resident was cognitively intact. The fall history on admission listed no fall history. Resident #1's functional status was listed as unable to ambulate with maximum assistance needed for ADL care including coming from sit to stand position. The MDS was in-complete and not signed therefore no CAA's areas were triggered. Record review of Resident #1's admission fall risk assessment dated [DATE] revealed the resident was at high risk for falls with a history of 3 or more falls in the past 3 months. Record review of Resident #1's baseline care plan dated 6/05/2024 revealed the resident required supervision or touch assistance to stand and transfer and walking was not attempted. The baseline care plan indicated Resident #1 had a history of falls in the last month prior to admission with no additional input on interventions to prevent falls. The baseline care plan was signed by the DOR. Record review of Resident #1's care plan conference dated 6/12/2024 revealed the resident had limited assist for ADL care and stood up unassisted. The notes stated he had a couple of falls, tended to be impulsive and was more active at night. It also noted his impaired vision related to glaucoma, diagnoses of fracture of vertebra sequala, and PSP. The Document was signed by the SW. Record review of physician orders revealed an order for fall mat to side of bed while in bed for safety with a start date of 6/05/2024. Record review of Resident #1's Fall Incident Report dated 6/5/2024 (date of admission) revealed a nurse (unknown) heard a banging sound coming from the resident room and observed Resident #1 lying on floor beside bed partially on the fall mat and partially on floor. No injuries noted. The report indicated Resident #1 was confused and listed predisposing situation factors as: admitted within last 72 hours and ambulating without assistance. No interventions to prevent future falls were documented. Report documented by LVN L. Record review of Resident #1's Physical Therapy Evaluation and Treatment Plan dated 6/07/2024 revealed Resident #1 was a fall risk and had a cervical collar (neck brace that prevents movement of the neck) in place 24/7 (24 hours a day, 7 days a week). The evaluation indicated Resident #1 had impairment of strength to his lower extremities (legs and hips). Fall predictors: inadequate postural control, discontinuity of steps and weak trunk and hip extensors. (Inability to control posture, unequal steps while walking and weakness). Record review of Resident #1's Fall Incident Report dated 6/09/2024 revealed Resident #1 was heard making a loud grunt when LVN P saw Resident #1 sitting on the floor with his back against the door. He stated he was sitting down and needed to use the restroom. He was noted with low blood pressure of 86/48 upon assessment and the MD was notified. No injuries noted. Predisposing factors were documented as confusion, gait imbalance, impaired memory and ambulating without assistance. No interventions to prevent future falls were documented. Report documented by the DON. Record review of Resident #1's Fall Incident Report dated 6/12/2024 at 3:20 p.m., revealed Resident #1 was reaching for his phone on the floor when he lost balance and sat on the floor. No injuries were noted. The report indicated Resident #1 was cognitively intact with predisposing factors which included: gait imbalance, ambulating without assist, transfer, using wheeled walker. The report stated Resident #1 transfers and ambulates without assistance. Nursing staff had educated the resident multiple times on how to use call light for assistance. There were no interventions to prevent future falls documented. The document was signed by LVN G. Record review of Resident #1's Fall Incident Report dated 6/12/2024 at 3:31 p.m. revealed Resident #1 stated he fell and hit his head on his walker but did not tell anyone. An abrasion was observed to the top of his scalp. Predisposing factors included poor lighting and using walker. No interventions were documented to prevent future falls. Record review of Resident #1's Fall Incident Report dated 6/24/2024 at 3:45 am revealed LVN P documented that around 3:45 am she heard Resident #1 yelling help from his room and found him seated on his bottom scooting towards the door. Resident #1 stated he was going forward in his wheelchair and fell . Later he stated he was standing up with his walker and fell back but does not recall what happened or why he fell . Upon assessment Resident #1's left pupil was larger than the right pupil and bleeding was noted from the back of his head. Resident #1 stated Where am I, where am I? Pressure was applied to his head and 911 was called. Resident #1 was sent to the hospital. Predisposing factors were listed as other without further explanation. No interventions were documented to prevent future falls. Record review of hospital ER records dated 6/24/2024 for Resident #1 revealed Resident #1 was brought into the ER via EMS after a fall at the nursing facility. Nursing home staff stated he fell backwards, hitting his head on the ground. He had an Aspen c-collar (stiff neck brace that prevents movement of the head) in place as he is currently recovering from a recent fracture of C5 (break to the bones in neck). Resident #1 reported pain to the back of his head. Upon exam Resident #1 had an abrasion to the back of his head and his left pupil was larger than the right. A brain CT revealed he had a small subdural hemorrhage (a pool of blood between the brain and its outermost covering) and posterior scalp (back of the head) soft tissue swelling. Resident #1 was transferred from the local hospital to a trauma center at larger hospital in a nearby city. Record review of hospital records dated 6/25/2024 from the trauma hospital revealed Resident #1 had a diagnosis of fall with subdural hemorrhage on aspirin use (anticoagulant medication). The resident was monitored in ICU for changes in neuro status. Repeated brain CT showed no worsening of the subdural hemorrhage and he was discharged back to the facility. Record review of a handwritten document of a witness statement dated 6/26/2024 for CNA Z revealed at 3:30 ish (am) patient (Resident #1) in living room- he walked back to his room with us observing him, heard yelling from room. Patient told staff he fell face first but head bleeding from back, then patient stated he was standing with walker and fell backwards, did not know what happened. Clarification written on 6/28/2024 added additional information which included: patient did have walker in TV room and used that to walk back to his room prior to hearing resident yell for help. Both walker and wheelchair were present close to resident when he was found. The document was signed by the Administrator. Record review of Resident #1's medical record revealed the comprehensive care plan was blank and no plan of care had been initiated. During an interview on 6/25/2024 at 12:02 p.m., Resident #1's family member stated Resident #1 does not sleep during the night very well. She stated he was strong in his legs but unsteady on his legs. She stated when he needed to go to the bathroom he will go and if he cannot sleep, he will get up and go sit in a chair. She stated his disease made it so he was oblivious to a lot of things. She stated he does not know pain or hunger but was able to make his needs known. She stated she was currently with Resident #1 at the hospital after his fall at the facility. She stated he had a bleed in his brain. She stated he had a history of many falls. 2. Record review of Resident #4's face sheet dated 6/25/2024 revealed an admitted [DATE] with diagnoses which included: insomnia, metabolic encephalopathy (brain dysfunction with symptoms which could include confusion), and muscle weakness (generalized). Record review of Resident #4's baseline care plan dated 6/12/2024 revealed she had a history of falls in the month prior to admission with no interventions to prevent falls listed. The document was not signed. Record review of Resident #4's Fall Risk assessment dated [DATE] revealed she was at high risk for falls, signed by the DON. Record review of Resident #4's Incident report dated 6/17/2024 revealed upon entering the resident's room to administer medications the nurse noticed the bathroom door was closed. Upon entrance the nurse found Resident #4 lying on the floor in front of the bathroom sink with her head facing the door. The light was off and the water was running in the sink. Her wheelchair was next to the toilet near her feet with the brakes not locked. The assessment revealed no injuries. The document was signed by the DON. Record review of Resident #4's medical record revealed a comprehensive care plan had not been started or initiated. Record review of Resident #4's Multidisciplinary Care Conference dated 6/19/2024 revealed the resident had a fall on Monday (date not specified) in the bathroom and required limited to extensive assistance for ADL care. The document indicated Resident #4's medication was reviewed. The evaluation/goals were listed as decrease fall risk. The document was signed by the SW. Record review of Resident #4's 5-day admission MDS assessment dated [DATE] revealed a BIMS score of 9 which indicated a moderate cognitive impairment. Resident #4's functional status upon admission was listed as requiring moderate assistance to go from sitting to standing, transferring from chair and toilet and she did not ambulate (walk). The MDS assessment was incomplete and not signed by an RN therefore no CAA's were triggered. 3. Record review of Resident #3's face sheet dated 6/25/2024 revealed an admitted [DATE] with diagnoses including: Sequelae of cerebrovascular disease (neurological deficits), depression, anxiety disorder, insomnia, glaucoma (eye disease that can affect vision), tremor, morbid obesity and hypertension (high blood pressure). Record review of Resident #3's Fall Risk assessment dated [DATE] revealed a score of 9 which indicated a moderate risk for falls. The assessment revealed Resident #3 had a history of 3 or more falls in the past 3 months. Record review of Resident #3's 5-day admission MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated the resident was cognitively intact. Resident #3's functional status was listed as set up assistance for sit to stand and transfers and touch assistance needed to walk 10 feet. The MDS assessment was incomplete and not signed by an RN therefore no CAAs were triggered. Record review of the facility incident/accident log revealed Resident #3 had no documented falls since admission. Record review of Resident #3's medical record revealed there was no comprehensive care plan, and the document was blank. During an interview on 6/25/2024 at 2:01 p.m., LVN B stated the CNAs were trained to identify residents at risk for falls by the POC and Kardex (a document that lists interventions for care). LVN B demonstrated how the Kardex was pulled up in PCC (Point Click Care - the facility's electronic charting system) which resulted in showing a blank Kardex. LVN B stated she had not seen any care plans for residents including Resident #1, #3, and #4. She stated if there were no care plans then the Kardex were not loading because they were generated from the care plan. LVN B stated without care plans they had no way of identifying interventions for falls. LVN B stated she was not sure who was responsible for completing the care plans but she knew no one in-house (in the facility) was completing them. She stated it was not a charge nurse duty. She stated she had not seen any completed for any residents in the facility. She stated the facility did not have an MDS Coordinator. She stated there was a Corporate MDS person, but she did not know the details. During an interview on 6/25/2024 at 3:30 pm with the Corporate HR Specialist and the BOM revealed the DON was not in the facility and the facility did not employee an ADON or MDS Coordinator. They stated the Corporate MDS specialist had been handling MDS assessments but was unavailable. They stated another Corporate Reimbursement Specialist was filling in for the Corporate MDS person. During an interview on 6/25/2024 at 3:37 p.m., the DOR (Director of Rehabilitation) stated the facility held Care Plan meetings at 48 hours after admission which was an introduction for the resident and family to facility staff and then a week later an interdisciplinary care plan meeting was held, where the plan of care for residents was discussed. She stated she typically participated in those meetings along with the DON when she could attend, SW, and BOM. The DOR stated for Resident #1 she was aware he had repeated falls. She stated she was not aware of any other resident in the facility with fall concerns. She stated they discuss how the resident(s) were doing at the facility. She stated during the meeting they had discussed contributing factors to the falls. She stated the notes were documented by whom ever was assigned to transcribe for the meeting. She stated the therapy department did not touch care plans. She stated the facility did not have an MDS Coordinator who typically completes care plans. She stated they had a Corporate MDS person who was overseeing care plans, but the DON was the one who was doing them to her knowledge. During an interview on 6/25/2024 at 4:32 p.m., Corporate MDS nurse stated she was unable to answer specific questions regarding the residents at the facility. She stated the facility did not have an MDS Coordinator nurse. She stated they needed one. The Corporate MDS nurse stated she would talk to the DON and the DOR about the residents, and she would open the MDS assessments but was not closing them. The Corporate MDS nurse stated the facility care plans were an assigned task to her. She stated she had done some care plans (residents unknown) but it was the facility who was supposed to do care plans. She stated the comprehensive care plans should be completed within 7 days of the MDS assessment. The Corporate MDS nurse stated she was a regional employee with two other facilities she was responsible for and was unable to complete them all. She stated she had not communicated her inability to complete her assignment with the facility Administrator personally but knows there was some sort of email that was circulated letting the Administrator know she needed to handle it. The Corporate MDS nurse stated the facility had a lot of admissions and it was really hard for her to manage 12 admissions a week. She stated care plans were important because it informed staff on how to take care of the residents, what their needs were, what their desires were and everything about the resident. The Corporate MDS nurse stated she was not familiar with Resident #1, and she was not able to answer questions about specific residents. During an interview on 6/25/2024 at 4:37 p.m., the Corporate Reimbursement Specialist stated she had not had contact with anyone at the facility and was not providing any oversite to patient care. She stated she did not work for the facility or Corporate and was an independent contractor. She stated she had spoken to Corporate but did not have a current contract and was not able to answer any question. During an interview on 6/25/2024 at 5:43 p.m., the SW stated he attended care plan meetings. He stated there was an informal meeting within 48 hours of admission and then a week later a comprehensive care plan meeting. The SW stated he facilated the meetings and documented the care plan notes and assessment. The SW stated he facilitated the discussion for the care plans but did not document or create care plans for the residents. The SW stated the DON and DOR had been completing resident care plans. The SW stated during Resident #1's comprehensive care plan meeting they discussed the resident's PSP disease which was related to Parkinson's disease because the diagnoses made people fall backwards. The SW stated this had happened several times before admission requiring Resident #1 to wear a neck collar. The SW stated Resident #1 was walking and therapy was encouraging him to be safe. The SW stated he was aware Resident #1 had several falls since admission to the facility. He stated he could not recall the specifics that were discussed about interventions. He stated Resident #1 was impulsive and would do things outside the realm of recommendations such as get on the floor by himself. The SW stated staff set verbal boundaries and they all know he was a fall risk and why he was here. He stated that was why he was getting therapy. He stated he did not note in his documentation or notes any specific interventions to prevent falls and was not responsible for the care plan. During an interview on 6/25/2024 at 6:00 p.m., the DON stated she was aware residents at the facility did not have comprehensive care plans and their initial baseline care plans were not signed. She stated as the only RN working at the facility, she was opening the care plans on admission but was not able to follow up. She stated it was a good question as to who was in charge of resident care plans. The DON stated the Corporate MDS nurse did not come to the facility and she had never met her. The DON stated she had reached out to the Corporate MDS nurse who stated she was too busy to complete the care plans. The DON stated the Corporate MDS nurse told her it was on her plate to do it. The DON stated she told the Corporate MDS nurse she (DON) did not have time to do it. The DON stated the facility did not have their own MDS Coordinator. The DON stated right now, to her knowledge, no one was assigned to complete resident care plans. The DON stated the facility was brand new and just got their license as of 5/31/2024. She stated since the opening she was having to work as a floor nurse, mostly at night because they did not have enough licensed staff. She stated she had worked as a charge nurse for the past 30 days which absolutely limited what she could do as a DON. She stated she was not able to attend morning meetings, IDT or care plan meetings. She stated her primary focus had been patient care and communication with floor staff. The DON stated the Administrator and Clinical Support Specialist (Corporate RN) were both aware of her limitations. She stated the response from the Administrator was nothing was being done to help the situation. The DON stated acknowledgement that Resident #1 did not have a care plan to address his falls. She stated they did have an order (physician order) for a fall mat. She stated the DOR was working specifically with Resident #1. The DON stated during his care plan meeting the family member of Resident #1 stated he did not sleep at night and that was his normal routine. The DON stated as Resident #1 had gotten stronger with therapy he was now more mobile and was coming out of his room. The DON stated she was aware of his fall history early in his admission process. The DON stated the family member typically sat with Resident #1 during the day and left in the early evening. The DON stated they were not updating the care plan after each fall because there was no care plan. She stated the incident/accident list was the most accurate documentation of his falls. She stated to her knowledge Resident #1 had 5 falls since admission. She stated the latest one was the only one in which he sustained an injury. The DON stated the causative factor in Resident #1's falls was his impulsivity. She stated fall interventions consisted of low bed, fall mat, keep an eye on him and therapy. She stated the Kardex was not updated for use by the CNAs because there was no care plan. The DON stated the CNAs were told verbally about fall risk and interventions since the Kardex was not accurate. She stated they were also rounding (checking on him) every 2-3 hours. The DON stated Resident #1 was on increased rounding of 1-hour intervals but his supervision was not spelled out. She stated they did not put any new interventions in place after each fall. The DON stated it was important to prevent falls to prevent injury. She stated she considered a brain bleed a serious injury. She stated all staff were responsible for ensuring resident safety. During an interview on 6/26/2024 at 9:05 a.m., the Administrator stated she was aware the residents did not have comprehensive care plans. She stated she was also aware Resident #1 had multiple falls while in the facility with no comprehensive care plan in place and a baseline care plan which had not been updated. The Administrator stated the facility was new and had opened at the end of March 2024 but had received their license more recently (date unknown). The Administrator stated she ensured staff knew how to care for Resident #1 by giving verbal report to each other. She stated they did not have specific interventions in place to prevent Resident #1 from falling. She stated they did talk about falls during morning meetings including the use of fall mats, keeping him in eyesight and reminding him to use the call-light but these were not written down. The Administrator stated the DON had communicated she was not able to fulfill her DON duties and the corporate leaders knew the DON was struggling. The Administrator stated the DON was working the floor, doing staffing and schedules and was on-call for clinical but was unable to do the care plans. The Administrator stated the DON did attend care plans meeting when she could. The Administrator stated she had tried to remedy the situation by continuing to hire more staff as the facility census rose. She stated the current census was 29 residents. The Administrator stated she had communicated with the medical director resident falls and the need for additional staff but not specifically about the lack of care plans at the facility. The Administrator stated she was responsible for facility management but was not always able to make decisions independently of Corporate. During an interview on 6/26/2024 at 12:12 p.m., the Corporate Clinical Operations Specialist stated he provided oversight to the Administrator. He stated the Administrator had been given full [NAME] to hire whatever staff was needed but was unsure of the date she was given this information. He stated, as of now, the corporate staff was helping to manage the building so that the Administrator did not need to hire for the positions. He stated this included the MDS Coordinator. The Corporate Clinical Operations Specialist stated the Corporate MDS coordinator was not located in the facility, but communicated with staff that was in the building including the DON and DOR. During an interview on 6/26/2024 at 2:08 p.m., the Corporate Clinical RN stated she split her time between three facilities. She stated she came to this facility approximately 1 time a week. The Corporate Clinical RN stated the Corporate MDS nurse and DON were responsible for care plans. The Corporate Clinical RN stated she was not aware the residents did not have comprehensive care plans until surveyor intervention but was aware there were residents with falls including Resident #1 whom had multiple falls. The Corporate Clinical RN stated she puts in orders for new admissions and audits the system but did not audit care plans. She stated she should have looked at it more closely. The Corporate Clinical RN stated approximately one week to a week and a half ago the Administrator was given the go ahead to hire the staff she needed, including an MDS Coordinator. She stated the facility's census was preventing the full go ahead prior to that point. Record review of a facility policy, titled Comprehensive Care Plans dated 10/2022 revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident., consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences will also be addressed in the plan of care. 4. The comprehensive care plan will be prepared by an interdisciplinary team . The Administrator was notified of an IJ on 06/26/2024 at 3:50 p.m. and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 06/27/2024 at 6:55 PM and included the following: 1. Immediate actions The Medical Director was notified by the Administrator on 6/26/25 of the Immediate Jeopardy The DON reassessed all residents using the Fall Risk Assessment Tool on 6/26/24. The DON ensured all residents identified as at risk for falls had safety measures, as well as resident specific interventions, added to their care plans. The DON ensured the safety measures and resident specific interventions that were added to the care plans were also reflected on the Kardex so that the CNAs had access to this information. Clinical support specialist has completed all comprehensive care plans for all current residents as of 6/27/24. 2. Education Inservice education to clinical staff regarding the comprehensive care plans of residents was completed with clinical staff by Clinical Care Specialist on 6/26/24. This includes how to identify a high fall risk resident, where to find information specific to each resident on the Kardex. The DON will make sure that all staff is educated before the start of their next shift. The Clinical Support Specialist instructed all the clinical staff including nurses and CNAs to review the updated Kardex prior to their next shift on 6/26/24. Inservice education on Kardex was completed by Clinical Care Specialist on 6/26/24. DON will make sure all remaining staff is educated before the start of their next shift. 3. Monitoring Incidents will be reviewed daily in morning clinical meeting by the IDT team. Interventions will be put in place on the care plan at this time by the DON and Kardex will be updated. Interventions will be reviewed weekly in the SOC meeting by the IDT to ensure proper interventions have been put in place. The monitoring will be presented at the monthly Quality Assurance Performance Improvement meetings for a minimum of three months. IDT team will schedule the comprehensive care plans to make sure they are completed within twenty one days after a resident admits. As of 6/27/24 and going forward the Clinical Support Specialist will monitor to make sure care plans are completed and going forward the DON will be responsible for completing the comprehensive care plan. 4. QAPI Committee Review - An Ad Hoc QAPI committee meeting will be completed on 06/27/2024. 5. Facility does not utilize agency staff The Plan of Removal was verified by: 1. -During an interview on 6/28/2024 at 4:27 pm the Administrator said she notified the Medical Director on 6/26/2024 of the IJ situation. She stated she explained the details of the IJ including the fall of Resident #1 and the POR including need for AD HOC meeting. The Administrator stated the Medical Director informed her she would come to the facility the following day (6/27/2024). -Record review of a facility Fall Risk Assessment tools revealed fall assessments dated 6/26/2024 were completed for all 26 current residents. -During an interview on 6/28/2024 at 3:50 pm the DON stated she completed a new fall risk assessment on 100% of the residents. She stated approximately 4-5 residents were upgraded to high fall risk for a total of 6 residents identified as high risk, and this included Resident #1. Record review of care plans for all 26 current residents revealed fall risk was added to all plans of care. -During an interview on 6/28/2024 at 5:17 p.m. the Clinical Support Specialist (Corporate RN) stated she assisted the DON with reviewing all resident care plans to ensure the residents had interventions in place for fall risk. -Record review of Kardex's for the 6 residents identified as high risk revealed each Kardex stated the resident was a high fall risk and had interventions that were specific to each resident as identified on the individualized care plan. -During an interview on 6/28/2024 at 3:52 pm the DON stated she reviewed the Kardex of the 6 residents identified as high-risk for falls including Resident #1, #5, #6, #7, #8, and #9. -During an interview on 6/28/2024 at

Based on observations, interviews, and record reviews, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents and supervision, in that; The facility failed to ensure Resident #1 was supervised while ambulating and had interventions in place to prevent falls. Resident #1 who was admitted with a significant history of falls, had 5 documented falls at the facility from admission to discharge, 6/05/2024 date of admission, 6/09/2024, 6/12/2024 x 2 and 6/24/2024 when he fell during the night and suffered a subdural hematoma (a pool of blood between the brain and its outermost covering) and required a hospital stay in ICU. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 6/26/2024 at 3:50 PM. The IJ template was provided to the facility on [DATE] at 3:50 PM. While the immediacy was removed on 6/28/2024 at 7:58 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm due to the facility's need to monitor the implementation of the plan of removal. This deficient practice could affect all residents and place them at risk for accidents and falls resulting in injury, disability, or death. The findings included: Record review of Form 3613-A Provider Investigation Report dated 6/24/2024 revealed the facility self-reported to the state agency a fall with major injury for Resident #1. The report indicated Resident #1 had a history of falls prior to admission, a history of falls in the facility, was independently ambulatory and required no special supervision. The report indicated Resident #1 had an unwitnessed fall with a laceration to the back of the head. The facility investigation findings of fall with injury were confirmed by the Administrator on 6/28/2024. Record review of Resident #1's face sheet, dated 6/25/2024 revealed an admitted [DATE] with diagnoses which included: unspecified fracture of fifth lumbar vertebra sequela (6/04/2024 - a fracture that occured after initial encounter), parkinsonism (movement disorder from deterioration of the brain which typically involves slowed movements, rigidity or stiffness and tremors), progressive supranuclear ophthalmoplegia [Steele-[NAME]-[NAME] syndrome] (Also known as PSP: a rare progressive brain disease which affects walking, balance, eye movements and swallowing. Damage of cells in the areas of brain that control body movement, coordination and thinking), abnormalities with gait and mobility, generalized muscle weakness (decrease in strength), glaucoma (damage to the optic nerve which provides information to the brain either with or without raised pressure in the eye and leads to vision loss) and insomnia (trouble falling or staying asleep). Record review of Resident #1's hospital discharge summary dated 6/04/2024 before admission to the facility on [DATE] revealed the resident had a fall on 5/11/2024 with fracture of spinous process of cervical vertebrae (break in the bones of the neck) (5/11/2024) with fusion of cervical spine on 5/17/2024 (surgical repair of the fracture). The hospital discharge stated Resident #1 had multiple falls in the past year. Record review of Resident #1's 5-day admission MDS assessment revealed a BIMS of 13 which indicated the resident was cognitively intact. The fall history on admission listed no fall history. Resident #1's functional status was listed as unable to ambulate with maximum assistance needed for ADL care including coming from sit to stand position. Record review of Resident #1's admission fall risk assessment dated [DATE] revealed the resident was at high risk for falls with a history of 3 or more falls in the past 3 months. Record review of Resident #1's baseline care plan dated 6/05/2024 revealed the resident required supervision or touch assistance to stand and transfer and walking was not attempted. The baseline care plan indicated Resident #1 had a history of falls in the last month prior to admission with no additional input on interventions to prevent falls. The baseline care plan was signed by the DOR. Record review of Resident #1's care plan conference dated 6/12/2024 revealed the resident had limited assist for ADL care and stood up unassisted. The notes stated he had a couple of falls, tended to be impulsive and was more active at night. It also noted his impaired vision related to glaucoma, diagnoses of fracture of vertebra sequala, and PSP. The Document was signed by the SW. Record review of physician orders revealed an order for fall mat to side of bed while in bed for safety with a start date of 6/05/2024. Record review of Resident #1's Fall Incident Report dated 6/5/2024 (date of admission) revealed a nurse (unknown) heard a banging sound coming from the resident room and observed Resident #1 lying on floor beside bed partially on the fall mat and partially on floor. No injuries noted. The report indicated Resident #1 was confused and listed predisposing situation factors as: admitted within last 72 hours and ambulating without assistance. No interventions to prevent future falls were documented. Report documented by LVN L. Record review of Resident #1's Physical Therapy Evaluation and Treatment Plan dated 6/07/2024 revealed Resident #1 was a fall risk and had a cervical collar (neck brace that prevents movement of the neck) in place 24/7 (24 hours a day, 7 days a week). The evaluation indicated Resident #1 had impairment of strength to his lower extremities (legs and hips). Fall predictors: inadequate postural control, discontinuity of steps and weak trunk and hip extensors. (Inability to control posture, unequal steps while walking and weakness). Record review of Resident #1's Fall Incident Report dated 6/09/2024 revealed Resident #1 was heard making a loud grunt when LVN P saw Resident #1 sitting on the floor with his back against the door. He stated he was sitting down and needed to use the restroom. He was noted with low blood pressure of 86/48 upon assessment and the MD was notified. No injuries noted. Predisposing factors were documented as confusion, gait imbalance, impaired memory and ambulating without assistance. No interventions to prevent future falls were documented. Report documented by the DON. Record review of Resident #1's Fall Incident Report dated 6/12/2024 at 3:20 p.m., revealed Resident #1 was reaching for his phone on the floor when he lost balance and sat on the floor. No injuries were noted. The report indicated Resident #1 was cognitively intact with predisposing factors which included: gait imbalance, ambulating without assist, transfer, using wheeled walker. The report stated Resident #1 transfers and ambulates without assistance. Nursing staff had educated the resident multiple times on how to use call light for assistance. There were no interventions to prevent future falls documented. The document was signed by LVN G. Record review of Resident #1's Fall Incident Report dated 6/12/2024 at 3:31 p.m. revealed Resident #1 stated he fell and hit his head on his walker but did not tell anyone. An abrasion was observed to the top of his scalp. Predisposing factors included poor lighting and using walker. No interventions were documented to prevent future falls. The document was signed by LVN P. Record review of Resident #1's Fall Incident Report dated 6/24/2024 at 3:45 am revealed LVN P documented that around 3:45 am she heard Resident #1 yelling help from his room and found him seated on his bottom scooting towards the door. Resident #1 stated he was going forward in his wheelchair and fell . Later he stated he was standing up with his walker and fell back but does not recall what happened or why he fell . Upon assessment Resident #1's left pupil was larger than the right pupil and bleeding was noted from the back of his head. Resident #1 stated Where am I, where am I? Pressure was applied to his head and 911 was called. Resident #1 was sent to the hospital. Predisposing factors were listed as other without further explanation. No interventions were documented to prevent future falls. Record review of hospital ER records dated 6/24/2024 for Resident #1 revealed Resident #1 was brought into the ER via EMS after a fall at the nursing facility. Nursing home staff stated he fell backwards, hitting his head on the ground. He had an Aspen c-collar (stiff neck brace that prevents movement of the head) in place as he is currently recovering from a recent fracture of C5 (break to the bones in neck). Resident #1 reported pain to the back of his head. Upon exam Resident #1 had an abrasion to the back of his head and his left pupil was larger than the right. A brain CT revealed he had a small subdural hemorrhage (a pool of blood between the brain and its outermost covering) and posterior scalp (back of the head) soft tissue swelling. Resident #1 was transferred from the local hospital to a trauma center at larger hospital in a nearby city. Record review of hospital records dated 6/25/2024 from the trauma hospital revealed Resident #1 had a diagnosis of fall with subdural hemorrhage on aspirin use (anticoagulated medication). The resident was monitored in ICU for changes in neuro status. Repeated brain CT showed no worsening of the subdural hemorrhage and he was discharged back to the facility. Record review of a handwritten document of a witness statement dated 6/26/2024 for CNA Z revealed at 3:30 ish (am) patient (Resident #1) in living room- he walked back to his room with us observing him, heard yelling from room. Patient told staff he fell face first but head bleeding from back, then patient stated he was standing with walker and fell backwards, did not know what happened. Clarification written on 6/28/2024 added additional information which included: patient did have walker in TV room and used that to walk back to his room prior to hearing resident yell for help. Both walker and wheelchair were present close to resident when he was found. The document was signed by the Administrator. Record review of Resident #1's medical record revealed the comprehensive care plan was blank and no comprehensive plan of care had been initiated. During an interview on 6/25/2024 at 12:02 p.m., Resident #1's family member stated Resident #1 does not sleep during the night very well. She stated he was strong in his legs but unsteady on his legs. She stated when he needed to go to the bathroom he will go and if he cannot sleep, he will get up and go sit in a chair. She stated his disease made it so he was oblivious to a lot of things. She stated he does not know pain or hunger but was able to make his needs known. She stated she was currently with Resident #1 at the hospital after his fall at the facility. She stated he had a bleed in his brain. She stated he had a history of many falls. During an interview on 6/25/2024 at 1:46 p.m., CNA A stated she identifies residents who are at risk for falls from report. She stated she just learned today that the POC (point of care, computer access for CNA's) also would indicate a risk for falls. She stated she had not looked at Resident #1's POC and was not aware of any interventions for fall risk for Resident #1. She stated, at times, Resident #1 did not call for assistance and was refusing ADL care. CNA A stated she was not certain if she had training on fall prevention. During an interview on 6/25/2024 at 2:01 p.m., LVN B stated the CNAs were trained to identify residents at risk for falls by the POC and Kardex (a document that list interventions for care). LVN B demonstrated how the Kardex was pulled up in PCC (Point Click Care - the facility's electronic record system) which resulted in showing a blank Kardex. LVN B stated she had not seen any care plans for residents including Resident #1. She stated if there were no care plans then the Kardex were not loading because they were generated from the care plan. LVN B stated without care plans they had no way of identifying interventions for falls. She stated most residents with fall risk had low beds and fall mats ordered by a physician. She stated another way was during CNA-to-CNA report. LVN B stated if there was anything specific going on she would tell the CNA. LVN B stated the facility did not have any visual identification for fall risk. LVN B stated Resident #1 had one side of his bed against the wall, a low bed and a fall mat. She stated at night, he got up to go to the bathroom and sometimes was unable to urinate. LVN B stated Resident #1 got up all the time, he was never in bed and only slept in small spurts. She stated this did not happen during the daytime, only at night. She stated during the day he used his call light. LVN B stated the DON had been working nights because a nurse had walked out and the Corporate DON was not on site for issues. LVN B stated she did not have access to the facility fall prevention policy and had no training for falls. During an interview on 6/25/2024 at 3:37 p.m., the DOR stated Resident #1 was making progress in therapy. She stated he had worked on strengthening, endurance and safety. She described Resident #1 as impulsive. The DOR stated therapy had him not walking by himself and walking with the assistance of staff. She stated when he used his walker on his own, he should be redirected. The DOR stated either the resident's family member or staff should walk with him with the walker, and he needed assistance with ADLs such as dressing. The DOR stated Resident #1 wore a cervical collar from a fall with injury prior to coming to the facility. She stated he wore the collar at all times, and it hindered his vision and view because his neck was not mobile. The DOR stated Resident #1's progress had fluctuated during therapy. She stated he was starting to need less assistance. For instance, he could now push up to standing with just stand by assistance. The DOR stated she was aware of 3 falls he had since admission. The fall on 6/24/2024 and two priors on unknown dates. She stated he had a fall mat in place and staff had expressed concerns for him using the walker by himself. She stated they tried to keep him in the TV room so they could visually see him, but he was pretty impulsive and would get up by himself and go back to his room on his own. The DOR stated on 6/12/2024 they had a care plan meeting in which the family member, DON, SW, BOM, and herself attended. She stated they discussed that Resident #1 stood up unassisted with a couple of falls and tended to be impulsive and that he was more active at night. She stated this should be documented in his care plan, but she was not responsible for it. She stated the notes from the meeting indicated Resident #1 was on a fall prevention program, but the facility did not have a fall prevention program in place. She stated she had spoken to the DON about starting a program with colored signs of red, yellow and green stop signs that would alert both the resident and staff to their fall risk, but nothing currently was in place, and it was on her to-do list. The DOR stated as of today, there was nothing used to identify residents at high risk for falls. She stated verbal reports were given to CNAs and nursing staff that a resident was at risk for falls. The DOR stated she had reviewed a lot of documents and could not say whether or not she had reviewed the facility fall prevention policy. During an interview on 6/25/2024 at 4:19 p.m., LVN L stated Resident #1 wore a neck brace due to a fall prior to admission. She stated on an unknown date (documented as 6/05/2024 which was date of admission), she heard a noise coming from Resident #1's room. She stated he had a fall mat beside his bed and she found him half-way on the fall mat. She stated he had no injuries. She stated to her knowledge he had no other falls. LVN L stated for fall interventions they had fall mat and low bed. She stated Resident #1 kept trying to get up on his own and needed assistance getting up. She stated he was able to walk with his walker but need help to stabilize while he walked because he would get off balance. She stated she did not edit or update his care plan after his fall although as a charge nurse she was able to do so. She stated CNA staff were informed of fall risk by the Kardex or by staff verbally telling them. She stated she had been trained on fall prevention (date unknown). During an interview on 6/25/2024 at 4:29 p.m., LVN D stated Resident #1 would stand up by himself and they had to keep a close eye on him, but she had other residents. She stated Resident #1 was able to walk with supervision, but that was not always the case. She stated the facility staff could not be there 24-hours a day and she had other residents to take care of. She stated she would sit him in his wheelchair and move him upfront. She stated she never witnessed a fall but did see him sit on the floor, crawl on the floor, and lean on the wall for support. She stated another nurse saw him stand and then watched him slide down the wall to the floor, but she never personally saw it. She stated she knows LVN P have found him on the floor in his room (date unknown) on night shift. She stated interventions she used to prevent falls were redirection, have him lay back down, have him sit in a chair and take him to watch TV. She stated he never stayed put and he took little naps during the night of approximately 30 minutes. She stated him attempting to get up was constant. She stated he did not use his call light. She stated even when she gave him the call light, he would not push it or if he pushed it he would not wait. LVN D stated she does not remember any safety devices for interventions. LVN D stated she just had basic fall training and could not remember the details or the date. During an interview on 6/25/2024 at 5:15 p.m., CNA C stated she was night shift. She stated Resident #1 was constantly up at night. She stated he did not stay in his room very often and did not sleep except for about 20 minutes at a time. She stated she usually helped him up to the bathroom and to his bed. She stated she was told she had to watch him for safety but did not know why. She stated she was not aware of his fall risk or history of falls. She stated she did not know what she was told about his fall risk. CNA C stated Resident #1 wore a neck brace, he was alert and he was able to answer questions. She stated he had a fall mat, walker and wheelchair for interventions and nothing else that she was aware of. CNA C stated she had been trained on fall prevention during orientation. She stated she knew she had to look at environmental things to make sure nothing was in the resident's path. During an interview on 6/25/2024 at 5:43 p.m., the SW stated Resident #1 had a comprehensive care plan meeting about one week after his admission. The SW stated he facilitated the meeting and documented the notes. He stated during Resident #1's meeting, his PSP disease which was related to Parkinson's disease was discussed because the diagnoses made people fall backwards. The SW stated this had happened several times before admission requiring Resident #1 to wear a neck collar. The SW stated Resident #1 was walking and therapy was encouraging him to be safe. The SW stated he was aware Resident #1 had several falls since admission to the facility. He stated he could not recall the specifics that were discussed about interventions. He stated Resident #1 was impulsive and would do things outside the realm of recommendations such as get on the floor by himself. The SW stated staff set verbal boundaries and they all know he was a fall risk and why he was here. He stated that was why he was getting therapy. He stated he did not note in his documentation or notes any specific interventions to prevent falls and was not responsible for the care plan. During an interview on 6/25/2024 at 6:00 p.m., The DON stated the facility was brand new and just got their license as of 5/31/2024. She stated since the opening she was having to work a floor nurse, mostly at night because they did not have enough licensed staff. She stated she had worked as a charge nurse for the past 30 days which absolutely limited what she could do as a DON. She stated she was not able to attend morning meetings, IDT or care plan meetings. She stated her primary focus had been patient care and communication with floor staff. The DON stated the Administrator and Clinical Support Specialist (Corporate RN) were both aware of her limitations. She stated the response from the Administrator was nothing was being done to help the situation. The DON stated she was available 24/7 by phone and staff was instructed to call her for any change of condition and they had clear direction on what to do. The DON stated the facility did not have an ADON and she was the only RN working at the facility. The DON stated acknowledgement that Resident #1 did not have a care plan to address his falls. She stated they did have an order (physician order) for a fall mat. She stated the DOR was working specifically with Resident #1. The DON stated during his care plan meeting the family member of Resident #1 stated he did not sleep at night and that was his normal routine. The DON stated as Resident #1 had gotten stronger with therapy, he was now more mobile and was coming out of his room. She stated they were all trying to keep an eye on him, but it was usually just her and 1-2 CNAs during night shift. She stated Resident #1 would move around and they were unaware he was up. She stated the facility was a big empty building with a lot of vacant real estate in which he could move around unsupervised before they realized he was up. The DON stated she was aware of his fall history early in his admission process. The DON stated the family member typically sat with Resident #1 during the day and left in the early evening. The DON stated they were not updating the care plan after each fall because there was no care plan. She stated the incident/accident list was the most accurate documentation of his falls. She stated to her knowledge Resident #1 had 5 falls since admission. She stated the latest one was the only one in which he sustained an injury. The DON stated the causative factor in Resident #1's falls was his impulsivity. She stated fall interventions consisted of low bed, fall mat, keep an eye on him and therapy. She stated the Kardex was not updated for use by the CNAs because there was no care plan. The DON stated the CNAs were told verbally about fall risk and interventions since the Kardex was not accurate. She stated they were also rounding (checking on him) every 2-3 hours. The DON stated since the facility was new the DOR had not had a chance to implement her fall prevention program and she was not aware of the yellow sticker identification mentioned in the facility's fall prevention policy. The DON stated Resident #1 was on increased rounding of 1-hour intervals but his supervision was not spelled out, meaning that the level of supervision needed wasn't made clear. She stated they did not put any new interventions in place after each fall. The DON stated it was important to prevent falls to prevent injury. She stated she considered a brain bleed a serious injury. She stated all staff were responsible for ensuring resident safety. The DON stated she monitored staff by working on the floor with them as she was and having direct contact with them. She stated she was not doing medical record audits because she did not have time. The DON stated she does not think Resident #1's fall could have been prevented due to the resident's impulsivity unless he had 1:1 supervision. The DON stated she did feel Resident #1 was appropriately placed and they had not discussed discharging him although they had discussed his need for supervision with the family member during the care plan meeting which was why the family member spent so much time at the facility. During an observation/interview on 6/26/2024 at 8:22 a.m., Resident #1 was observed in bed with a cervical collar in place. He was laying on his right side in a fetal position with an eye mask covering his eyes. Although he was sleeping with his eyes closed, his right hand was fiddling with the light cord constantly. His call light was under the covers. A fall mat was on the floor beside the bed with the bed in low position. There was no yellow sticker beside his name on the door name plate to indicate he was at risk for falls. During an interview on 6/26/2024 at 9:05 a.m., the Administrator stated the facility was new and had opened at the end of March 2024 but had received their license more recently (date unknown). She stated she was aware Resident #1 had repeated falls and had no comprehensive care plan and that his baseline care plan had not been updated. The Administrator stated she ensured staff knew how to care for Resident #1 by giving verbal report to each other. She stated they did not have specific interventions in place to prevent Resident #1 from falling. She stated they did talk about falls during morning meetings including the use of fall mats, keeping him in eyesight and reminding him to use the call-light but these were not written down. The Administrator stated it was important to write the interventions down so staff will know how to take care of patients and for communicating. The Administrator stated she was ensuring the safety of the residents by doing visual checks of staff answering call lights and going into rooms and by verbal communication with staff, management, and therapy. The Administrator stated management was assisting with call lights and that leadership staff would monitor call lights/answer them as needed. She stated she did not have an ADON on staff and would not until the census reached approximately 40 residents. She stated the current census was 28. She stated she was hiring staff as they build their census. The Administrator stated she had briefly reviewed the facility fall prevention policy. She stated she was not aware certain aspects were not implemented. She stated the DON was responsible for the implementation. The Administrator stated the consequences of the fall prevention policy not being implemented were potential resident harm. The Administrator stated the DON had communicated she was not able to fulfill her DON duties and the corporate leaders knew the DON was struggling. The Administrator stated she had tried to remedy the situation by continuing to hire more staff. The Administrator stated she was responsible for facility management but was not always able to make decisions independently of Corporate. During a interview on 6/26/2024 at 9:47 p.m., LVN P stated she worked night shift. She stated Resident #1 came to the facility to recover from a C4-5 fracture (from a fall). She stated they knew he was a fall risk. She stated the first week in the facility she would take him everywhere with her, including when she was passing medications to other residents because he was constantly getting up. She stated she would also round on him every 30 minutes to 1 hour. LVN P stated Resident #1's family member stated at home he would sleep on the couch and got a max of 2 hours of sleep and would wander at night. LVN P stated she would tell him to use the call light and she would let him watch movies on the TV because he was alert and oriented. LVN P stated he knows how to use the call light and will use it when he has to go to the bathroom. She stated Resident #1 had a low bed. LVN P stated Resident #1 was able to walk on his own. She stated at first, they had him in the wheelchair, then he had therapy and now used the walker. LVN P stated she does supervise Resident #1 while he was using the walker but did not know what everyone else does. She stated she had not seen anything on his chart and no one had told her he needed supervision while walking. She stated she supervised him because she knows he is a fall risk and she tried to tend to him the best she could. LVN P stated she told the CNAs verbally what the residents needs were and she will explain if there is a fall risk and remind the CNAs to make rounds. LVN P stated she had not looked for Resident #1's care plan because the DON told her about Resident #1's needs. She stated she went off what she was verbally told. LVN P stated on 6/24/2024 she put Resident #1 to bed and then had to deal with an emergency with another patient. She stated she finally had a chance to sit down and chart when she heard Resident #1 yell for help. She stated she went into his room and he was seated on his butt while scooting to the door. She stated Resident #1 stated he was scooting in his wheelchair and fell forward. She stated she assessed him and noted a cut on the back of his head. She stated while she was applying pressure to his head, she asked him again what happened, and he repeated it but it did not make sense since the cut was on the back of his head. LVN P stated he then stated he stood up with his walker and fell back. LVN P stated she was assessing his pupils when she noted one was getting larger than the other. She stated she called the DON but already knew she needed to send him out and called 911. LVN P stated Resident #1's character began to change. He started saying Where am I and started to get confused. She stated his pupils were also not equal. LVN P stated she did not notice anything that could have contributed to his fall. She stated Resident #1 must have gotten up and walked to his walker. She stated she assumed he fell back and hit his head because the wound was on the back of his head and he did not remember how he fell . LVN P stated prior to the fall the last time she checked on him was when she was walking down the hall a few minutes before. LVN P did not answer direct questions about whether or not she had addressed Resident #1's insomnia with the physician. She stated he was on Seroquel (an antipsychotic medication) for delirium which also helps with sleep, but the family member had requested it be discontinued (date unknown). She stated the family member did not want him on any sleep medications because she said his wakefulness at night was his normal pattern. LVN P stated Resident #1 needed 1:1 supervision at night. She stated everyone in administration was aware he needed lots of attention. She stated they had all talked about how frequently he got up. LVN P stated she was not aware of the fall policy. She stated staff needed a visual indicator of fall risk. During an observation on 6/26/2024 at 11:22 a.m., Resident #1 was observed sleeping with low bed and fall mat in place. Resident #1 responded to his name when called but put up his hand and declined an interview. During an interview on 6/26/2024 at 11:36 a.m., LVN G stated she could not recall any falls or specific care for Resident #1. During an observation/interview on 6/27/2024 at 10:17 a.m. Resident #1 was observed sleeping in bed. His family member was at bedside. The family member refused entrance to the resident's room and stated Resident #1 did not want to talk to the surveyor. The family member stated Resident #1 had PSP which caused him to fall. She stated since his last fall she had purchased a soft helmet to protect his head from falls. During an interview on 6/28/2024 at 3:39 p.m. CNA Z stated on 6/24/2024 at approximately 3:40 am Resident #1 was seated in the living room watching TV. She stated she observed him get up and use his walker heading back to his room. She stated he was using his walking and was walking perfectly fine. CNA Z stated she knew he needed assistance with walking but LVN P told her he was fine and that he was okay without the assistance. CNA Z stated when she was watching him walk, he was doing just fine. She stated he was a fast mover and he would sneak past them, but she did watch him walk and he seemed okay. She stated a short while later she heard help help help coming from his room. She stated Resident #1 was on the floor in his room with bleeding from his head. CNA Z stated he demonstrated leaning forward from his wheelchair, but he had a cut on the back on his head. CNA Z stated LVN P was the nurse who also responded. CNA Z stated later Resident #1 [TRUNCATED]