Every finding on record at Brenham Nursing and Rehabilitation Center

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 in 1 of 1 kitchen reviewed for kitchen sanitation.1. The facility failed to ensure foods in the reach in refrigerator located in the kitchen were labeled and dated to include the use by date or prepared/pulled date.2. The facility failed to ensure food was stored in a manner as to prevent contamination (sealed) in the walk-in refrigerator.3. The facility failed to ensure foods in the walk-in refrigerator were labeled and dated to include the use by date or prepared/pulled date.Findings included:During a tour of the kitchen on 06/20/2026 at 09:48 AM revealed the following:In the reach-in refrigerator in the kitchen revealed a salad in a Styrofoam container with two small, sealed cups of a white thick liquid substance sitting on top of it. Two plates with salads on them wrapped in plastic wrap. There was no labeling to include what the food was, the prepared date, or a use by date on the items listed.In the walk-in refrigerator revealed an opened clear bag with a block of cheese and a plastic container with mixed vegetables in a clear liquid with the lid opened approximately 1/2 inch on one of the four corners on the shelves and a box of bananas sitting on the floor.In the walk-in refrigerator revealed a pan with 11 meat and cheese sandwiches individually wrapped in plastic bags, a container labeled crumbs for puree cereal, a container with a dark brown/grayish substance without labels with a pulled/prepared or use-by date. During an interview on 06/20/2026 at 09:53 AM, CK B stated she was responsible for the kitchen at that time. She stated all food items stored were required to be labeled with their contents and when they were prepared or opened. CK B stated all opened food items were to be stored in a sealed bag or covered container. She stated all food items were expected to be stored off the floor and on the shelves. She stated the bananas were on the floor because someone must have been getting something off the shelf and forgot to put the bananas back. CK B stated she had been off work the previous two days and she was unsure why the food was open or unlabeled, but she was going to throw the items away. CK B stated if residents were served food that was unlabeled or left open when stored, then the food could possibly make the residents very sick.During an interview on 06/20/2026 at 12:21 PM, the RDD stated she had been trained in how to store food. She stated all left-over food items were required to be labeled and dated and have a use by date. She stated all dietary staff are expected to label all leftovers immediately upon storing it. The RDD stated it was the responsibility of the DM to monitor during his daily rounds for food items to be stored and labeled according to policy. She stated the food items were required to be stored and labeled according to policy so the staff will be certain of the expiration date. The RDD stated she did not have an answer for why the food was not stored or labeled according to facility policy.During an interview on 06/20/2026 at 02:18 PM, the DM stated he had received training related to food storage. He stated the most recent training included all food items should be labeled with what the contents were, when it was made and when the contents expired. He stated he expected all dietary staff to label everything prior to placing the item in the refrigerator. He stated all food items were required to be stored in sealed containers off the floor. He stated if food was not labeled then staff would not know when food was old and unusable. The DM stated the old food, or improperly stored food could potentially make the residents sick. He stated the cooks were responsible for monitoring food storage and labeling at the beginning of their shift. The DM stated he did not know why food was not labeled in the refrigerators and there were food items that were not covered or stored off the floor.During an interview on 06/20/2026 at 02:40 PM, the DON stated there was one resident in the facility that had orders for nothing-by-mouth indicating they are not allowed to eat anything. She stated she had received training for food storage that included all food items required labeling with contents, open date and expiration dates. She stated the training also included the requirement to store food off the ground and in sealed containers. The DON stated the dietary staff were responsible for the storage and labeling of all food items in the refrigerator. She stated if food was not stored according to policy, then the food could cause sickness including diarrhea. The DON stated the ADM was not available at the time of the interview.Review of facility policy titled Food Storage, dated 10/01/2018 and last revised 06/01/2019, reflected, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to state, federal and US Food Codes and HACCP guidelines.Procedure:.2. Refrigerators.b. Store all foods on racks or shelves off the floor.d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.e. Use all leftovers within 72 hours. Discard items that are over 72 hours old.

Based on interviews, and record review, the facility failed to ensure the resident's right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 of 11 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's door and privacy curtain were closed during personal care to provide respect and dignity. This failure could place residents at risk of feeling uncomfortable, embarrassed, and a decreased quality of life.Findings included: Review of Resident #1's admission record, dated 06/19/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included: unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), heart failure (the heart does not pump blood as well as it should making it harder to provide the body with oxygen and nutrients that it needs), and chronic kidney disease (the kidneys gradually lose their ability to filter waste and extra fluid from the blood).Review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS was not conducted due to short-term and long-term memory problems. Section GG - Functional Abilities reflected Resident #1 was dependent on staff for toileting hygiene. Section H - Bowel and Bladder reflected Resident #1 was always incontinent (inability to control bodily functions) of bowel and bladder.Review of Resident #1's care plan dated 11/01/2024 and last revised 02/17/2026 reflected a problem of [Resident #1]'s side of room is monitored by video-surveillance per family and resident request with goal of [Resident #1] and her family's request will be honored for video surveillance of room through the next review.Review of Resident #1's care plan dated 05/09/2024 and last reviewed 03/18/2026 reflected a problem of [Resident #1] has an ADL self-care performance deficit r/t Dementia, weakens [sic], unsteadiness, and muscle wasting. with interventions that included INCONTINENT CARE: The resident requires total assist by 1-2 staff for INCONTINENT CARE.Review of video dated 06/08/2026 from 09:26 AM - 09:31 AM reflected NA F entered Resident #1's room, uncovered Resident #1 and provided incontinence care, which exposed Resident #1's bare skin from waist down to knees, without pulling the privacy curtain closed or shutting the door to provide privacy for Resident #1.During an interview on 06/20/2026 at 10:40 AM, Resident #1 was asked if it bothered her that staff left the door open when they provided incontinence care and exposed her private areas to the hallway. Resident #1 stated that it did not bother her. Resident #1 answered other questions appropriately during the interview.During an interview on 06/20/2026 at 12:33 PM, LVN A stated she had been trained in resident rights that included the resident's right to privacy. She stated all staff are responsible for providing privacy to all residents by closing the door and privacy curtain when staff are providing incontinence care. LVN A stated the nursing managers monitored to ensure staff provided privacy for the residents during incontinence care by making observations during their nurse manager rounds. LVN A stated by not providing privacy during incontinent care, the resident may feel embarrassed.During an interview on 06/20/2026 at 12:52 PM, CNA E stated she had been trained in resident rights that included the resident's right to privacy. She stated all staff are responsible for providing privacy to all residents by closing the door and privacy curtain when staff are providing incontinence care. CNA E stated the nursing managers monitored to ensure staff provided privacy for the residents during incontinence care by making observations during their nurse manager rounds. CNA E stated by not providing privacy during incontinent care, the resident may feel very uncomfortable.During an interview on 06/20/2026 at 01:06 PM, CNA D stated she had been trained in resident rights that included the resident's right to privacy. She stated all staff are responsible for providing privacy to all residents by closing the door and privacy curtain when staff are providing incontinence care. She stated she was unsure if anyone monitored to ensure staff provide privacy to the residents during incontinence care. CNA D stated by not providing privacy during incontinent care, the resident may feel like their rights were violated and shamed that their private areas were exposed to other residents.During an interview on 06/20/2026 at 01:39 PM, RN C stated she had been trained in resident rights that included the resident's right to privacy. She stated all staff are responsible for providing privacy to all residents by closing the door and privacy curtain when staff are providing incontinence care. RN C stated CNAs, nurses and the DON monitored to ensure staff provided privacy for the residents during incontinence care by making observations during their rounds. RN C stated by not providing privacy during incontinent care, the resident may feel like they are not a person anymore.During an interview on 06/20/2026 at 02:00 PM, NA F stated she had been trained in resident rights that included the resident's right to privacy. She stated all staff are responsible for providing privacy to all residents by closing the door and privacy curtain when staff are providing incontinence care. NA F stated the nurses monitored to ensure staff provided privacy for the residents during incontinence care by making observations during their rounds. NA F stated by not providing privacy during incontinent care, the resident may feel uncomfortable. NA F was provided with the video to review. NA F acknowledged it was her in the video and stated, I forgot to close the door and privacy curtain, I am not sure what I was thinking.During an interview on 06/20/2026 at 02:40 PM, the DON stated she had been trained in resident rights that included the resident's right to privacy. She stated all staff are responsible for providing privacy to all residents by closing the door and privacy curtain when staff are providing incontinence care. The DON stated all staff were responsible for monitoring for the privacy curtains and doors to be closed when incontinence care is provided to the residents. The DON stated that by not providing privacy during incontinent care, the resident may feel uncomfortable.Review of, undated, facility policy titled Resident Rights, reflected .Statement of Resident Rights.You the resident, do not give up any rights when you enter a nursing facility.You have the right to:.6. Privacy.Rights of Elderly Individuals.g. An elderly individual is entitled to privacy while attending to personal needs.This right applies to medical treatment.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Residents #1) reviewed for care plans. The facility failed to have a comprehensive person-centered care plan for Resident #1 to address his discharge. This failure could place residents at risk of not receiving care and services to meet individualized, behavioral, medical and nursing needs. Findings included:Record review of Resident #1's face sheet, dated 05/27/2026, revealed an eighty-two-year-old female who was admitted to the facility on [DATE] with a diagnosis that included hemiplegia (severe or complete paralysis of one entire side of the body), nontraumatic intracerebral hemorrhage in hemisphere, cortical (bleeding within the cerebral cortex not caused by an injury), and dementia (a decline in cognitive abilities-such as memory, reasoning, and language-severe enough to interfere with daily life). Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) dated 05/13/2026, Nursing Home Comprehensive Section C - Cognitive Patterns revealed a score of 6 indicating severe cognitive issues. Record review of Resident #1's care plan revealed a focus dated 04/28/2025, discharge planning has been discussed with family. Discharge to the community is not expected.Date Initiated: 06/30/2025 Record review of Resident #1's MDS Nursing Home discharge date d 04/24/2026 reflected Section A - Identification Information reflected Type of discharge - planned. Record review of Resident #1's progress notes dated 04/25/2026 reflected Resident #1 discharged from the facility. Vital signs were stable. During an interview on 05/24/2026 at 12:17 PM the Administrator said the facility should have care planned for Resident #1's discharge beginning 04/02/2026 because Resident #1 was wandering and exit seeking. The Administrator said he told Resident #1's family that the facility was not the best placement for him and gave the family suggestions for facilities that had locked units. During an interview on 05/25/2026 at 2:06 PM with the facility SW, she said she said she did not care plan for Resident #1's discharge. The SW said the care plan should have been changed when it was decided he was going to be discharged to another facility. The SW said a care plan as where they documented what need the resident needed including their goals and interventions. The SW said she was responsible for care planning Resident #1's discharge. She said a possible negative effect of not care planning for a resident's discharge was that the staff would not know what was going on and with the resident and there is a possibility that the discharge would not go smoothly and thing would get missed. During an interview on 05/25/2026 at 2:24 PM with the Administrator, he said the SW and the LT MDSC would be responsible for care planning a resident's discharge. The Administrator said a care plan was a snapshot of a resident's abilities and disabilities. The Administrator said it was important to care plan a discharge so everyone would understand the end goal. The Administrator said a possible negative effect of not care planning for a resident's discharge would be that something might be left off or there might be a misstep for the resident. Attempted interview on 05/25/2026 at 2:27 PM of the LT MDSC. Left a VM and sent a text message. Record review of facility policy Care Plan Revisions Upon Status Change dated 10/23/2022 revealed the purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident conditions and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the residents will report resident responses to new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The Unit Manager or other designated staff members will communicate care plan interventions to all staff involved in the resident's care. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. 3. The MDS Coordinator will determine whether a Significant Change in Status Assessment is warranted. If so, the assessment will be completed according to established procedures

Based on interview and record review the facility failed the facility failed to ensure the resident environment remained as free of accidents and hazards as is possible for one resident (Resident #2) of six reviewed for mechanical lift transfers.The facility failed to ensure Resident #2 received adequate supervision and assistive devices to prevent accidents as CNA B failed to transfer Resident #2 with a mechanical lift (assistive device) with another staff to assist as required. This failure puts residents at risk for harm, injury and decreased quality of life.Findings included:Review of Resident #2 face sheet dated 05/19/2026 revealed Resident #2 was a [AGE] year old female admitted to the facility on [DATE] with a diagnoses of previous history of a stroke, dementia (decline in mental ability affecting memory, thinking and communication), heart failure (serious chronic condition where the heart cannot pump enough oxygen rich blood to meet the body's demands), high blood pressure and chronic kidney disease stage 3 (disease from moderately damaged kidneys functioning at 30%-59% of their normal capacity with a history of kidney cancer. Review of Resident #2 MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of zero to indicate severely impaired cognition. The functional abilities section GG was blank regarding Resident #2's functional limitations and abilities. Review of Resident #2 Care Plan dated 01/26/2026 revealed Resident #2 required total assist with transfers with mechanical lift by two to move between surfaces and as necessary.During an interview on 05/22/26 at 11:26 AM Resident #2 Family Member stated she had video of Resident #2 being transferred with only one staff using the mechanical lift. She stated she did not feel it was safe for Resident #2 to be transferred with the mechanical lift with only one staff member. She stated she notified the DON and wrote a grievance about her concern. She stated she was not sure what was done with the complaint. Review of a video dated 4/22/26 at 8:28 PM revealed CNA B transferred Resident #2 via mechanical lift from Resident #2's wheelchair to her bed. There were no other staff in the room and no other staff assisted with the transfer. Resident #2 was transferred without injury.During an interview on 05/22/26 at 12:30 PM, the DON stated it was facility policy for residents to be transferred using two staff members if a resident was being transferred using the mechanical lift. She stated she had not seen the video in which Resident #2 was transferred via mechanical lift with the only staff member being CNA B. She stated using only one person for the transfer with a mechanical lift put residents at risk for injury or harm as a result of an unsafe transfer. She stated all staff were trained to use two people when using the mechanical lift to transfer residents. During an interview on 05/27/26 at 12:30 PM CNA C stated she used the mechanical lift to transfer residents with another staff member at all times. If no one was available she would wait until someone was available rather than transferring a resident by herself with the mechanical lift. She said transferring a resident with only one staff member with a mechanical lift could put the resident at risk for injury. During an interview on 05/27/26 at 12:45 PM CNA D stated she and another staff member would use the mechanical lift to transfer residents. She stated she would not use the mechanical lift to transfer a resident unless there was another staff member to assist with the transfer. She stated a resident could be injured if a transfer with a mechanical lift was done incorrectly. Review of Mechanical Lift Policy dated 08/11/22 revealed The portable lift requires 2 people assist, that have completed competency training on the lift.

Based on observation, interview, and record review the facility failed to protect the resident's right to be free from involuntary seclusion for 1 of 5 residents (Resident #1) reviewed for involuntary seclusion.The facility failed to ensure Resident #1 was not secluded when Resident #1 was placed in a vacant bathroom that was 60 degree Fahrenheit for approximately 5 hours. CNA A and LVN B knew Resident #1 was in the bathroom when the Surveyor found Resident #1 alone and cold. These failures resulted in an Immediate Jeopardy (IJ) situation on 02/21/2026. The IJ template was provided to the facility on [DATE] at 5:20 AM. While the IJ was removed on 02/21/2026, the facility remained out of compliance at a severity level of no actual harm at a scope of isolated due to staff needing more time to monitor the plan of removal for effectiveness.This failure could place residents at risk of injury and isolation, leading to a decreased quality of life, severe emotional distress and trauma leading to distrust of staff. Findings include:Review of Resident #1's face sheet, dated 02/21/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses profound intellectual disabilities ( the most severe classification of cognitive impairment, typically characterized by an IQ below 20-25- a standardized score derived from tests designed to measure human mental abilities, such as reasoning, logic, memory and problem solving - profound limitations in self-care and mobility), anxiety disorder ( a chronic mental health condition marked by excessive, persistent, and uncomfortable worry about everyday things such as: health work, and family that's hard to control and interfere with daily life), major depressive disorder ( a serious mental health condition characterized by persistent, intense feelings of sadness, worthlessness, and a loss of interest in activities), contracture of muscle in left and right hand (a chronic, often permanent stiffening and shortening of skin, tendons, muscles, forcing fingers into a bent, flexed, or claw-like position), stiffness of right and left hands ( a reduced range of motion, tightness, or difficulty moving fingers and joints, often accompanied by pain and swelling), muscle wasting and atrophy, not elsewhere classified in right and left shoulder ( involves the loss of muscle mass in the rotator cuff- a group of muscles surrounds a persons shoulders- often causing visible shoulder sagging, weakness, and limited mobility), and lack of coordination ( a muscle control problem causing jerky, unsteady, or clumsy movements due to an inability to orchestrate voluntary muscle actions. Review of Resident #1's Annual MDS Assessment, dated 12/10/2025, reflected Resident #1 was unable to complete BIMS assessment. She was assessed to have poor short- and long-term memory recall. Resident #1's decision making ability was severely impaired. She did have behavioral symptoms daily not directed toward others (verbal/ vocal symptoms like screaming, disruptive sounds). This behavior significantly interfere with the resident's participation in activities or social interactions. Resident #1 significantly disrupt care or living environment. Resident #1 was assessed to enjoy doing things in groups of people , snacks between meals, and staying up past 8:00 pm. She had functional limitation in Range of Motion with impairment on both sides of upper and lower extremities. Resident #1 ambulated in wheelchair. She was dependent ( helper does all of the effort. Resident does not of the effort to complete the activity or the assistance of 2 or more helpers was required for the resident to complete the activity) on staff for mobility. Resident #1 was dependent on staff for the following: personal hygiene, showers , oral hygiene, toileting hygiene, upper and lower body dressing, putting on/ taking off footwear, shower transfers and chair to bed /bed to chair transfers. Resident #1 was not able to sitting on side of bed or walk. She required Supervision or touching assistance with eating- helper provides verbal cues and /or touching /steadying and / or contact guard assistance as resident completes the activity. Review of Resident #1's Comprehensive Care Plan, revised on 01/02/2026 reflected: Resident #1 preferred to remain in wheelchair and out of bed at all times. She had severely poor posture in wheelchair. Resident #1 had history of not sleeping in bed prior to admission. Interventions: Assist Resident #1 to shift weight frequently throughout the day and night. Custom wheelchair provided to resident. Monitor for signs and symptoms of pain every shift. Resident #1 will scream out when upset and refused medications. Interventions: Notify MD/NP of refusal of medication. Medication review by MD to alter form of medication from tablet to liquid. Resident #1 had an ADL self-care performance deficit related to muscle wasting and atrophy of right and left shoulder. Interventions: Resident #1 used a wheelchair for mobility requiring extensive assistance ( a care level where an individual requires hands-on, weight-bearing support, or full assistance for ADL tasks) from staff for purposeful locomotion Contractures- Resident #1 had contractures of bilateral hands. Resident #1 refuses to wear palm protectors to bilateral hands and required custom wheelchair. Transfers: Resident #1 required extensive assistance with 2 staff to move between surfaces. OT contracture management began on 01/23/2026. Resident #1 cusses out loud, name calling, and hollers out in a disruptive manner. ( Resident #1 behavior increase in stressful situations when encountering new/ unfamiliar people or surroundings). Intervention: Analyze Resident #1's key times, places , circumstances, triggers, and what de-escalates behaviors and document. Assess Resident #1's coping skills and support system. Assess Resident #1's understanding of the situation, allow time for Resident #1 to express self and feelings toward the situation. Offer Resident #1 reassurance in new settings/ situations or moving from place to place. Resident #1 was a high risk for falls related to unsteadiness on feet, lack of coordination, abnormal gait and mobility, poor posture, need for assistance with elimination, use of medications and poor safety awareness. Interventions: Custom wheelchair provided for proper body alignment and comfort. Resident #1 needs prompt response to all request for assistance. Observation on 02/20/2026 at 10:53 pm, this surveyor was walking down 100 hall where Resident #1 resided. Surveyor heard a strange noise at the end of 100 hall. At 10:55 pm surveyor entered a vacant room (#118) and observed Resident #1 sitting in the bathroom. Her wheelchair was facing the wall in perfect straight position, and the middle section of the wheelchair was aligned sideways by the door leading into the bathroom. Resident #1 was making loud sounds (not yelling) but moaning/ chanting like sounds. She continuously stated, I am cold get me out of here. Resident #1 was tearful and was shaking. She had on a dirty clothing protector covered with food. Resident #1 was very upset. The room was cold when surveyor entered the room and bathroom. The temperature in the vacant room (room [ROOM NUMBER]) was 60.2 and this temperature was taken 1:10 am.Interview on 02/20/2026 at 10:58 pm LVN B stated, am I going to lose my license (when surveyor asked LVN B her name). LVN B hands were shaking, and she was going from one subject to another subject such as I need to get Resident #1 out of the bathroom where is her things, we going to get a blanket, etc. LVN B was not making complete sentences at the beginning of the interview. LVN B stated the room was vacant and no one was assigned to room [ROOM NUMBER]. She stated to Resident #1 you are cold and shaking. LVN B stated to Resident #1 calm down I am going to get you out of this bathroom. LVN B began to attempt to get the food off the clothing protector. LVN B stated Resident #1 was very anxious and her body was shaking. LVN B stated, I don't know if it is because it is cold in this room or because she is so anxious. She stated to Resident #1 she would get Resident #1 a blanket and assist her somewhere else. LVN B constantly attempted to reassure Resident #1 stating it will be ok you need to relax, and I will get you out of this bathroom. LVN B stated to surveyor Resident #1 was cold and was very anxious. LVN B stated Resident #1 has anxiety and she was extremely anxious and needed to assist her as soon as possible out of the bathroom and get her to somewhere warm.Interview on 2/20/2026 at 11:45 pm LVN B stated she came to work around 6:00 pm. She stated Resident #1 was sitting in the common area approximately 6:30 pm. She stated Resident #1 does have behaviors where she makes grunting / moaning loud sounds and this was her baseline. LVN B stated Resident #1 became calmer when she was assisted out of the bathroom and she was assisted to shower and LVN B changed her clothes. LVN B stated Resident #1 rarely slept in her bed. She would stay up all night and sleep in her wheelchair this was more comforting to her than her being in bed. LVN B stated no one reported to her of Resident #1 being found in vacant room ( room [ROOM NUMBER]). She stated am I going to lose my license? LVN B stated she did not know why she asked about her license. She stated she did make rounds every two hours . LVN B stated she informed CNA A to assist Resident #1 to her room and clean her and assist her to bed. LVN B stated she thought maybe Resident #1 would want to go to bed. She stated Resident #1 rarely went to bed at night and she usually slept in her chair in the common area. She stated Resident #1 was calmer at night if she slept in her chair in common area instead of her bed. LVN B stated she did not know what she gave the instructions to assist Resident #1 to bed. She stated, will I be reported to nurses licensing about tonight? LVN B stated it was around 9:30 pm the last time she observed Resident#1 in the common area and did not see her again until surveyor walked into the facility and she saw Resident #1 around 11:00 PM. LVN B stated she needed to go make rounds and walked away from surveyor.Interview on 02/20/2026 at 11:15 pm CNA A stated he clocked in approximately 6:00 pm. He stated he went to the 100 and 200 hall nurses' desk and begin making his rounds. CNA A stated meal cart was delivered to the common area in front of the nurse's desk, and he stated it was approximately 6:30 pm. He stated he had Resident #1's meal tray and noticed she was not sitting in the common area. He stated she was always sitting in the common area for supper and especially on the night shift. CNA A stated he went to Resident #1's room and she was not in her room. He stated he heard sounds from the end of the hall, and it sounded like Resident #1. CNA A stated he went 2 doors down and found her in vacant room (room [ROOM NUMBER]) and she was sitting in the bathroom. He stated she was making the same loud sounds as she normally made, and he did not notice if she was cold or anxious. He did state it was difficult assisting her out of the bathroom related to how she was positioned and bathroom was small. He stated he assisted Resident #1 to the common area in front of the nurses desk for supper approximately 6:30 pm. CNA A stated he informed LVN B where he found Resident #1. He stated he explained to LVN B Resident #1 was in the bathroom in room [ROOM NUMBER]. CNA A stated Resident #1 was eating her meal in the common area in front of nurses desk. He stated she continued to make her weird sounds. CNA A stated LVN B threw up her hands and informed him to take Resident #1 back to where he found her. He stated he assisted Resident #1 to the vacant room ( room [ROOM NUMBER]) and put her in the bathroom. He stated he did assist her sideways where side of her wheelchair was beside the door and she was facing the wall in front of her. CNA A stated if he had disobeyed the LVN B's orders he would have been written up, reported to DON and possibly fired. He stated he notified the nurse supervisor, and he thought this was all he needed to do. He stated he had been in-service on abuse and neglect. He did not recall the date. He stated the Administrator was abuse coordinator. The DON became closer to CNA A during interview, and he stopped answering questions about calling the abuse coordinator and if he thought the incident with Resident #1 was abuse or neglect. Interview on 02/21/2026 at 1:00 am, CNA A stated he realized he should have called the Administrator and spoke to him about the directive he received from LVN B, and he should not have assisted Resident #1 back to the bathroom. He stated this was isolating Resident #1 and was against her resident rights. CNA A stated he had been in serviced on abuse , neglect, and resident rights. He stated he did not recall the dates of the in-services. CNA A stated he did not know what CNA C was doing during this time. He stated he was not assigned to Resident #1 CNA C was assigned to her.Observation on 02/20/2026 at 11:25 pm Resident #1 was in common area, and she was calm and was not anxious. She was not shaking, and she stated no when asked her if she was cold. Resident had blanket over her and was not chanting or making loud sounds. She was calm and relaxed (not making loud sounds and was not saying she was afraid and to move her).Interview on 02/20/2026 at 11:30 pm CNA C stated she was late coming into work. She stated she arrived to facility approximately 6:20 pm. CNA C stated she was usually assigned to 100 hall. She stated when she entered the common area in front of the nurse's desk on 100 and 200 halls, she observed CNA A assisting Resident #1 down the hall to the common area for supper. She stated she was assigned to Resident #1. CNA C stated Resident #1 frequently stayed in the common are and does better when she sleeps in her chair and sit in common area. She stated Resident #1 did not prefer to lay down in bed very often and preferred to stay in chair all night in the common area in front of the nurses desk. She stated she went down the hall assisting residents with their supper meal and was making her rounds. CNA C stated she did not recall the last time she saw Resident #1. She stated she was expected to make rounds every 2 hours. CNA C stated she made rounds around 8:00 but did not remember where Resident #1 was located when she made rounds. CNA C stated she never saw Resident #1 propel herself. She stated from her understanding Resident #1 was unable to propel herself because of her contracted hands. CNA C stated she was not aware Resident #1 was found in bathroom of room [ROOM NUMBER]. She stated she continued to pick up meal trays and assist residents. CNA C stated she was not aware of anyone assisting Resident #1 to a bathroom and leaving her in a bathroom. She was totally dependent on staff for all mobility and transfers. She stated she had an hour for supper break and took her break at approximately 10:15 pm and had just returned from her supper break. She stated no one had reported to her about Resident #1 being in the bathroom in room [ROOM NUMBER]. CNA C stated Resident #1 does make weird sounds and can be very loud and this was her baseline. She stated Resident #1 does talk sometimes.Interview on 02/20/2025 at 11:59 pm LVN D stated she was working 200 hall. She stated she was assigned to 200 hall majority of the time and she did work the night shift (6pm to 6am). She stated she did not hear any conversation between LVN B and any CNAs. She stated Resident #1 does make strange loud sounds and was disruptive to other residents at times. She state if staff gives her a snack it usually helps Resident #1. LVN D stated Resident #1 preferred to sleep in her chair in the common area. LVN D stated Resident #1 does not prefer to sleep in her bed. She stated she had always observed Resident #1 sleeping in her wheelchair in the common area. She stated she had not noticed Resident #1 until around 11:30 pm sitting in the common area. LVN D stated she usually worked 200 hall and did not recall seeing Resident #1 earlier than approximately 11:30 pm. She stated she was not aware of any staff assisting Resident #1 to a vacant room. She did state she never witnessed Resident #1 propelling self. She stated staff always assisted her with propelling Resident #1's wheelchair. LVN D stated she did not know very much about Resident #1 and did not have any further information to provide to surveyor. LVN D stated she had been in-service on abuse, neglect and resident rights, however, she did not recall the date of the in-services. She stated if she saw any resident abused or neglected she was expected to contact the administrator. She stated the administrator is the abuse coordinator.Interview on 02/21/2026 at 12:15 am CNA E stated she usually worked on 200 hall on the night shift. She stated there were a few times she did work on 100 hall. She stated she never witnessed Resident #1 propelling herself. She stated Resident #1 was unable to propel self. CNA E stated she has something wrong with her hands and they are contracted. CNA E stated she had witnessed Resident #1 sitting in the common area at night and sleeping in her chair. She stated from her understanding Resident #1 did not prefer to sleep in her bed. CNA E stated she had not witnessed any staff assisting Resident #1 to a bathroom or empty room and leaving her in that room or bathroom. She stated she had not heard any staff reporting this to anyone. CNA E stated she did not witness any conversation from LVN B and CNA around supper time. She stated she was down 200 hall assisting resident with meals. CNA E stated if she witnessed any resident being abused or neglected it did not matter what time of day or night she would call the administrator who was the abuse coordinator. She stated she had been in-service on abuse, neglect and resident rights. She did not recall the date of the in-services.Interview on 02/21/2026 at 12:30 am LVN B stated last time she saw Resident #1 was in the common area around supper time, and she did not see Resident #1 again until surveyor entered the facility. She stated she instructed CNA A to assist Resident #1 to get a shower. LVN B stated she did not instruct CNA A to lay Resident #1 in her bed due to Resident #1 prefers to sleep in her wheelchair in the common area. She stated she did not check and ensure CNA A gave Resident #1 a shower. She stated she was expected to make rounds every 2 hours. LVN B stated she was busy getting blood sugar checks and blood pressures the rest of the night until Surveyor entered the facility. She stated she was doing this on 100 hall from around 7:00 pm until 10:50 pm. LVN B stated she did not know how many residents on 100 hall was diabetic and how many needed their blood pressure checked. She stated she had been suspended and was leaving the facility at this time. LVN B asked if she was going to be referred to board of nurses. When asked LVN B why did she ask about losing her license in earlier interview and now asking about being referred to board of nurses, she stated well you just never know these days what will happen. She exited the room where surveyor was interviewing her. She stated she had been in-serviced on abuse and neglect. She stated she did not recall the date of the in-service.Interview on 2/21/2026 at 1:30 am CNA C stated she did not hear any conversation between LVN B and CNA A of directions of where to assist Resident #1 to after she finished her supper on 2/21/2026. She stated if she saw anyone neglect a resident or abuse a resident she would immediately call the administrator who was the abuse coordinator.Observation on 02/21/2026 at 2:00 am the temperature in room [ROOM NUMBER] was 60.2. The temperature was obtained by surveyor with a room infrared thermometer.Observation on 02/21/2026 at 2:30 am Resident #1 was sitting in the common area across from the 100 and 200 nurses' desk asleep in her chair. She was still in her chair while sleeping.Interview on 02/21/2026 at 2:30 am The Director of Nurses stated no one had reported to her of Resident #1 or any resident being assisted to a bathroom in a vacant room tonight or in the past. She stated this was her first knowledge of this occurring in the facility. The Director of Nurses stated the administration was in the process of conducting a full investigation. She stated Resident #1 was isolated in the vacant room on 100 hall ( room [ROOM NUMBER]). She stated this was involuntary isolating of a resident. The Director of Nurses did not respond to any further questions about the Resident #1 and the observation made on 02/21/2026 at 11:55 pm. Interview on 02/21/2026 at 3:30 am The ADON stated she was not aware of any incident with Resident #1 being assisted to a bathroom in a vacant room until tonight (02/21/2026). She stated no one had reported to her of any incident similar to this situation with Resident #1. She stated anytime a Resident was left in a bathroom without their permission it was considered isolating that resident from other residents and would be considered seclusion. The ADON stated if a resident did not agree to be left in the bathroom it would be considered against Resident #1's preference. The ADON did view the MDS and stated on the MDS it was coded Resident #1 was dependent on staff for ambulation in her wheelchair. ADON stated she did not have anything else to add about the situation with Resident #1.Interview on 02/21/2026 at 4:30 a.m. The Administrator stated what he considered the incident with Resident #1 being found sitting in a vacant room's bathroom, was involuntary seclusion. He stated there was a possibility Resident #1 may have increased anxiety and being afraid. The Administrator stated there was potential for Resident #1 to be affected emotionally (he did not elaborate on what he considered emotionally). He stated there was potential harm for all residents if left alone. He stated he could not comment on exactly what happened and the condition Resident #1 was in when found in the vacant room because he was not present when she was found on 02/20/2026 around 11:00 pm. He stated his expectations was all staff was to make rounds every 2 hours at a minimum. The Administrator stated he was investigating the incident with Resident #1, and he suspended CNA A, LVN B and CNA C. Observed Resident #1 at 4:45 am in her specialized wheelchair asleep in the common area across from the nurses desk on 100 and 200 halls. She was calm and still while sleeping.Interview on 02/21/2026 at 6:09 am Med Aide F stated she did work 6 am to 6 pm on 02/20/2026. She stated she gave medications on 100 and 200 halls. Med Aide F stated she was aware of Resident #1 making loud strange sounds. She stated Resident #1 preferred to sit in the common area and did not enjoy being in her room. Med Aide F stated she did not recall the last time she saw Resident #1 on 02/20/2026. She stated she had not witnessed or heard of Resident #1 being isolated anywhere in the facility. Med Aide F stated if she saw any resident being abused or neglected she would report it immediately to the Administrator who was the abuse coordinator. She stated she had been in-service on abuse, neglect and resident rights. She stated if a resident was placed in an empty room without the resident permission it would be considered isolating that resident against their will. She stated she was never involved in the assignments of the CNAs that was nurses responsibility. Interview on 02/21/2026 at 6:15 am LVN G stated she was at the facility working on 02/20/2026 from 6am to 6pm. She stated she was in the dining room around 4:30 pm to 5:00 pm assisting residents into the dining room and assisting with meal service. LVN G stated she usually worked on 100 and 200 hall. She stated she did not recall the last time she observed Resident #1 on 02/20/2026 between 6 am and 6pm. LVN G stated she exited the dining room approximately 5:50 pm and entered into the nurses station on 100 and 200 hall. She stated she did not recall seeing Resident #1, however, she was focused on giving report to oncoming nurse ( when asked the name of the oncoming nurse she did not specify). LVN G stated she left the facility at the end of her shit approximately 6:10 pm. LVN G stated she had not witnessed or heard of anyone assisting Resident #1 to an empty bathroom and leaving her in the bathroom for long periods of time. She stated Resident #1 was not able to propel herself. LVN G stated Resident #1 was totally dependent on staff for ambulation in her specialized wheelchair. She stated Resident #1 both hands was contracted. LVN G stated Resident #1 did enjoy sitting in the common area and she did have behaviors of making loud sounds. She stated giving her snacks usually helped with Resident #1's behaviors. LVN G stated it had been reported in the past of Resident #1 not wanting to go to bed and sleep in her chair while sitting in common area. She stated she did not remember who was assigned to Resident #1 on 02/20/2026 from 6am to 6pm Interview on 02/21/2026 at 6:22 a.m. CNA H stated she was on duty at the facility on 02/20/2026 from 6am to 6pm. She stated she worked 200 hall. CNA H stated she did not recall the last time she saw Resident #1. She stated she stayed on 200 hall majority of her shift. CNA H stated she was not familiar with Resident #1 except she did make loud weird sounds and could be disruptive to other residents. She stated she did not know any other information on Resident #1. CNA H stated she had never witnessed Resident #1 propelling herself when she observed her in the common area across from the 100 and 200 nurses desk. She stated if she witnessed any resident being abused or neglected she would report it immediately to the administrator. She stated the administrator was the abuse coordinator. She stated she did not know who was assigned to Resident #1 on 02/20/2026 from 6am to 6pm. Interview on 02/21/2026 at 6:35 am CNA I stated she did work 100 and part of 200 hall on 02/20/2026 during the 6am to 6 pm shift. She stated she did not know who was assigned to Resident#1 on 2/20/2026 during the day shift. CNA I stated she did not recall the last time she saw Resident #1. She stated when it was near supper time it was a busy time of assisting residents to the dining room passing out trays in dining room. She stated the meal trays had not come on the hall prior to her clocking out around 6:00 pm. CNA I stated Resident #1 does prefer to sit in the common area most of the time. She stated she did not prefer to be laid down in bed. CNA I stated she preferred to sleep in her wheelchair, and she been informed by nurses and other CNAs ( did not state the nurses and CNAs names when asked) of Resident #1 staying in her wheelchair at night in the common area and would not go to bed. She stated she had observed many mornings when she arrived to work at 6:00 am Resident #1 would be sitting in the common area across from the 100 and 200 hall nurses desk. She stated she was not aware of Resident #1 or any resident being isolated against their will in a vacant room or anywhere in the facility. CNA I stated she had been in-service on abuse, neglect and resident rights. She did not remember the date of the in-services. Record review on 02/21/2026 for the nursing schedule for 02/20/2026 for 6 am to 6pm and it did not indicate who was assigned to Resident #1. Attempted interview on 02/21/2026 at 7:05 am with LVN J and she refused to interview with surveyor. Attempted interview on 02/21/2026 at 7:30 am with CNA K ( she worked day shift on 2/20/2026) via phone and she did not answer the phone. Surveyor left message and CNA K did not return phone call. Attempted interview on 02/21/2026 at 7:40 am with CNA L ( she worked 6am to 6pm on 02/20/2206) via phone and she did not answer the phone. Surveyor left message and CNA L did not return phone call. Reviewed the Facility Policy on Abuse, Neglect and Exploitation, dated 07/15/2025, reflected Involuntary Seclusion refers to separation of a resident from other residents or from his/her room or confinement to his/her room against the resident's will or the will of the resident's legal representative. The Administrator was notified on 02/21/2026 at 5:20 am that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 02/21/2026 at 12:16 pm. Letter of Credible Allegation For the Removal of Immediate Jeopardy Attention Sir or Madam On February 21, 2026, the Facility was notified by the surveyor that immediate jeopardy had been called and the Facility needed to submit a Plan of Removal. The Facility respectfully submits this Letter for a Plan of Removal pursuant to Federal and State regulatory requirements. The alleged immediate jeopardy allegations are as follows: F603- Free from Involuntary Seclusion The facility failed to ensure that the resident was from involuntary seclusion.The facility failed to ensure Resident #1 was not placed in a vacant bathroom. Actions for Resident Involved On 02/20/2026 and by 02/20/2026, Resident #1 was removed from room [ROOM NUMBER] by the Licensed Nurse (LVN B). Resident #1 was assisted to the shower room via wheelchair and soiled clothing changed. Blankets were placed around Resident #1. Resident #1 was assessed by the Licensed Nurse ( LVN B) related to abuse and neglect, as well as psychosocial status with no concerns noted. On 02/21/2026, an allegation of potential seclusion was reported to HHSC as well as Law Enforcement for Resident #1 by the Facility Administrator. An investigation into the incident was immediately initiated by the Facility Administrator, which included interviews with facility staff on duty on 02/202/2026. On 02/21/2026, the Licensed Nurse ( LVN B) and the two Certified Nursing Assistants ( CNA A and CNA C) assigned to 100 hall on the 6 pm-6 am shift on 02/20/2026 were suspended pending investigation outcome by the Facility Administrator. Identify residents who could be affected: On 02/21/2026, the Administrator and/ or designee conducted facility rounds in all rooms to observe for the presence of abuse and/or neglect, to include potential seclusion with no concerns noted. Observations included ensuring residents were present in their assigned rooms and beds, as well as observing for residents unattended in bathrooms and/or resident areas; and/or visibly noted or reporting symptoms of distress. Findings were documented on a resident room roster and facility map. On 02/21/2026 and by 02/21/2026, the Administrator and /or designee interviewed interviewable residents related to abuse and neglect, to include involuntary seclusion with no concerns noted. Interviews consisted of abuse and neglect questions and documentation on a questionnaire for each resident.On 2/21/2026 and by 2/21/2026, the Director of Nursing and/ or designee assessed residents with a BIMS score below 13 head to toe related to abuse and neglect and psychosocial status, with no concerns noted. Findings were documented in the resident's progress note.On 2/21/2026 and by 2/21/2026, the Director of Nursing and/ or designee reviewed the resident progress notes for the last 30 days to ensure concerns related to abuse and neglect, to include potential seclusion were identified. No additional concerns were identified. Progress note review was completed and documented using printed progress notes for each current resident.On 2/21/2026 and 2/21/2026, the Administrator and/ or designee completed temperature checks in all resident rooms and resident use areas. All temperatures were found to be within the required temperature of 71 - 81 degrees Fahrenheit. The audit findings were documented on an audit tool and will continue daily Monday to Friday. Action Taken/ System Change: Effective 2/21/2026, any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator and/or designee and/ or Director of Nursing and/ or designee on all reeducation detailed below prior to the start of their next scheduled shift. On 2/21/2026, the Regional [NAME] President of Operations reeducated the Facility Administrator (Abuse Coordinator) and Director of Nursing on the facility's abuse and neglect policy and procedure to include involuntary seclusion. Reeducation included examples of actions that would meet the criteria for i[TRUNCATED]

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen.The facility failed to properly store, label, and date all food items located in the facility's walk-in refrigerator, freezer and in the dry food pantry area on 02/17/2026, 02/18/2026 and 02/19/2026 . The facility failed to properly seal food product bags in the walk-in refrigerator to prevent exposure to air on 02/17/2026. The facility failed to properly seal food product containers in the dry food area on 02/18/2026.The facility failed to discard outdated food items located in the dry food pantry area on 02/18/2026 and 02/19/2026 . These failures could place residents who received meals from the kitchen at risk of foodborne illnesses.Observation during the initial tour of the kitchen on 02/17/2026 beginning at 9:00 AM revealed the following:Refrigerator:1 storage bag that appeared to be leftover ham, no name, no discard/use by date5 open 1-gallon containers of salad dressings, no open date, no discard/use by date1 large pack of [NAME] open to air, no opened date, no discard/use by dateFreezer:1 storage bag no name, appeared to be french fries, no name, no discard/use by date1 storage bag no name, appeared to be sweet potato fries, no name label, no discard/use by date Observation/Interview during the follow up tour of the kitchen on 02/18/2026 beginning at 11:13 AM, revealed the following:Refrigerator-1 sandwich with no name, labeled 2/16, discard date of 2/181 sandwich with no name, no dates.1 container of 3 unknown items in storage bags, no names. It showed a use by date of 2/13/26 on side and showed a Prep and use by date of 2/19/26. Interview conducted with DM, he was asked to identify the items in the container with the 3 unknown items. He first stated he did not know, then stated, Looks like old breakfast. DM asked the Regional Dietary Consultant and she stated she was not sure herself, and cConsultant went to ask [NAME] J. [NAME] J stated it was pureed eggs, pureed sausage, and pureed cream of wheat for the next day. [NAME] J stated she forgot to place the item name on the bags., sShe stated they are for tomorrow's breakfast which is the 19th.1 container of cooked scrambled eggs, no name, 2/19/26 incorrect Prep date1 container of cooked cream of wheat, no name, 2/19/26 incorrect Prep date1 container of parmesan cheese, with Prep date of 2/8, no use by dateDry food storage area:1 bag of opened walnuts, no use by date1 large box of snack crackers and bars, the best by date was 01/28/20261 Large container of opened flour with prep date of 02/01/26, no discard/use by date1 large container of open cornmeal, with prep date of 02/01/26, no discard/use by date1 large container of sugar open to air , with prep date of 02/01/26, no discard/use by dateObservation during the final tour of the kitchen on 02/19/2026 beginning at 3:05 PM, revealed the following:Dry food storage area:1 large box of snack crackers and bars, the best by date was 01/28/20261 Large container of opened flour with prep date of 02/01/26, no discard/use by date1 large container of open cornmeal, with prep date of 02/01/26, no discard/use by dateInterview conducted with the DM on 02/19/2026, at 3:10 PM. The DM stated he has worked at the facility for 4 to 5 months. He stated he became the DM as of Monday. According to the DM, all heated and cooked foods must be consumed or disposed of within a 3-day period. The DM further stated cooked foods must be labeled with the date of prep, the product name, and the discard date which is calculated as 3 days from the cooking date. The DM stated processed foods must be labeled with the product name, the date received, and a discard date set 5 days after receipt. The DM stated his position is responsible for training on all dietary procedures. He further noted that the Cooks on duty are tasked with daily checks to identify and remove expired food items. When addressing the risks of serving expired food products, the DM stated the harm level depended on the specific food item. He stated food could grow salmonella or other harmful bacteria, that could result in residents being at risk of illness that can lead to hospitalization or death .Interview conducted with Regional Dietary Consultant on 02/19/2026, at 3:39 PM. Regional Dietary Consultant stated the DM is new to the role, having held the position for only a few days. The Regional Dietary Consultant stated that she arrived at the facility on the same day as the surveyors. The Consultant stated the specific protocols for managing leftovers and open products are that theleftover items must be labeled on the day they become leftovers and must be used within a 72-hour window. She stated all items must be labeled with the product name. The Dietary Consultant stated that prepackaged food products have a manufacturer's use by date. The consultant stated that staff should label the item with the date it was opened. The consultant stated a resident could potentially become seriously ill if they received expired food.Interview conducted with DON on 2/19/2026 at 4:21 PM. The DON stated she is familiar with the facility's protocols regarding labeling, dating, and the discarding of food items. She stated items should be labeled with the date open, the name of the product, and the discard date. The DON stated she expects all dietary staff to discard expired items. The DON stated the risks to residents depend on the type of food. She stated that different food can cause different interactions.Interview conducted with Administrator on 2/19/2026 at 4:38 PM. The Administrator stated he has been with the facility for 9 years. He stated he expects all his dietary staff to follow the food labeling policy. He stated the food in the kitchen should have the name, open date, and throw out date within 72 hours. The Administrator stated a resident could become ill if they ate expired food items. Record review of the facility's policy dated October 1, 2018, with revision date June 1,2019, named food storage, revealed [in part] Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines.Procedure:1. Dry storage roomsd. To ensure freshness. store opened and bulk items in tightly covered containers. All containers must be labeled and dated.e. Provide scoops for items stored in bins, such as sugar, flour. rice and other items. Store scoops covered in a protected area near the food containers. Wash and sanitize scoops weekly or as needed.f. Where possible, leave items in the original cartons placed with the date visible.g. Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are used first.2. Refrigerators d. Date, label and tightly seal all refrigerated foods using clean. nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old.3. Freezers d. Do not line shelves with foil or paper. Do not over stock the freezer and leave space between items to further improve air circulation. e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated.A record review of the 2022 U.S. Food and Drug Administration Food Code reflected the following:Food items in the refrigerator(s) are covered/sealed, labeled, dated, and shelved to allow air circulation.Food items in the freezer(s) are covered/sealed, labeled, dated, and shelved to allow air circulation.Food is discarded on or before the expiration date.

Based on observation, interview and record review, the facility failed to make sure that its menus documented any substitutions made to the menus on 4 of 4 halls reviewed for food and nutrition services.The facility failed to place the correct weekly menu in the dining hall on 2/18/2026 for lunch and dinner meals. This failure could place residents who eat food from the kitchen at risk of not knowing what was on the menu so they could request an alternate meal timely. Observation on 02/17/26 at 1:07 PM revealed the menu board for halls 300/400 did not display the breakfast, lunch, or dinner menu.Observation on 02/17/26 at 1:15 PM revealed the menu board for halls 100/200 did not display the breakfast, lunch, or dinner menu.Observation on 02/18/26 at 8:00 AM revealed the menu board for halls 100/200 did not display the breakfast, lunch, or dinner menu.Observation on 02/18/26 at 11:11 AM revealed incorrect facility's weekly menu on the wall in the dining room, as it displayed week 5.Observation/Interview on 2/18/2026 at 11:25 AM. Surveyor observed chicken being prepared for lunch instead of pork and veggie stir fry listed on menu on dining room wall. Regional Dietary Consultant stated she made meal substitutions for this week. She brought out a meal substitution approval form, no approval signatures noted on form. Consultant stated the menu was changed to what the residents preferred to eat.Observation on 2/18/26 at 6:30 PM, surveyor noted residents were served Beef Stroganoff over pasta , the posted menu in the dining room displayed turkey loaf with buttered corn.Observation on 02/19/26 at 8:18 AM, revealed the menu board for halls 300/400 did not display the breakfast, lunch, or dinner menu.Observation on 02/19/26 at 12:51 PM, revealed the menu board for halls 100/200 did not display the breakfast, lunch, or dinner menu.Record review of Resident # 104's MDS Assessment, dated 02/03/2026, reflected she was a [AGE] year-old female, admitted [DATE] with a readmission of 06/25/2024with a BIMS score of 14, which indicated cognitively intact. The residents' diagnoses included chronic obstructive pulmonary disease (incurable respiratory condition primarily caused by smoking), morbid (severe)obesity due to excess calories, diabetes mellitus (high blood sugar) and depression (mood disorder, loss of interest).Interview conducted with Resident # 104 on 02/17/2026, at 10:16 AM. Resident #104 stated she had concerns of the food not being good and not receiving a menu to select an alternative meal choice as she had previously. She stated she does not go all the way to the dining room to view the chalkboard for posted meal options. During a confidential group interview on an undisclosed date at an undisclosed time, 6 of 7 residents voiced that they have requested individual menus for their rooms, but the facility has failed to provide them. The group stated the menu in the dining room is frequently inaccurate. The group further stated that they would like the menus so they can choose what each of them wanted to eat.Interview conducted on 2/18/2026 at 1:18 PM, Resident #82 stated lunch has not come yet and she does not know what they are having, she stated they never get a copy of the menu. Resident #82 stated she was told the dining room has two menus. She stated the facility doesn't seem to care anything about them; and that they have changed.Interview conducted with Administrator on 2/18/2026, at 12:42 PM. The Administrator was asked how residents who do not attend the dining room are made aware of the available menu options. The Administrator stated that staff inform residents in the morning of the meal for the day. He reported that if a resident wants something different, they may notify the aides. The Administrator further stated that the menu is posted in each hallway near the nurses' stations. The Administrator was advised that the menus had not been posted on either day the surveyors were present. The Administrator then stated that the facility encourages all residents to come to the dining room to eat. He acknowledged that residents have the right to eat in their rooms and know what they are eating. The administrator stated that he would speak with the DM to ensure copies of the menus are provided to residents.Interview conducted with the DM on 02/19/2026, at 3:10 PM. The DM stated he has worked at the facility for 4 to 5 months. He stated he became the DM as of Monday. The DM stated that he the DM or Dietary Supervisor, is responsible for posting the breakfast, lunch, and dinner menus in the dining hall and on the units. He reported that if he is not present, he directs the cook to post the menus. He stated that menus are expected to be posted first thing in the morning. The DM stated he does not know why the menus had not been posted on the units. He reported that the previous Dietary Manager walked out recently. The DM acknowledged that he did not post the menus that morning because he was behind and stated he had been working double shifts. He further stated that he understands this is not an excuse for the menus not being posted.The DM stated that residents need to know what they are going to eat so they can determine whether they want to request an alternative meal.Interview conducted with Regional Dietary Consultant on 02/19/2026, at 3:39 PM. Regional Dietary Consultant stated the DM is new to the role, having held the position for only a few days. The Regional Dietary Consultant stated that she arrived at the facility on the same day as the surveyors. The Regional Dietary Consultant stated that the Dietary Manager is responsible for posting the breakfast, lunch, and dinner menus in the dining hall and on the units. She reported she does not know why the menus were not posted on the units. The consultant stated the facility has some issues to work through, as the previous Dietary Manager left and they are in the process of training new staff. She stated they can only continue to educate staff and do the best they can for the residents. She acknowledged that residents have the right to know what is being served.When asked about menus not matching the meals being served, the consultant stated that the meal served that day did match the menu. She reported that she corrected the menu posted on the wall after identifying an error that morning. The Regional Dietary Consultant stated the Nutrition Consultant can sign off on substitutions upon next visit to facility.On 2/19/2026 at 10:54 AM, a policy was requested from the administrator on Notification of menu changes and Residents access to the availability of menus. The administrator responded, We do not have a policy on that. We have posted menus as well as the alternate menu, and we accommodate as needed and when we are notified of preferences of the residents. Review of facility policy dated October 1, 2018, named Alternate Food Choices and Substitutions and Honoring Preferences revealed: Policy: The facility believes that adequate nutrition is essential to each resident's well being and good health. An alternate entree and vegetable will be offered at each meal. The facility also supports resident choice and allowing residents to choose foods by honoring their food preferences. Other substitutions will also be available in the event a resident does not choose the main meal or the alternate. Procedure: 1. Residents will be informed on admission that there is an alternate for each meal and will also be informed of substitutions which are available on a daily basis.

Based on observation and interview, the facility failed to ensure storage of drugs and biologicals used in the facility for 2 of 8 medication carts and 1 of 2 medications rooms observed for medication storage and labeling. The facility failed to ensure expired medications were removed from the medication carts and rooms. The facility failed to ensure loose medications were removed from the medication carts. This failure could place residents who received medications at risk of not receiving the intended therapeutic effect of the medication. This failure could place residents who received medications at risk of receiving the wrong dose of medication.Findings included: During an observation on 02/18/2026 at 11:43 a.m., the 100 hall medication cart revealed two bottles of Losartan 50 mg with the expiration date of 01/03/2026 and one white, round medication tablet which was loose in the cart. During an observation on 02/18/2026 at 12:29 p.m., the 100/200 hall medication room revealed one bottle of B-50 Vitamin Supplement with the expiration date of 11/2025 and one loose pink, round medication tablet. During an interview on 02/18/2026 at 11:51 a.m., the Medication Aide stated they were supposed to check the medication's expiration date prior to placing them in the medication cart. During an interview on 02/19/2026 at 5 p.m., the DON stated the expectation was for staff to check the expiration dates for medications prior to storing them in the medication carts and medication rooms. She stated, loose pills happen especially with blister packs.

Based on interviews, and record review the facility failed to provide a private space for residents' confidential resident group meeting during the survey for seven of seven residents reviewed for resident council. The facility did not provide a private space for resident council meeting. This failure could place residents, who attended confidential resident group meeting, at risk of not being able to exercise their rights of being able to voice their grievances in private without uninvited staff being present.Findings included:During an observation on 02/18/2026 at 10:15 am the Regional Dietary Consultant opened the door from the kitchen and leading into the dining room during the residents' confidential group meeting with the surveyor. She walked 2 or 3 steps into the dining room while the residents were voicing concerns about dietary. The residents would not voice any of their concerns after the Regional Dietary Consultant entered the dining room. During an interview on 02/18/2026 at 10:20 a.m., all the residents in the residents' confidential resident group meeting stated they did not feel comfortable voicing their concerns any further during the meeting. They stated there was a possibility the lady from dietary may come back in the meeting area and may hear what they had to say about dietary. They all stated they were expected to have privacy during all their resident council meetings and today they did not have privacy and had concerns if the lady (Regional Dietary Consultant) heard what they were saying about the kitchen. The residents in the group stated their meetings was never interrupted during their monthly Resident Council meetings. The group stated this was against their resident rights and that lady (Regional Dietary Consultant) needed to respect the residents and their rights to voice their opinions in privateDuring an interview on 02/18/2026 at 10:30 a.m., the Regional Dietary Consultant stated she did not enter the dining room. She stated what was expected of me now do you (speaking to surveyor) want me to be in-service on this what is it you are wanting from me. She stated she was in-serviced on resident rights. She stated she took maybe two steps into the dining room when the residents were meeting but that was not interrupting the meeting. The Regional Dietary Consultant stated if the residents were unhappy with her opening the door and stepping into the dining room for a few seconds, it was their right to meet privately. The Regional Dietary Consultant would not respond to any further questions of how interrupting the Resident Group was violation of their resident rights for privacy.During an interview on 02/18/2026 at 10:45 a.m., the Regional Dietary Consultant requested to continue interview with the Administrator. The Administrator was present, and she continued to ask what did surveyor want to do give her in-services on resident rights. What was expected for her to do now. And she stated she was in serviced on resident rights but did not recall the date. She stated, Am I going to get the facility a citation? The Regional Dietary Consultant would interrupt when questions were asked about her entering the dining room. She stated she opened door and took a step and returned to the kitchen. During an interview on 02/19/2026 at 10:20 a.m., the Activity Director stated she placed signs on both dining room doors. She stated she wrote on the signs do not disturb resident group in progress. She stated she went into the kitchen and reported to all dietary staff not to enter the dining room until after the resident group with surveyor was finished. She stated the Regional Dietary Consultant was in the kitchen when she reported not to enter the dining room until after the resident group meeting. The Activity Director stated the resident had rights to meet in privacy and anytime they had a resident council meeting the residents did meet in private. She stated no one was to enter the room when resident council was in progress. The Activity Director stated the only time other staff could be int the resident council meeting was if the staff was invited by the residents. She stated the residents may not feel comfortable voicing their opinions or concerns if they thought the meeting would not be private.During an interview on 02/19/2026 at 8:51 a.m., the Administrator stated the resident council group should be able to meet in a private area, and staff could not attend unless invited. He stated if the resident council did not have a private area to meet there was a potential staff who could overhear what the residents were saying, and the residents may feel uncomfortable to voice their opinions. He stated it was against resident rights not to have a private area to meet during a survey and during their monthly resident council meeting. He stated the Regional Dietary Consultant did not follow resident rights by entering the dining room even if it was only for a few seconds.Record review of the policy titled, Facilities Resident Rights, not dated, reflected, An elderly individual is entitled to privacy while attending to personal needs and a private place or receiving visitors or associating with other individuals unless providing privacy would infringe on the rights of other individuals. This right applies to medical treatment, written communications, telephone conversations, meeting with family, and access to resident council.

Based on interviews, and record review, the facility failed to ensure that each resident had the right to self-determination and the right to make choices about aspects of life in the facility that were significant to the residents for 3 of 5 residents (Resident #39, Resident #40, and Resident #104) whose care was reviewed.The facility failed to honor Resident #39 and Resident #40's request to eat at an earlier time because they preferred to dine in their room.The facility failed to provide Resident #104 who prefers to dine in her room, with a method of choosing her meal selections from the available daily menu.The facility failed to provide 6 confidential residents menus for their rooms per their request.This failure could place residents at risk of diminished feelings of self-worth and/or diminished quality of life. Record review of Resident #39's MDS Assessment, dated 11/10/2025, reflected he was a [AGE] year-old male, admitted [DATE] with a BIMS score of 10, which indicated moderate cognitive impairment. The resident's diagnoses included hypertensive chronic kidney disease with stage 1-4 (kidney damage caused by long-term high blood pressure), cancer, gout (painful inflammatory arthritis), and muscle wasting and Atrophy of right and left shoulder (nerve damage).Record review of Resident #40's MDS Assessment, dated 12/20/2025, reflected she was a [AGE] year-old female, admitted [DATE] with a readmission of 9/17/2025 with a BIMS score of 12, which indicated moderate cognitive impairment. The resident's diagnoses included unspecified dementia (impaired thinking, severe memory loss), age related osteoporosis with current pathological fracture (fragile fracture related to bone loss) and hyperlipidemia (high levels of cholesterol in blood).Record review of Resident # 104's MDS Assessment, dated 02/03/2026, reflected she was a [AGE] year-old female, admitted [DATE] with a readmission of 06/25/2024 with a BIMS score of 14, which indicated cognitively intact. The resident's diagnoses included chronic obstructive pulmonary disease (incurable respiratory condition primarily caused by smoking), morbid (severe) obesity due to excess calories, diabetes mellitus (high blood sugar) and depression (mood disorder, loss of interest).Interview conducted with Resident # 104 on 02/17/2026, at 10:16 AM. Resident #104 stated she had concerns of the food not being good and not receiving a menu to select an alternative meal choice as she had previously. She stated she does not go all the way to the dining room to view the chalkboard for posted meal options. Resident #104 further stated that the facility staff will always provide an excuse when she inquiries about not receiving a menu.Interview conducted with Resident # 40 on 02/17/2026, at 11:07 AM. Resident #40 stated her and Resident #39's food is late because they are served after the dining hall.Interview conducted with Resident #39 and Resident #40's family member on 02/17/2026, at 11:08 AM. The family member stated she was informed by facility staff that the residents could receive their meals earlier if they would eat in the dining room. The family member further expressed concerns regarding the lack of information provided to Resident #39 who received a ground diet. Family member stated that Resident #39 is unable to identify the specific food items served on his tray. The family member stated the facility should list the item on the tray ticket or at least have staff explain the meal to the residents. The family member stated Resident #39 would like to know what he is eating.Interview conducted with Resident # 40 on 02/17/2026, at 1:28 PM. Resident #40 stated she was waiting for her lunch tray. She reported that she did not understand why she was served last, explaining that she prefers to eat in her room. She stated that as the DON walked by, the DON said, I was looking for you [Resident #40] in the dining room. Resident #40 replied, What? I do not know why she said that. I do not ever eat in the dining room. Resident #40 further stated that she has been told she should consider eating in the dining room if she wants to receive her meal earlier; however, she reported that she does not feel it is best for her and Resident #39, as they prefer privacy. She stated, [Resident #39] is [AGE] years old, and it is not convenient for us to go to the dining room. When asked by the surveyor whether she had spoken with the Administrator regarding the concern, Resident #40 stated that he would likely tell her again to eat in the dining room if she wanted her food earlier.During a confidential group interview on an undisclosed date at an undisclosed time, 6 of 7 residents voiced that they have requested individual menus for their rooms, but the facility has failed to provide them. The group stated the menu in the dining room is frequently inaccurate. The group further stated that they would like the menus so they can choose what each of them wanted to eat.Interview conducted with Administrator on 2/18/2026, at 12:42 PM. The Administrator was asked how residents who do not attend the dining room are made aware of the available menu options. The Administrator stated that staff verbally inform residents in the morning of the meal for the day. He reported that if a resident wants something different, they may notify the aides. The Administrator further stated that the menu is posted in each hallway near the nurses' stations. The Administrator was advised that the menus had not been posted on either day the surveyors were present. The Administrator then stated that the facility encourages all residents to come to the dining room to eat. He acknowledged that residents have the right to eat in their rooms and know what they are eating. The Administrator stated that he would speak with the DM to ensure copies of the menus are provided to residents.Interview conducted with CNA D on 2/19/2026, at 2:56 PM. CNA D stated she has been employed at the facility since April of last year. CNA D stated she does not know the scheduled mealtimes for the units. CNA D reported that Resident #40 has complained about meals not arriving in a timely manner. She stated she encourages Resident #40 to attend the dining room for meals; however, the resident prefers to remain in her room to eat. CNA D further stated that Resident #104 has also complained about late mealtimes, but she prefers to stay in her room as well. CNA D stated menus are not provided in the residents' rooms. She stated that she has not been told to provide the menu information to the residents in the mornings. CNA D stated sometimes a resident may ask and she would tell them the information. Record review of the facility policy Resident Rights, received 02/19/2026, undated, revealed the following [in part]: Statement of Resident RightsYou, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. It is against the law for any nursing facility employee to threaten, coerce, intimidate or retaliate against you for exercising your rights. If anyone hurts you, threatens to hurt you, neglects your care, takes your property, or violates your dignity, you have the right to file a complaint with the facility administrator or with the Texas Department of Human Services by calling 1-800-458- 9858.You have a right to:(1) all care necessary for you to have the highest possible level of health;(2) safe, decent and clean conditions;(3) be free from abuse and exploitation;(4) be treated with courtesy, consideration, and respect;(5) be free from discrimination based on age, race, religion, sex, nationality, or disability and to practice your own religious beliefs;(6) privacy, including privacy during visits and telephone calls.(7) complain about the facility and to organize or participate in any program that presents residents' concerns to the administrator of the facility;Sec 102.003 Rights of Elderly IndividualsAn elderly individual has all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this state and the United States, except where lawfully restricted. The elderly individual has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights.An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual without regard to race, religion, national origin, sex, age, disability, marital status, or source of payment. This means that the elderly individual:has the right to make the individual's own choices regarding the individual's personal affairs, care, benefits, and services; (2) has the right to be free from abuse, neglect, and exploitation; and (3) if protective measures are required, has the right to designate a guardian or representative to ensure the right to quality stewardship of the individual's affairs.

Based on observations, interviews, and record reviews, the facility failed to provide each resident at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for 7 (Resident #11, Resident #30, Resident #39, Resident #40, Resident #79, Resident #82, and Resident # 104) of 7 residents reviewed for timely meals on hall 200. The facility failed to provide lunch according to the lunch meal service schedule on 02/17/26 to Residents #39, #40, and #82.The facility failed to provide breakfast according to the breakfast meal service schedule on 02/18/26 to Residents #30 #39, #40, #79 and #82.The facility failed to provide lunch according to the lunch meal service schedule on 02/18/26 to Residents #30 #39, # 40, #79, #82 and #104.The facility failed to provide dinner according to the dinner meal service schedule on 02/18/26 to Residents #11 #30, #39, # 40, #79, #82, and #104.The facility failed to provide breakfast according to the breakfast meal service schedule on 02/19/26 to Residents #11, #30, # 39, #40, #79, #82, and #104. This deficient practice could place residents at risk of increased hunger, low blood sugar levels, increased stress levels, slowed metabolism rates, and malnutrition. Review of an undated document provided by the Administrator, titled [Facility] Resident Dining Hours and Locations, revealed: Breakfast- 7:00 AM: Dining room [ROOM NUMBER]:20 AM: 100 Hall 7:30 AM: 400 Hall 7:40 AM: 300 Hall 7:50AM: 200 HallLunch-11:50 AM: Dining room [ROOM NUMBER]:20 PM: 100 Hall 12:30 PM: 400 Hall 12:40 PM: 300 Hall 12:50 PM: 200 HallDinner-5:00 PM: dining room [ROOM NUMBER]:20 PM: 100 Hall 5:30 PM: 400 Hall 5:40 PM: 300 Hall 6:00 PM: 200 HallObservation/Interview on 2/17/2026 at 1:25 PM in resident's room on 200 hall, Resident # 82 stated lunch had not been served yet and she was still waiting.Observation/Interview on 2/17/2026 at 1:28 PM in residents' room on 200 hall, Resident #39 and #40 had not received their lunch meal. Resident #40 stated she was waiting for her lunch tray. She reported that she did not understand why she was served last, explaining that she prefers to eat in her room. She stated that as the DON walked by, the DON said, I was looking for you [Resident #40] in the dining room. Resident #40 replied, What? I do not know why she said that. I do not ever eat in the dining room. Resident #40 further stated that she has been told she should consider eating in the dining room if she wants to receive her meal earlier; however, she reported that she does not feel it is best for her and Resident #39, as they prefer privacy. She stated, [Resident #39] is [AGE] years old, and it is not convenient for us to go to the dining room. When asked by the surveyor whether she had spoken with the Administrator regarding the concern, Resident #40 stated that he would likely tell her again to eat in the dining room if she wanted her food earlier. Observation/Interview on 2/18/2026 at 8:01 AM, Resident #39 and Resident #40 were in their room. Resident #40 was shaving Resident #39, and she stated breakfast had not arrived.Observation/Interview on 2/18/2026 at 8:04 AM, Resident #30 and Resident #79 were in their room. Resident #30 stated breakfast has not arrived.Observation/Interview on 2/18/2026 at 8:05 AM, Resident #11 and Resident #82 were in their room. Resident # 82 stated her breakfast has not come. She stated her roommate Resident #11 received her breakfast early today because she has dialysis. Resident #82 stated, the breakfast does not come this early.Observation/Interview on 2/18/2026 at 1:18 PM, Resident #82 stated lunch has not come yet. She stated the facility doesn't seem to care anything about them; and that they have changed.Observation/Interview on 2/18/2026 at 1:20 PM, Resident #79 and Resident #30 were in their room, and lunch had not been served. Resident #30 stated, no food yet, this is ridiculous. Advised her food cart just entered floor 200.Observation on 2/18/2026 at 1:21 PM, food cart entered hallway 200.Observation on 2/18/2026 at 1:22 PM, food was served to Resident #104 .Observation on 2/18/2026 at 1:24 PM, food was taken to Resident #39 and Resident #40's room. Observation/Interview on 2/18/2026 at 1:25 PM with Resident #82 who stated she now had her food. Observation on 2/18/2026 at 6:23 PM, food was served to Resident #104.Observation/Interview on 2/18/2026 at 6:24 PM, Resident #11 and Resident #82 were in their room. DON came into room and said Resident #11's call light was on. Resident #82 stated the food is not here, and she was advised it was on the hallway. Resident #82 stated, they must have saw you come in because it's never this early in the evening.Observation/Interview on 2/18/2026 at 6:25 PM, Resident #39 and Resident #40 were in their room, and stated they are waiting to eat. Food was delivered to the room at 6:28 PM.Observation/Interview on 2/18/2026 at 6:29 PM, Resident #30 and Resident #79 were in their room. Food was delivered at 6:31 PM by DON. Resident #30 stated, the food is coming out sooner, soon State leave it will go back to later times. On 2/18/2026 at 6:36 PM, an interview was attempted with the evening cook. The DM was present; he stated the evening cook left the facility a few days prior. He stated the swing cook is on vacation and will return tomorrow. DM stated he was working a double shift.Observation/Interview on 2/19/2026 at 8:21 AM, Resident #11 and Resident #82 were in their room. The residents stated they have not received breakfast. Resident #82 stated, breakfast is not here and it's almost 8:30 AM. Trays were served to the room at 8:43 AM. Resident #82 stated, the tall nurse never pass out trays.Observation on 2/19/2026 at 8:45 AM, breakfast was delivered to Resident #39 and Resident #40 in their room.Observation on 2/19/2026 at 8:48 AM, breakfast was delivered to Resident #30 and Resident #79 in their room.Observation /Interview on 2/19/2026 at 8:49 AM, Resident #104 had her breakfast. She stated it was just delivered after 8:30 AM. Resident #104 stated that a long time ago she received copies of the menu. She stated that meals are frequently served late and that this occurs often. She reported that weekends are worse. She stated that breakfast may be served around 10:00 a.m., lunch around 2:00 p.m., and supper around 7:00 or 8:00 p.m. She reported that she brings in snacks from outside the facility. When asked whether she has filed a grievance regarding the meal concerns, she stated that it is no use.During a confidential group interview on an undisclosed date at an undisclosed time, 6 of 7 residents voiced that breakfast meals are not delivered to the 100 and 200 hallways until 8:20 AM and 8:45 AM. Group members said that the food would sit in the hallways a long time before the staff pass out the meals. The group stated that the supper/dinner meal is served between 7:30-8:00 PM. The group all agreed something needed to be done about the meals.Interview conducted with the DM on 02/19/2026, at 3:10 PM. The DM stated he has worked at the facility for 4 to 5 months. He stated he became the DM as of Monday. The DM stated that any meal delays are communicated to the floor by the dietary aides. When asked whether residents are offered snacks when meals are delayed, the DM stated that, on the dietary department's side, meals have only been delayed by approximately five minutes. He stated that meal carts are delivered to the units after service in the dining room. The DM stated he is unsure whether the facility has a policy regarding timely meal service, as he has not seen one. He reported that meals are scheduled to leave the kitchen for the units immediately after the dining room is served, which he stated averages about 20 minutes. He stated that breakfast typically takes less time because fewer residents eat in the dining room. The surveyor presented the DM with the posted mealtimes for Hall 200: breakfast at 7:50 a.m., lunch at 12:50 p.m., and dinner at 6:00 p.m. The DM stated meals should never arrive late but the kitchen is currently short staffed . He reported that one cook recently left and the swing cook was on vacation. The DM stated he had never seen the specified unit mealtimes and reported he has not been trained on the designated mealtimes for the units. The DM stated the potential harm to residents is that they could lose weight if they do not accept the meal being late. The DM stated the former DM would send out the plates without being in a warmer and he has been correcting the process.Interview conducted with Regional Dietary Consultant on 02/19/2026, at 3:39 PM. Regional Dietary Consultant stated she believed the facility mealtimes are 7:00 a.m., 12:00 p.m., and 5:00 p.m. She stated that the halls are served shortly after completion of the main dining room service, which she estimated to be approximately 35 to 45 minutes after the dining room meals are served. She reported she is not aware of any specific scheduled mealtimes designated for the units. The consultant stated she feels the facility has been serving meals on time and reported she has been impressed with the meal service times. She stated that, in her opinion, serving dinner at 7:00 p.m. would be late, whereas 6:30 p.m. would be acceptable. She further stated the facility serves approximately 120 residents and emphasized that this is a large number of individuals to serve. When asked about the potential effect delayed meals could have on residents, she stated residents would likely be upset; however, she reported she has not personally observed any late meal service. Interview conducted with DON on 2/19/2026 at 4:21 PM. The DON stated dining room mealtimes are 7:00 a.m., 12:00 p.m., and 5:00 p.m. She stated that the units are served approximately 45 minutes after the dining room service is completed. The DON reported that a list of unit's mealtimes is posted indicating when residents should receive their meals. She stated that for a 7:00 a.m. dining room meal, the units should receive breakfast at approximately 8:00 a.m. The DON stated that when she conducts rounds, residents are vocal and inform her if meals are late. She reported that if meals are running behind schedule, she would provide education and conduct in-services with staff. The DON was advised of the reported times meals have been arriving at the units. She was also informed that the evening meal was late on the previous night while she was present. The DON acknowledged that the meal was late and stated she would ensure the Administrator is made aware.Interview conducted with Administrator on 2/19/2026 at 4:38 PM. The Administrator stated the mealtimes are 7AM for breakfast, noon for lunch, and 5PM for dinner. The Administrator stated the facility does not have a specific scheduled time for meals to be served to the units. He was reminded he provided a mealtime schedule to surveyor. He reported that the goal is to serve the entire facility within an hour and a half. He stated there were some prior complaints regarding late meal service under the previous Dietary Manager; however, he feels the concern has been rectified but described the process as a work in progress. When asked about the potential harm to residents related to delayed meal service, the Administrator stated residents could possibly feel anxious. He further stated he has not heard any recent complaints from residents regarding late mealtimes.Record review of facility grievances revealed on 12/26/2025, one resident on hall 200 complained of late trays on her hall. On 12/28/25, multiple residents complained of late breakfast, and on 1/14/2026, all residents complained of breakfast being served late on 1/14/2026. Record Review of the facility's policy named Meal Times, dated October 1, 2018, revealed: Policy: The facility provides three meals daily at regular times which are comparable to meal times in the community setting. Meals are served at the specified times except in emergency situations.Procedure:1. Meals will be served according to the state and federal regulations, with no more than fourteen hours between the evening meal and breakfast the following day.2. There will be at least a four hour interval between breakfast and lunch and between lunch and dinner.3. The Dietary Department will develop an order of service for all meals which best suits the needs of the residents. The scheduled order will be followed.4. A schedule of the meal times will be posted in all resident areas.5. Meal times may be altered according to resident preference, such as brunch or late continental breakfast, early or late lunch or other changes in order to accommodate cultural differences and preferences among the residents. Standard meals must be offered as required by the regulations above, but altered meal times should be offered as requested by the resident(s). A plan of care must be developed to document the resident's altered meal times.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review(PASARR) Level I assessment accurately reflected the resident's status for 2 of 5 residents ( Resident #4 and Resident #129). The facility failed to ensure the accuracy of the PASARR Level 1 (PL1) screening for Resident # 4. The PASARR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis ( major depressive disorder, single episode, unspecified ( experience major depressive episode with no history of previous depressive episodes - sadness, loss of interest in daily activities) was present upon Resident #4's admission date on 01/19/2026.The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident #129. The PASARR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis major depressive disorder, recurrent, unspecified (person has experienced multiple, separate episodes of major depression, but there is insufficient information for a clinician to specify the severity. Symptoms: sadness and loss of interest in daily activities) was present upon Resident #129's admission date 02/11/2026.This failure could place residents at risk of not receiving a needed assessment (PASARR Evaluation), individualized care, or specialized services to meet their needs.Findings included:1. Record review of Resident #4's face sheet, dated 02/12/2026, reflected a [AGE] year-old female, admitted [DATE], with the following diagnoses: major depressive disorder, single episode, unspecified ( a serious mental health condition characterized by intense feelings of sadness, worthlessness, and loss of interest in activities, lasting at least 2 weeks), insomnia ( a common sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or waking up too early and struggling to return to sleep, resulting in poor sleep quality and significant daytime impairment), and chronic pain ( pain lasting for more than three months often persisting beyond the normal healing time of an injury or illness). Record review of Resident #4's admission MDS Assessment, dated 01/22/2026, reflected Resident #4 had a BIMS score of 15 indicating her cognition was intact. Resident #4 was assessed to have the following 7 to 11 days out of the 14-day assessment period: little interest or pleasure of doing things feeling down, depressed, or hopelessFeeling tired or having little energyResident #4 had the following symptoms 2 to 6 days out of the 14-day assessment period:Poor appetite or overeatingFeeling bad about herself or felt she was a failure or let herself or her family down.Resident #4 had diagnoses of depression. Record review of Resident #4's Comprehensive Care Plan, dated 02/02/2026, reflected Resident # 4 had a potential for nutritional problems related to diet restrictions, depression and pain. Record review of Resident #4's PASARR Level 1 Screening, dated 02/11/2026, reflected that Section C, Primary Diagnosis of Dementia, was marked no, which indicated she did not have dementia, and Mental Illness was marked as No, which indicated Resident #4 did not have a mental illness. During an interview on 02/18/2026 at 2:30 p.m., Resident #4 stated she had depression majority of the time. She stated some days she felt good and did not have depression. Resident #4 stated she felt since she was in this facility she would benefit from having someone to talk to, such as mental health person, that helped people with depression. She stated she may not want it all the time, but she thought it may help if she tried talking to someone with a professional career with helping others with depression. She stated she had not spoken to anyone about getting help with depression and no one had asked her if she needed help. 2.Record review of Resident #129's Face Sheet, dated 02/18/2026, reflected an [AGE] year-old female, admitted [DATE] with diagnoses: major depressive disorder, recurrent, unspecified, insomnia ( a common sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or waking up too early and struggling to return to sleep, resulting in poor sleep quality and significant daytime impairment),chronic pain syndrome ( a condition characterized by persistent pain lasting longer than 3-6 months, often continuing well after an injury or illness has healed). Record review of Resident #129's MDS, dated [DATE], was in progress. Record review of Resident #129's Baseline Care Plan, dated 02/11/2026, reflected Resident #129 used antidepressant medication. Record review of Resident #129's PASARR Level 1 Screening, dated 02/11/2026, reflected that Section C Mental Illness was marked as No, which indicated Resident #4 did not have a mental illness. Primary Diagnosis of Dementia was marked no.Interview on 02/18/2026 at 2:50 p.m., Resident #129 stated she had depression and some days it is very difficult for her to do anything. She stated some days she prefers to stay in bed but not every day. She stated being in a new place and trying to get better was difficult sometimes. She stated she had seen psychologist in the past and it did help her. She stated if there was a psychologist available and, after she met the psychologist, she may be interested in receiving counseling. Resident #129 stated no one worked in the facility had talked to her about her depression. She stated she has had depression over the past few years. Interview on 02/18/2026 at 9:05 am, MDS Coordinator LVN A stated Resident # 4 and Resident #129 had major depression as their diagnosis. She stated the PASARR did not reflect Resident #4 and Resident #129 had a mental illness. She stated the hospital had completed both of the Residents (Resident #4 and Resident #129) PASARR's prior to the residents being admitted to the facility. She stated it was the MDS Coordinators responsibility to review the PASARRs, when residents were admitted , to ensure they were coded correctly. MDS Coordinator LVN A stated Resident #4's and Resident #129's was missed. She stated there was a possibility both residents (Resident #4 and Resident #129) may benefit from services from PASARR. She stated MDS Coordinators were responsible for the PASARR's on all residents. She stated Resident #4 and Resident #129 did not have a primary diagnosis of Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory). Interview on 02/18/2026 at 9:30 am, MDS Coordinator LVN B stated Resident #4 and Resident #129 PASARR was not coded correctly. She stated both of the residents (Resident #4 and Resident #129) had mental illness and on their PASARR forms it was coded they did not. She stated it was the MDS Coordinators' responsibility to review the PASARR forms when a resident was admitted and if the PASARR forms were not correct they were expected to fill out another one and make the corrections. She stated Resident #4's and Resident #129's was missed. She stated Resident #4 and Resident #129 did not have a primary diagnosis of Dementia. MDS Coordinator LVN B stated she was in serviced on the PASARR process but did not remember the date. She stated Resident #4 and Resident # 129 may benefit from PASARR services. Record review of the facilities Policy on Guide for Local Authorities and Nursing Facilities to Complete the PASARR Level 1 (PL1) Screening, dated 06/2023, reflected, The PASARR Level 1 Screening Form is designed to identify individuals who are suspected of having mental illness), intellectual disability (ID) or a developmental disability (DD). Developmental Disabilities are also referred to as related conditions. If documentation entered on the PL1 Screening Form indicates a suspicion of MI, ID, OR DD, a PASARR evaluation (PE) must be completed to confirm PASARR eligibility. The PE is designed to confirm suspicion of MI, ID, or DD and ensure an individual is placed in the most integrated residential setting receiving the specialized services needed to improve and maintain an individual's level of functioning.Section C:Primary Diagnosis of Dementia- Is there evidence that dementia is the primary diagnosis of this individual (this must be listed in the medical record as the primary diagnosis by the physician). Mental Illness- Is there evidence or an indicator this is an individual that has a Mental Illness?Examples of Mental Illness are:SchizophreniaMood Disorder (Bipolar Disorder, Major Depressive Disorder, or other mood disorder).Paranoid DisorderSevere Anxiety DisorderSchizoaffective DisorderPlease explain/define the medical diagnoses/terms in layman terms for reader comprehension as this document is an official record and available to the public upon request.Recommend updating throughout this document, per the NF handbook, the source of evidence is listed at the beginning of the sentence on the CMS 2567, such as, During an interview., During an observation. or Record review of.Recommend updating throughout this document, per the NF handbook, the source of evidence is listed at the beginning of the sentence on the CMS 2567, such as, During an interview., During an observation. or Record review of.Per the PoD, we write the report after the survey ends so we are always describing something that happened in the past, hence the past tense requirement. Recommend making this edit to reflect past tense throughout the document.

Based on observation, interview, and record review, the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs and preferences for 1 resident (Resident #114) of 8 residents reviewed for call lights. The facility failed to ensure Resident #114's soft pad call light device was within reach. This failure could place residents at risk for their needs not being met. Findings included: Record review of Resident #114's face sheet, dated 02/19/2026, revealed Resident #114 was an [AGE] year-old male, admitted [DATE], readmitted [DATE], diagnoses included hemiplegia (paralysis on one side of the body caused by brain or spinal cord injury, often resulting from stroke) and hemiparesis (a common, often stroke-related condition characterized by partial weakness or reduced motor control on one side of the body) following cerebral infarction (the death of brain tissue resulting from a prolonged lack of blood supply) affecting left non-dominant side, aphasia (language disorder caused by brain damage that impairs the ability to speak, understand, read, or write, while leaving intelligence intact), dysphagia (difficulty swallowing) dysarthria (motor-speech disorder caused by nerve or brain damage that weakens, paralyzed, or impaired coordination of the muscles used for speech), repeated falls, contracture of muscle, multiple sites, unsteadiness on feet, and gastrostomy status ( presence of a surgically created opening in the stomach, usually with a feeding tube inserted for long-term nutritional support). Record review of Resident #114's Quarterly MDS Assessment, dated 01/26/2026, revealed a BIMS score of 5 which indicated severe cognitive impairment. Resident #114 was assessed as dependent on staff for the following ADLs: eating, oral hygiene, toileting hygiene, showers, dressing, and personal hygiene. Resident #114 was assessed as dependent on staff for mobility including the following: chair/bed to chair transfers, shower transfers, ability to wheel at least 50 feet and make two turns using his manual wheelchair, and the ability to wheel at least 150 feet in a corridor or similar space. Resident #114 was assessed to require substantial/maximal assistance to move from sitting on the side of the bed to lying flat on the bed. Resident #114 was assessed to require partial/moderate assistance to roll from lying on his back to left and right side, and to return to lying on his back on the bed. Resident #114 was assessed as dependent on staff for the management of his feeding tube. Resident #114 was at risk of developing pressure ulcers, so he required frequent turning and repositioning. Record review of Resident #114's comprehensive care plan, dated 01/26/2026, revealed Resident #114 had an ADL self-care performance deficit related to fatigue, hemiplegia, contractures, impaired balance, limited mobility and abnormal posture with the following interventions: The resident was totally dependent x 2 staff for bathing/showering; the resident required extensive assist x 2 staff to turn and reposition in bed; the resident used a Halo ring x 1 to maximize independence with turning and repositioning in bed; the resident required extensive assist x 1 staff to dress; the resident required extensive assist x 1 staff to eat; the resident required total assistance by nurse for g-tube feedings; the resident required extensive assist x 2 staff with personal hygiene and oral care; the resident required extensive assist x 2 staff for incontinent care; and the resident required mechanical lift to transfer x 2 staff for assistance. Record review of Resident #114's comprehensive care plan, dated 05/31/2024, revealed Resident #114 had a communication problem related to aphasia and dysarthria with the following interventions: Ensure/provide a safe environment: Call light in reach. Resident #114 required peg tube feedings continuous related to dysphagia with the following intervention: Nurse to administer all tube feedings and water flushes. Record review of Resident #114's comprehensive care plan, dated 10/03/2023, revealed Resident #114 was a high risk for falls related to disoriented x 1, regularly incontinent, medication use and predisposing diseases; resident also has impaired Gait/balance and impulsivity with the following interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. During an observation on 02/17/2026 at 11:08 a.m., Resident #114 was lying in bed, and his soft pad call light device was lying face-down in the bottom of a drawer located to the left of his bed. During an interview on 02/19/2026 at 9:30 a.m., LVN C stated when a resident was in their room the call light was expected to be within reach. She stated if the resident needed nursing assistance it would be difficult for the resident to obtain that assistance. She stated a resident may attempt to move themself out of a wheelchair or bed, and the resident could fall resulting in an injury. She stated she attended an in-service on call lights, but she could not recall the date or time.During an interview on 02/19/2026 at 9:41 a.m. CNA E stated call lights were to be within the residents reach when residents were in their room. She stated some residents could not move themselves to the door to yell for help. She stated if a resident needed immediate assistance from staff, it would be difficult for them to receive help if they did not have their call light within reach. She stated the resident may attempt to locate the call light. She stated if the call light was on the floor, the resident could fall out of the wheelchair or bed. She stated it was possible the resident could sustain an injury such as a broken hip or head injury. During an interview on 02/19/2026 at 10:25 a.m., the ADON stated all call lights were to be within reach when a resident was in their room. She stated it was possible a resident may fall attempting to move themself from the bed or wheelchair to go to the bathroom. She stated a resident may have difficulty yelling for assistance. She stated the resident would not receive timely nursing care if the call light was out of their reach. She stated staff attended an in-service on placing call lights within reach of the residents, but she could not recall the date or time of the in-service.

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident# 92, and Resident #127) reviewed for ADL care.The facility failed to ensure Resident #92's and Resident # 127's nails were cleaned and did not have any rough edges.This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem.Findings included: Record review of Resident #92's face sheet, dated 02/18/2026, reflected an [AGE] year-old male, admitted [DATE], with diagnoses: hemiplegia and hemiparesis following cerebral infarction following nontraumatic intracerebral hemorrhage affecting left non-dominant side (complete or partial loss of motor function on one side of the body, caused by damage to the right hemisphere of the brain- controls the left side of the body), need for assistance with personal care ( when an individual cannot independently prefer essential Activities of Daily Living due to age, illness, or disability), and lack of coordination (an inability to produce smooth, precise, and voluntary muscle movements).Record review of Resident #92's Quarterly MDS Assessment, dated 12/11/2025, reflected Resident #92 was assessed to have a BIMS score of 4 indicating cognition was severely impaired. Resident #92 did not refuse care. Resident #92 required - partial/moderate assistance (helper does less than half the effort) with personal hygiene, lower body dressing, toileting hygiene, and shower transfers. He required- substantial/ maximal assistance (helper does more than half the effort) with showers. Record review of Resident #92's Comprehensive Care Plan, dated 12/24/2025, reflected Resident #92 had arthritis in his joints. Interventions: notify physician of any significant changes. Administer medications as ordered. Resident #92 had an ADL self-care performance deficit related to weakness. Intervention: Resident #92 required limited to extensive assistance by one staff with personal hygiene.Observation and interview on 02/17/2025 at 9:45 am, revealed Resident #92 was in his room lying in bed. He had a blackish/ brownish substance underneath the middle and ring fingernails on his right hand. Resident #92's middle fingernail on his right hand was uneven around the edges. Resident #92 did not respond to questions or conversation about his nails.Record review of Resident #127's face sheet, dated 02/18/2026, reflected an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes mellitus ( the body develops insulin resistance and cannot use insulin properly, or fails to produce enough insulin, leading to high blood sugar),cognitive communication deficit ( an impairment in communication skills caused by underlying disruptions such as memory, attention, and processing information- rather than a primary speech or language disorder), and other lack of coordination ( the inability to produce smooth, accurate, and voluntary muscle movements, resulting in clumsy, jerky, or unsteady actions).Record review of Resident #127's five-day Medicare MDS Assessment, dated 2/16/2026, was in progress. Record review of Resident #127's Baseline Care Plan, dated 02/15/2026, reflected Resident #127 had an ADL self-care performance deficit related to weakness. Intervention: Resident #127 required extensive assistance by one staff with personal hygiene.Observation and interview on 02/17/2026 at 9:40 a.m., revealed Resident #127 was in his room lying in bed. He had a blackish/ brownish substance underneath the middle ring and fore fingernails on his right hand. He stated on Monday night (02/17/2026) he asked a staff if she would clean his nails. Resident #127 did not recall the employee's name or their position. Resident #127 stated the person stated his nails would be cleaned sometime that night or the next day. He stated he did not ask anyone else to assist him in cleaning his nails.In an interview on 02/19/2026 at 9:30 a.m., LVN M stated the nurses were responsible for residents with diagnosis of diabetes with nail care such as trimming, cleaning, filing. She stated the CNAs were responsible for all other residents' nail care. LVN M stated if a resident had brownish/blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill such as stomach problems nausea and vomiting. LVN M stated if a resident refused any type of care, the nurse would document the refusal in the nurse's notes. She stated Resident #92 and Resident #127 did not refuse nail care. She stated Resident # 92 sometimes refused showers. She stated no one reported to her Resident #92 or Resident #127 refused nail care. LVN M stated she worked with Resident #92 and Resident #127 for several weeks. She stated she had been in- serviced on nail care, however, she did not recall the date. In an interview on 02/19/2026 at 9:35 am, CNA E stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA E stated the residents' nails were usually cleaned on their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill such as vomiting and diarrhea. CNA E stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated Resident #127 did refuse showers; however, she was not aware of him refusing nail care. She stated if any resident refused nail care, she reported it to the nurse. CNA E stated she was not sure where the nurse documented the refusal of nail care. In an interview on 04/24/2025 at 10:25 am, the ADON stated the nurses completed all nail care on residents except cleaning resident's nails. She stated the nurses were responsible to complete nail care such as trimming, filing, and cleaning once a week or as needed on residents with diagnosis of diabetes. The ADON stated the CNAs were responsible for nail care on all other residents. The ADON stated if a CNA noticed any concerns of a resident's nails, the CNA was expected to report any concerns to the nurse. The ADON stated if a resident had blackish substance underneath their nails there was a possibility a resident may become ill such as nausea or diarrhea depending on the type of bacteria. The ADON stated if a resident had rough edges around their nails, it was a possibility the resident may scratch themselves and develop a skin tear. She stated the nurse supervisors were responsible for monitoring the CNAs and nail care. Record review of the Facility's Policy on Activities of Daily Living (ADLs), dated 05/26/2025, reflected, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview and record review the facility failed to ensure residents received proper treatment and care to maintain good food health for one of nine residents (Resident #6) reviewed for foot care. The facility failed to schedule a podiatrist consultation for Resident #6 who was admitted to the facility on [DATE] with long, jagged toenails. This failure could place residents at risk of diminished quality of life by not receiving care and services to meet their needs. Findings included: Review of Resident #6's face sheet dated 02/19/2026 reflected a [AGE] year old male admitted to the facility on [DATE] with the following diagnoses: Atrial Fibrillation (A disease of the heart characterized by irregular and often faster heartbeat.), Hypertension (High pressure in the arteries and vessels that carry blood from the heart to the rest of the body), and Cachexia (complex metabolic syndrome characterized by involuntary weight loss, muscle wasting, and often fat loss, typically associated with chronic illnesses and cannot be fully reversed by conventional nutritional support.). Review of Resident #6's admission MDS assessment dated [DATE] reflected Resident #6 was assessed to have a BIMS score of seven indicating he had severe cognitive impairment. Resident #6 was assessed to not have behaviors or rejection of care. Resident #6 was further assessed to be dependent on staff for ADL assistance. Review of Resident #6's comprehensive care plan reflected a problem dated 01/23/2026 .has an ADL self-care performance deficit related debility and weakness. Interventions included .check nails cleanliness, length and trim as needed on bath day and PRN. Report any changes to the nurse. Observation on 02/18/2026 at 8:55 AM revealed Resident #6 sitting up in his wheelchair at nursing station. His sock on his left foot was off revealing his toenails to be long and jagged with the ends of some of the toenails curling over at the tips. The DON noticed and came over to the resident to put his sock back on and stated Yes his toenails were very long. In an interview on 02/19/2026 at 10:13 AM Resident #6 was in his room up in his wheelchair. Resident #6 was alert and was answered questions appropriately. Resident #6 stated he would like his toenails trimmed. When he was asked if he would let staff trim his toenails he stated he would love to have them cut. When asked if his toenails got hung on anything or scratched him he stated, surprisingly no they are pretty long. In an interview on 02/19/2026 at 10:20 AM The DON stated the social worker puts together the list for the podiatrist. She stated she tells the social worker who to put on the list. The DON stated she told the social worker to put Resident #6 on the list for the next podiatrist visit. The DON stated Resident #6 does refuse care and has refused nail care. The DON stated when asked if Resident #6 would still be added to the podiatry list even though he has refused care in the past she stated yes he would need to be added to the podiatry list. Review of the podiatry list provided by the facility on 02/19/2026 at 10:34 AM reflected the list was sent to the podiatrist on 02/16/2026 for the visit scheduled for 02/24/2026. The list did not include Resident #6. In an interview on 02/19/2026 at 10:39 AM the Treatment Nurse LVN L stated she checks residents' nails during her skin assessments for need of care. She stated she did not know why Resident #6 would not be on the podiatry list. She stated his nails were long and he should be on the list. In an interview on 02/19/2026 at 10:55 AM the Social Worker stated Resident #6 was on the podiatry list. After reviewing the list that did not include Resident #6's name she stated she still needed to get a signature from the resident. In an interview on 02/19/2026 at 11:05 AM the Social Worker stated Resident #6 had refused podiatry services on admission and presented the surveyor with the admission document. Review of Resident #6's admission paperwork dated 01/23/2026 reflected a section that for request for Podiatric services the documented reflected the resident declined podiatry care/services. Further review of the document reflected This can be changed at any time. In an interview on 02/19/2026 at 1:48 PM Social worker stated she had not re interviewed Resident #6 regarding the podiatry consult and stated she usually did not until they come and tell her the resident needed to be on the list which they just told her today (02/19/2026) that he needed to be on the list. The Social worker stated she would put him on the list to see the podiatrist. Request for the facility's policy for podiatry services on 02/19/2026 at 10:34 AM revealed a response from the facility Administrator that the facility did not have a podiatry policy.

Based on observation, interviews, and record reviews the facility failed to ensure the facility remained free of accidents and hazards a for one of three housekeepers (Housekeeping Cart #1) reviewed for hazards.The facility failed to ensure Housekeeping Cart #1, with chemicals inside the compartments, was locked when unsupervised. The housekeeping cart was located on 300 hall in front of biohazard room. This failure could place residents at risk for injuries, illness, and hospitalization.Findings included:Observation on 02/17/2026 at 8:55 am Housekeeping Cart #1 was located in front of biohazard room on 300 hall. The compartment where chemicals were stored was not locked. There was not a label on two bottles of the chemicals. The compartment had micro-kill bleach, disinfectant cleaner, Clorox, and two bottles filled with chemicals without a label on the bottles. Housekeeper G was not standing near the housekeeping cart. She exited the biohazard room [ROOM NUMBER]:00 a.m. and walked around the housekeeping cart and was standing beside surveyor. There were not any residents near the housekeeping cart or in the hallway on 300 hall.During an interview on 02/17/2026 at 9:00 a.m., Housekeeper G stated she did not know the name of the chemicals in the unlabeled bottles. She stated the housekeeping cart was expected to be locked anytime housekeeper walked away from the cart. Housekeeper G stated she could not see Housekeeping Cart #1 from inside the biohazard room because the door was closed. She stated there was a possibility that if a resident drank some of the chemicals the resident may become sick with stomach issues or have an allergic reaction. She stated it was possible a resident may need to be evaluated at the hospital. Housekeeper G stated all chemicals were required to have labels on the bottles. She stated she did have a key to the housekeeping cart. Observation on 02/17/2026 at 9:10 am, Housekeeper G located the key to the housekeeping cart and used the key to lock the compartment where chemicals were stored. Interview on 02/18/2026 at 1:30 p.m., the Housekeeping Supervisor stated all bottles with chemicals were expected to be labeled. She stated if a resident swallowed the chemical the nurse would not know what type of care to give the resident without knowing the name of the chemical. She stated all housekeeping carts were expected to be locked anytime the housekeeper was not standing in front of the cart. The Housekeeping Supervisor stated if a resident ingested some chemicals there was a potential for an allergic reaction, such as burning their throat, stomach and may need to be assessed at the hospital. She stated all housekeeping staff was in-service on locking housekeeping carts. She stated there was a possibility if a resident spilled chemical on their skin it may cause irritation to the skin. Interview on 2/19/2026 at 8:51 a.m., the Administrator stated he expected the housekeeping cart to be locked at all times when the housekeeper was not obtaining an item from the housekeeping cart. He stated all chemical bottles were expected to be labeled with the correct chemical name and directions how to use the chemical. The Administrator stated all housekeeping staff had been in-service on locking the housekeeping carts. He stated he checked with the nursing staff and there was not any residents who wandered on the 300 hall. He stated all the residents on 300 hall was in the facility for rehabilitation and would be discharging home when finished with their therapy. The Administrator stated if a resident drank a chemical there was a possibility a resident may become ill with nausea and vomiting. He stated there was a possibility a resident may need to be transported to the emergency room for further evaluation. Review of the Facilities Environmental Services Policies and Procedures, not dated, reflected All bleaches, detergents, disinfectants, insecticides, and other potentially hazardous substances are labeled and kept ins a safe place accessible only to employees. These items are not kept in containers that previously contained food or medicine.

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 3 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1 had her call light within reach on 12/18/2025. This failure could put residents at risk of being unable to contact staff in the event of an emergency or when assistance was needed with daily care.Findings include: Review of Resident #1's face sheet dated 12/18/2025 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia (significant memory and thinking problems), unspecified macular degeneration (the area of the eye responsible for sharp vision breakdown which causes vision loss), weakness, and generalized anxiety disorder (mental health condition marked by excessive uncontrollable worry about everyday things). Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 7 (severe impairment). Further review reflected Resident #1 required supervision or touching assistance (helper provides verbale cues and steading) for chair/bed-to-chair transfers. Review of Resident #1's care plan with revision date of 07/31/2025 reflected Resident #1 had an ADL self-care performance deficit related to weakness. Interventions included to encourage Resident #1 to use the call bell for assistance. Review of care plan dated 07/31/2025 reflected Resident #1 was a high risk for falls with interventions to ensure the resident's call bell was within reach and encourage the resident to use it for assistance when needed. Interventions also included that the resident needed prompt response to all requests for assistance. During an interview and observation on 12/18/2025 at 10:49 AM it was revealed that CNA B exited Resident #1's room. Resident #1 laid in bed and with her call light on the floor between the wall and head of her bed. Resident #1 stated that she got herself in and out of bed. Resident #1 stated that staff told to ask for help, but she forgets. Resident #1 stated she could not reach her call light. Observation on 12/18/2025 at 11:57 AM revealed Resident #1's call light on the floor between her wall and headboard as she laid in bed. Observation on 12/18/2025 at 2:46 PM revealed Resident #1's call light on the floor between her wall and headboard as she laid in bed. Observation on 12/18/2025 at 3:31 PM revealed Resident #1's call light on the floor between her wall and headboard as she laid in bed. During an interview on 12/18/2025 at 1:00 PM, LVN A stated that Resident #1's fall interventions were to encourage her to use her call light if she needed anything and to ensure her call light was within reach. LVN A stated she usually worked overnight and that during the night Resident #1 did not use her call light. During an interview on 12/18/2025 at 1:23 PM CNA C stated that fall prevention interventions included to ensure a resident had their call light in place. During an interview on 12/18/2025 at 2:18 PM, LVN D stated that residents who were at risk of falling had interventions in place to ensure their call light is within reach. During an interview on 12/18/2025 at 2:41 PM, CNA B stated she usually worked from 6:00 am to 6:00 PM. CNA B stated that she usually worked on the hall with Resident #1. She stated that rounds were done at least every two hours. CNA B stated fall prevention included to ensure the resident had their call light within reach. During a subsequent interview on 12/18/2025 at 3:22 PM, CNA B stated that when she checked on Resident #1, she checked Resident #1's brief, fixed her bed, checked her clothes to ensure they were clean and CNA B stated she had been in Resident #1's room throughout her shift because Resident #1 had been asleep most of the day. CNA B stated she laid Resident #1 down around 45 minutes ago and that Resident #1 had not turned on her call light today (12/18/2025). CNA B stated it was important for residents to have their call light in case they fell or needed something they could not reach, if they were scared to get out of bed because they may fall, or if they needed to be changed or needed care provided. At 3:24 PM, CNA B observed Resident #1's call light on the floor between her wall and headboard and stated that it was not within reach of Resident #1. CNA B stated she had just been in Resident #1's room. During an interview on 12/18/2025 at 3:28 PM, LVN E stated fall interventions included to ensure the resident had their call light within reach and that this was important so that the resident could get hold of staff and have their needs taken care of. LVN E stated if the call light was on the floor behind the bed, that would not be considered in reach of the resident. During an interview on 12/18/2025 at 3:49 PM, the DON stated that fall prevention included to ensure residents had call lights within reach. The DON stated that staff were expected to round and check on residents at least every two hours. The DON stated that it was important for residents to have call lights within reach in case they needed assistance they would have been able to contact staff. The DON stated that at times Resident #1 will forget to use her call light and wanted to be as independent as possible. The DON stated that she expected staff to ensure residents had their call light during their rounds. During a telephone interview on 12/18/2025 at 3:59 PM, the ADM stated that fall prevention included staff rounding every two hours and that he expected staff to ensure residents had their call light. The ADM stated Resident #1 moved stuff in her room and staff should anticipate her needs as far as ensuring her call light with within place. The ADM stated that anytime staff entered a resident's room they should check that the resident's call light is in place. Review of facility in-service dated 11/11/2025 reflected topic of resident checks and cleanliness and that call lights must be within reach of the resident and answered timely. Review of facility in-service dated 11/17/2025 reflected topic of falls and falls management and reflected that call lights must be within reach of the resident and answered timely. Review of facility in-service dated 11/25/2025 reflected topic of call lights and included that call lights should be within reach of the resident. Review of facility in-service dated 11/29/2025 reflected topic of falls and falls management and reflected that call lights must be within reach of the resident and answered timely. Review of facility policy titled Call Lights: Accessibility and Timely Response dated 12/13/2022 reflected the purpose of this policy is to ensure the facility is adequately equipped with a call light at each residents bedside to allow residents to call for assistance. Review reflected staff will ensure the call light is within reach of resident and secured, as needed. Review also reflected The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Review of facility policy titled Fall Prevention Program dated 08/15/2025 reflected low risk fall protocols included call light and frequently used items are within reach.

Based on interviews and record reviews , the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 (Resident #1) of 5 residents reviewed for care plans. The facility failed to ensure Resident #1's care plan was revised to reflect recent falls on 11/10/2024, 12/31/2024 and, 01/04/2025. This failure could place residents at risk of not receiving appropriate care to meet their current needs. Findings included: Record review of Resident #1's face sheet, dated, 01/23/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included repeated falls, unspecified dementia, unspecified moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a decline in mental ability that affects memory, thinking, and behavior), adult failure to thrive (a syndrome in older adults characterized by unexplained weight loss, decreased appetite, poor nutrition, and inactivity), muscle wasting and atrophy (loss of muscle and strength), not elsewhere classified, right and left shoulder, and right and left upper arm (wasting or thinning of your muscle mass), and lack of coordination (uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements). Record review of Resident #1's Quarterly MDS Assessment, dated 12/31/2024, reflected the resident had a BIMS score of 3, which indicated her cognition was severely impaired. Resident #1 was total dependent on staff for personal hygiene, showers, and toileting hygiene. Resident #1 required partial/moderate assistance where helper does less than half the effort with transfers, eating, and dressing. Resident #1 was assessed for falls. Record review of Resident #1's Comprehensive Care plan, with completion date of 12/31/2024 , reflected Resident #1 had an ADL self-care performance deficit. Intervention: Bathing, toileting, transfers, and dressing: Resident #1 required one staff assistance. Resident #1 required 1-2 staff assistance with bed mobility. Resident #1 was low risk for falls. Intervention: Be sure call light was within reach and encourage the resident to use call light for assistance as needed. Resident #1 required prompt response to all request and assistance. Review information on past falls and attempt to determine cause of falls. Record root causes. Alter remove any potential causes if possible. Resident #1 had an actual fall with no injury. She had poor balance and, unsteady gait. Intervention: Check range of motion. Ensure personal items are within reach. Fall mat in place when resident in bed. New intervention dated 12/31/2024: Room modification to ensure safety and repositioning. Resident #1 had an actual fall with no injury (date initiated 07/12/2024) Interventions: Check range of motion. Ensure personal items are within reach. Fall mat in place when resident in bed. Room modification to ensure safety and repositioning. Record review of Resident #1's fall risk assessment dated , 12/31/2025, reflected Resident #1 was high risk for falls with a score of 15. If the total score was 10 or greater, the resident should be considered high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. Resident #1 had 1-2 falls in the past 3 months. Record review of the facility's incident/accident report from 11/2024 thru 01/2025 reflected Resident #1 had a fall on the following dates: 1. 11/10/2024- result of a fall with abrasion 2. 12/31/2024- result of a fall without injury 3. 01/04/2025 - result of a fall with laceration In an interview on 01/23/2025 at 1:30 PM MDS Coordinator RN stated the most current completed care plan is the one with the completion date of 12/31/2024. (Surveyor and MDS Coordinator RN was reviewing the care plans in electronic medical record at the same time to verify the care plan completed on 12/31/2024 was the most current completed care plan). She stated there was a care plan opened but it had not been completed with all the information needed to be documented on the care plan. MDS Coordinator RN stated Resident #1's care plan needed to be revised on the completed care plan dated 12/31/2024 to reflect resident fall on 01/04/2025. She reviewed Resident #1 fall risk assessments with surveyor and she stated the same care plan with completion date of 12/31/2024 needed to be revised to reflect Resident # 1's low risk for falls problem needed to be revised to reflect Resident #1 was high risk for falls and revise the interventions as needed. The MDS Coordinator, RN stated she missed the fall risk assessments for December 2024 that reflected she was high risk for falls. She stated there was a care plan opened at this time but was not completed. She stated anytime a resident had a fall with injury their care plan was expected to be revised the day of the fall. The MDS Coordinator RN stated the importance of a care plan revision after a fall or any type of incidents the interventions needed to be reassessed and make any changes to prevent further falls or incidents. She stated she was responsible for completing comprehensive care plan, revising care plans. She stated she had been in serviced on care plans but did not recall the date or time of the in-service. She stated she was expected to revise Resident #1's care plan on 12/31/2024 when she completed Resident #1's comprehensive care plan and on 01/04/2025 when she fell . She stated Resident #1's fall on 12/25/2024, 12/31/2024, and 01/04/2025 would be considered a change with Resident #1 with having three falls less than two weeks. In an interview on 01/23/2025 at 2:45 PM the DON stated Resident #1 care plan should have been revised on 12/31/2024 and resolved of Resident #1 had a low risk for falls and changed the care plan to Resident #1 was high risk for falls. She stated there is care plan opened but it was not completed. She stated the MDS Coordinator RN was documenting on the care plan today (01/23/2025). She stated the MDS Coordinator RN was responsible for ensuring the care plans were correct. The DON did not respond to the question of a possibility of a negative outcome if the care plan was not revised after a fall or incident. Record review on 01/23/2025 the facilities Care Plan Revisions upon status change, dated 10/23/2022, reflected the purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change. The care plan will be updated with the new or modified interventions. Care plans will be modified as needed by the MDS Coordinator or other designated staff member.

Based on observations, interviews, and record review the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs for 1 (Resident # 2) out of 5 residents reviewed for call lights. The facility failed to ensure Resident # 2's call light was within reach. This failure could affect all residents who needed assistance and could result in needs not being met. Findings included: Record review of Resident #2's face sheet, dated, 01/23/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included muscle wasting and atrophy (loss of muscle a not elsewhere classified, in multiple sites (wasting or thinning of your muscle mass), need for assistance with personal care (required help with basic daily living activities such as: bathing, dressing, eating and personal hygiene), unsteadiness on feet, lack of coordination ( the inability to control the movement of one's body). Record review of Resident #2's Quarterly MDS, dated [DATE], reflected the resident had a BIMS score of 10, which indicated his cognition was moderately impaired. Resident #2 required partial to moderate assistance (helper does less than half the effort) with toileting hygiene, dressing, personal hygiene, and showers. Resident #2 was dependent on staff for bed-to-chair transfer and chair to bed transfer. He required substantial/maximal assistance ( helper does more than half the effort) for all other transfers and bed mobility such as: lying to sitting on side of bed, sit to lying, and sit to stand. Record review of Resident #2's Comprehensive Care Plan, with a completion date 12/02/2024, reflected Resident #2 had an ADL self-care performance deficit. Interventions: Resident #2 required assistance by one staff to turn and reposition in bed, dressing, personal hygiene, and toileting. Resident #2 required mechanical lift by two staff for transfers. Encourage Resident #2 to use bell to call for assistance. Resident #2 was at risk for impaired mobility. Resident #2 was at high risk for falls. Interventions: Be sure the call light is within reach and encourage the resident to use the call light for assistance as needed. Resident #2 needs prompt response to all requests for assistance. Observation and interview on 01/23/2025 at 9:41 AM, revealed upon entering Resident #2's room he was attempting to reach for the call light located at the foot of the bed. The overhead bed table was over the bed with water and cup located on the overhead bed table. Resident #2 stated I have been trying to get that light to call someone. He stated I prefer my call light to be next to me where I can use it when I need help. He pointed to the halo (device on the bed for resident to help with mobility in bed) on his bed and stated this is where I like for my call light to be. Resident #2 stated I have difficulty sometimes yelling for help. In an interview on 01/23/2025 at 9:46 AM, CNA A entered Resident #2's room and stated Resident #2's call light was at the foot of the bed and Resident #2 was unable to reach the call light. She stated all residents call light was required to be within reach at all times when a resident was in their room. CNA A stated she did not know how the call light got at the end of the bed. She stated she was not assigned to Resident #2. She stated if a resident was unable to reach their call light and needed assistance, there was a possibility a resident may need nursing assistance. CNA A stated a resident may attempt self out of bed and fall trying to get assistance. She stated she had been in-serviced on placing call lights within resident's reach, however, she did not recall the date or time of this in-service. In an interview on 01/23/2025 at 2:45 PM The DON stated if a resident was in their room lying in bed or sitting in a wheelchair, the call light was expected to be within reach of resident. She stated she could not determine what may happen to a resident if the call light was not within reach and the resident needed assistance. The DON stated any staff who entered the room was expected to check the call lights of the resident and if the call light was not in reach, any staff was capable of placing call light within reach of resident. Record review of the facilities policy on Call Lights: Accessibility and Timely Response, dated 10/13/2022, reflected The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

49097 Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 5 of 7 residents (Resident #9, Resident #49, Resident #61, Resident #98 and Resident #106) reviewed for resident rights . 1. The facility failed to ensure Resident #49, Resident #61, Resident #98 and Resident #106's were served their lunch tray at the same time as other residents at the same table for lunch on 11/19/2024 and 11/20/2024 . 2. The facility failed ensure CNA P spoke respectfully to Resident #9 when the resident attempted a self-transfer. These failures could place residents at risk of poor self-esteem and unmet needs and risk of skin breakdown. Findings include: 1. Record review of Resident #9's face sheet, dated 11/20/2024 , reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #9 had diagnoses which included muscle wasting and atrophy (loss of skeletal muscle mass), major depressive disorder (mental health disorder), aphasia (damage to the brain) following cerebral infarction (a condition that that impacts the ability to speak, write and understand language after a stroke) and unsteadiness on feet. Record review of Resident #9's quarterly MDS Assessment, dated 09/27/2024, reflected a BIMS of 06 which indicates severe cognitive impairment. Section GG (Functional Abilities and Goals) reflected she was dependent for chair/bed-to-chair transfers. Record review of Resident #9's quarterly care plan, dated 02/01/24 , reflected she was at high risk for falls related to poor balance, unsteady gait, and poor safety awareness with an intervention of using a mechanical lift for transfers, provided signs in room to remind resident to use call light, and continue to interventions on at-risk plan . An observation on 11/19/24 at 11:29 AM revealed Resident #9 transferred herself to the toilet assisted by her family member . An observation on 11/20/24 at 3:30 PM revealed Resident #9 smelling of urine. There was water on the floor and the resident was attempting to transfer herself. The State Surveyor went to notify CNA P. The State Surveyor and CNA P walked into the room and CNA P said to the resident in a condescending tone oh no, sit down, you know you're not supposed to do that. CNA P proceeded to help Resident #9 sit in the wheelchair. The resident was faced away from the door, still undressed, shaking her head in her hands. CNA P walked back out and grabbed CNA Q who both assisted her into bed without a mechanical life . After the resident care was completed Resident #9 had a distressed look on her face and was crying in bed. In an interview with Resident #9 on 11/20/2024 at 3:50 PM, she stated her feelings were hurt when they told her to sit down. She did not respond to more questions . In an interview with Resident #9's RP on 11/20/24 at 04:08 PM, she stated she was worried about the resident. She was not supposed to be in the bathroom, but insisted, so she helped her. The facility denied the resident a pad alarm because it was considered a restraint. Resident #9 was not depressed when she was admitted to the facility and was able to voice her needs. RP stated her mood and condition had declined since she moved into the facility. She did not leave her room. She would glare at the staff. She cried and stated they were rough with her Resident #9 would not name any specific staff. RP stated that she had no concerns about the way staff treated the resident. She was concerned about the lack of supervision. The RP stated she asked the facility to get her out of bed and dressed for breakfast. RP stated Resident #9 would not leave her room until she was dressed. The RP stated she asked for increased monitoring by the CNAs, but they started monitoring at the end of the hall every time she visited. Interview with LVN R on 11/20/24 at 04:15 PM, LVN R said she was the only daytime charge nurse on the hall. She did not tolerate any disrespect geared at the residents. She stated there were no reports of CNA P speaking disrespectfully to Resident #9. She stated it would be hard to identify people who were non-verbal who felt uncomfortable around the caregiver. She stated signs demeanor change would be their posture changed when they saw that person. She stated if a resident reported a CNA who disrespected them, she would report it. Interview with the Administrator on 11/21/24 at 3:30 PM, he stated he expected staff to treat the residents with respect and dignity. He did not believe Resident #9 was more vulnerable because of her low BIMS score than the rest of the population. He did not believe the CNA abused Resident #9. He believed CNA P reacted in the moment, and there was no negative or harmful intention in her action. He reported there was no change in Resident #9's demeanor and the resident were upset due to a lack of family at the holiday event in the evening . Record review of records indicated there was no at-risk plan available for the resident #9's chart. A record review of the facility's grievance log for September of 2024 reflected an entry on 09/30/2024, which documented the resident's RP grievance about checking and changing Resident #9. That issue was marked to be resolved the same day by the DON. 2. Record review of Resident #49's face sheet, dated 11/20/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included dementia (memory, thinking difficulty), muscle wasting, lack of coordination, repeated falls, unsteadiness on feet, anemia (not enough healthy red blood cells), hypertension (high blood pressure), muscle weakness, age related osteoporosis (skeletal disorder), cognitive communication deficit (problems with communication), altered mental state, heart failure and protein-calorie malnutrition. Record review of Resident #49's Quarterly MDS, dated [DATE], reflected Resident #49 had a BIMs score of 2, which meant the resident was severely impaired. Record review of Resident #49's comprehensive care plan, dated 11/06/2024, reflected the resident sometimes was able to make needs known and understood others. 3. Record review of Resident #61's face sheet, dated 11/20/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included abnormal posture, unsteadiness on feet, type 2 diabetes mellitus without complications (high blood sugar), anxiety, protein- calorie malnutrition, pain in left shoulder, major depressive order, impulsiveness, malaise (feeling of general discomfort), abnormalities of gait and mobility, muscle wasting, and profound intellectual disability . Record review of Resident #61's Quarterly MDS, dated [DATE], reflected Resident #61's BIMs score was 99, which meant the resident was unable to complete the interview. Record review of Resident #61's comprehensive care plan, dated 10/29/2024, reflected the resident rarely was able to make needs known and sometimes understood others. 4. Record review of Resident #98's face sheet, dated 11/20/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included dementia (memory, thinking difficulty), muscle wasting, lack of coordination, repeated falls, unsteadiness on feet, depression, hypertension (high blood pressure), insomnia (difficulty sleeping), chronic kidney disease, dysuria (painful or uncomfortable urination), delirium due to physiological condition, and abnormalities of gait and mobility . Record review of Resident #98's Quarterly MDS, dated [DATE], reflected Resident #98's BIMs score was 2, which meant the resident was severely impaired. Record review of Resident #98's comprehensive care plan, dated 11/19/2024, reflected the resident had severe impaired cognation. 5. Record review of Resident #106's face sheet, dated 11/20/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included dementia (memory, thinking difficulty), cognitive communication deficit (problems with communication), impulsiveness, type 2 diabetes mellitus without complications (high blood sugar), weakness, difficulty walking, repeated falls, need for assistance with personal care, insomnia (difficulty sleeping), malaise (feeling of general discomfort) and hypertension (high blood pressure). Record review of Resident #106's Quarterly MDS, dated [DATE], reflected Resident #106's BIMs score was 4, which meant the resident was severely impaired. Record review of Resident #106's comprehensive care plan, dated 11/20/2024, reflected the resident had severe impaired cognitive function. Observation of dining services at lunch on 11/19/2024 at 12:00 PM revealed Resident #61 did not get their meal trays with their tablemate. Residents #61 did not get their meal tray until 6 minutes after their tablemate and staff were passing meal trays to other tables. Observation of dining services at lunch on 11/19/2024 at 12:05 PM revealed Resident #106 did not get her meal tray at the same time as her tablemates. Resident #106 did not get her meal tray until 10 minutes after her tablemates and staff were passing meal trays to other tables. Observation of dining services at lunch on 11/20/2024 at 12:17 PM revealed Residents #49 and #98 did not get their meal trays with their tablemate. Residents #49 and #98 did not get their meal tray until 7 minutes after their tablemate and staff were passing meal trays to other tables. An interview with Resident #106 on 11/19/2024 at 12:07 PM revealed she did not know where her meal tray was, and she said she was starving. She said she was so hungry she did not want to watch her tablemates eat. She said she felt like the staff wanted her to beg for food and she was not going to beg. She said it was not right for her to be so hungry and must watch other people eat and smell the food and not given anything to eat. An interview with Resident #61 on 11/20/2024 at 12:04 PM revealed she did not want to talk to the State Surveyor. An interview with Resident #49 on 11/20/2024 at 12:20pm revealed that she had to wait for her tray all the time. She said that she just wanted her food. An interview with Resident #98 on 11/20/2024 at 12:22 PM revealed the resident did not want to talk to the State Surveyor and just looked at the surveyor. An interview with the DON on 11/21/2024 at 11:16 AM revealed she was trained on resident rights. She said she was not sure what the policy was for meal tray pass. She stated she expected the staff to pass the trays by table. She said all staff in the dining room were responsible for ensuring all residents had their meal tray at the same table before moving on. She said if all residents did not get their meal tray at the same table residents may try to eat of someone else's plate. She said everyone was responsible for monitoring residents all got their trays together. She said everyone should be vigilant when passing by the tables. She said she did not know why the residents did not get their meal tray at the same time. An interview with CNA J on 11/21/2024 at 12:54 PM revealed she was trained on resident rights. She said staff were to pass meal trays to residents at the same table. She said all staff were responsible for ensuring all the residents at a table had their meal trays before moving on. She said it had never happened where a resident had to wait. She said all staff in the dining room were responsible for monitoring to ensure all residents had their meal tray with their tablemates. She said staff would walk around and ensure residents had fluids when they would monitor also. She said she did not know why the residents did not get their meal tray with their tablemates. An interview with LVN B on 11/21/2024 at 2:05 PM revealed she was trained on resident rights. She said the policy was for the nurse to check the meal trays and for the CNAs to give the trays by table. She said all staff were responsible for ensuring residents at the same table had their meal tray before moving on. She said it was a dignity issue and the resident did not want to watch others eat. She said all staff monitored to ensure the residents all had their meal tray at the same time by walking around and observing. She said she did not know why the residents did not get their meal tray at the same time as their table mates. An interview with the Administrator on 11/21/2024 at 3:26 PM revealed the policy was to pass meal trays by tables so all the resident at the same table could eat together. He said the nurse was responsible for ensuring the residents had their food at the same table. He stated if residents did not get their meal tray together it would leave residents waiting for their food. He said the charge nurse was responsible for monitoring to ensure all residents at the same table had their meal tray before moving on. He said the monitoring was done by observation. He stated the residents did not get their meal tray with their table mates because the nurse pulled the meal tickets was disorganized. Record review of the facility's policy entitled Promoting/Maintaining Resident Dignity, implemented 1/13/23, reflected the following: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . 10. Speak Respectfully to the residents. Record review of the Meal Service Policy, dated 10/01/2028, reflected all residents at one table will be served at the same time prior to serving residents at other tables .

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 4 residents (Resident #1) reviewed for pharmaceutical services. The facility failed to provide antibiotic medication to Resident #1 from 05/17/24 through 05/21/24. On 05/21/24, the facility sent Resident #1 to the ER by EMS. On 05/22/24, Resident #1 was admitted to the hospital for higher level of care. The noncompliance was identified as PNC. The IJ began on 05/21/24 and ended 05/24/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving their medications, hospitalization , infection or death. Findings include: Record review of Resident #1's Admission Record, dated 05/17/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included unspecified fluid overload (A condition in which the liquid portion of the blood (plasma) is too high) and hepatic encephalopathy (The loss of brain function when a damaged liver doesn't remove toxins from the blood). Record review of Resident #1's Admission MDS assessment, dated 04/17/24, reflected she had a BIMS of 14, which indicated she was cognitively intact. Record review of Resident #1's Discharge MDS assessment, dated 05/21/24, reflected she had active diagnoses which included unspecified fluid overload and hepatic encephalopathy. Record review of Resident #1's Hospital Records, dated 05/17/24, reflected Resident #1 was required to start taking Rifaxmin 200 MG tablet, commonly known as Xifaxan, last time they were given the medication was at 400 MG on 05/17/24 at 1:57 p.m., indications for impaired brain function due to liver disease, and instructions included taking 2 tablets 400 mg by mouth 3 times daily for same indications. There were also instructions to take antibiotics exactly as prescribed, do not skip doses or stop taking antibiotics even if you feel better, and antibiotics only work for bacterial infections. Record review of Resident #1's Order Summary Report, as of 05/21/24, reflected she was required to take two Rifaximin 200 milligram tablets by mouth three times a day for hepatic encephalopathy that was verbally ordered and started on 05/17/24. Record review of Resident #1's MAR, from 05/18/24 through 05/21/24, reflected Resident #1 received Rifaximin 200 milligram tablets by mouth three times a day on 05/17/24 at 4:00 p.m. and 8:00 p.m, 05/18/24 at 4:00 p.m. and 8:00 p.m., 05/19/24 at 8:00 p.m., 05/20/24 at 8:00 p.m., and 05/21/24 at 8:00 p.m. Resident #1 did not receive the Rifaximin 200 milligram tablets by mouth three times a day on 05/18/24 at 8:00 a.m., 05/19/24 at 8:00 a.m. and 4:00 p.m., 05/19/24 at 8:00 a.m. and 4:00 p.m., 05/20/24 at 8:00 a.m. and 4:00 p.m., and 05/21/24 at 8:00 a.m. and 4:00 p.m. Record review of Resident #1's EMAR Progress Notes, from 05/18/24 through 05/21/24, reflected the following: -A note on 05/18/24 at 5:41 p.m., on 05/19/24 at 9:58 a.m., and on 05/19/24 at 5:07 p.m., Rifaximin Oral Tablet 200 Note MG Give 2 tablet by mouth three times a day for hepatic encephalopathy waiting on pharmacy. -A note on 05/20/24 at 11:27 a.m., Rifaximin Oral Tablet 200 Note MG Give 2 tablet by mouth three times a day for hepatic encephalopathy on order. -A note on 05/20/24 at 4:55 p.m., Rifaximin Oral Tablet 200 Note MG Give 2 tablet by mouth three times a day for hepatic encephalopathy on order nurse aware. -A note on 05/21/24 at 8:23 a.m., Rifaximin Oral Tablet 200 Note MG Give 2 tablet by mouth three times a day for hepatic encephalopathy spoke to the pharmacy and the nurse is aware of this situation -A note on 05/21/24 at 4:34 p.m., Rifaximin Oral Tablet 200 Note MG Give 2 tablet by mouth three times a day for hepatic encephalopathy unavailable. Record review of Resident #1's Admission and Discharge Report, from 03/05/24 through 06/05/24, reflected Resident #1 was discharged to the hospital on 05/21/24. An observation of the medication room on 06/05/24 at 3:02 p.m. revealed there was no Rifaximin 200 MG available or listed as an available medication in the emergency medication kit. During an interview on 06/05/24 at 12:09 p.m., Resident #1 revealed she would never return to the facility because staff found her on the floor on 05/21/24. Resident #1 stated she could not remember anything about how she ended up on the floor and could only remember waking up in the hospital. Resident #1 stated staff administered medications to her. Resident #1 stated she could not remember what medications she received and did not receive. Resident #1 also stated she did not know if she received any discontinued medications during her stay at the facility. Resident #1 did not have any additional information to provide and advised to speak with her POA . During an interview on 06/05/24 at 12:29 p.m., Resident #1's POA revealed Resident #1 had poor liver function. The POA stated staff did not administer certain medications to Resident #1. The POA explained staff should have administered the same medications Resident #1 was administered in the hospital. The POA stated on 05/21/24, the facility called the ER to pick up Resident #1 because her pneumonia levels were high. The POA also stated they spoke with the ADM on 05/23/24 about Resident #1's hospitalization . The POA stated Resident #1 had the capacity to make decisions for herself and knew she needed to take her medication. Attempted interview with CMA A on 06/05/24 at 12:54 p.m. was unsuccessful. A voicemail and call back number was left. CMA A did not return the call. Attempted interview with LVN B on 06/05/24 at 12:56 p.m. was unsuccessful. A voicemail and call back number was left. LVN B did not return the call. During an interview on 06/05/24 at 12:58 p.m., CMA C revealed they were trained and in-serviced on medication administration. CMA C stated they learned to notify a nurse whenever a residents' medication was unavailable. CMA C also stated they did not know Resident #1 received her medication on 05/17/24 and ran out on 05/17/24 because she did not work on 05/17/24. CMA C stated she notified LVN D, who told them they called the Pharmacy to send Resident #1's medication. CMA C also stated they did not know Resident #1 received any medication from the emergency kit on 05/18/24 because they did not know what medications were available . During an interview on 06/05/24 at 1:11 p.m., the SW revealed on 05/21/24, they had a care plan meeting with Resident #1's family and Resident #1. The SW stated the nurses monitored Resident #1's fluid and the DON and the ADON evaluated Resident #1. The SW explained the ADON notified the MD and the MD recommended to send Resident #1 out to the ER. The SW stated Resident #1 made all her own decisions, had the capacity to make decisions for herself, and had a POA. During an interview on 06/05/24 at 1:19 p.m., LVN D revealed they were trained and in-serviced on medication administration. LVN D stated they learned to notify the pharmacy whenever a residents' medication was unavailable. LVN D also stated on 05/18/24, CMA C informed them Resident #1's medication was not refilled. LVN D stated she did not make a progress note of contacting the pharmacy and physician when they notified them on 05/18/24, did not know why they did not make a progress note, and thought it was because they might have been busy. LVN D stated they notified the Pharmacy and determined Resident #1's medication was on back order, which they explained meant there was a local shortage on the particular medication. LVN D stated they also notified the Physician that the medication was on back order, the Physician did not give them any new orders, and the Physician did not provide them with any instruction or direction on 05/18/24. LVN D also stated they did not notify anyone else about Resident #1's medication backorder. LVN D stated they were supposed to notify the ADON and DON if the Physician did not give any direction or instruction. LVN D also stated they did not notify the ADON and DON because the day was probably busy. LVN D stated residents' health could be affected if the resident went long periods of time without medication if the medication was on back order. LVN D stated they were in-serviced on proper protocol to take when a medication was unavailable at the facility. LVN D explained they learned to contact the pharmacy, have the pharmacy STAT order the medication if the pharmacy had the medication, document contacting the pharmacist, each person they spoke to and new order given, and notify the ADON, the DON and the physician for alterative medication recommendations . During an interview on 06/05/24 at 1:59 p.m., the Physician revealed they were not informed by the facility on 05/18/24 about the facility still waiting on the Pharmacy to send Resident #1's medications. The Physician stated the facility might have informed the on-call physician on 05/18/24. Physician explained on-call physicians worked during the weekends and weekdays after 6:00 p.m. Physician went on to explain they worked on weekdays until 6:00 p.m. The Physician stated there were no on-call physician notes. The Physician stated they would work with the Pharmacy to find an alternative medication if they were notified that a medication was on back order. The Physician also stated Rifaximin did not need to be administered daily, but it depended on the resident's condition. The Physician stated the facility could wait one or two days to administer antibiotics to a resident, but it depended on the resident's condition. The Physician also stated they were not working when Resident #1 was sent to theER on [DATE] . During an interview on 06/05/24 at 3:03 p.m., the DON revealed Resident #1 was readmitted to the facility on [DATE]. The DON stated they trained staff to notify the Pharmacy about medications unavailable at the facility and notify the MD if the MD wanted to change or continue to use the medication unavailable. The DON also stated they expected CMAs to document medications unavailable and notify a nurse if a medication was unavailable. The DON stated they expected nurses to notify the pharmacy and the MD when determining a resident's medication was unavailable. The DON also stated they in-serviced staff about documentation, notifying the physician and pharmacy, and medication availability. The DON stated staff did not notify them or the ADON about Resident #1's medications being unavailable from 05/18/24 through 05/21/24. During an interview on 06/05/24 at 3:40 p.m., the ADON revealed Resident #1 came from the hospital on 05/16/24, 05/17/24, or over the weekend (05/18/24-05-19/24), but they were not at the facility. The ADON stated Resident #1 went out to the hospital after the weekend. The ADON stated Resident #1 was on antibiotics during her admission. The ADON stated Resident #1 also had fluid overload prior to her admission. The ADON stated they expected CMAs to alert a nurse if a resident's medication was unavailable. The ADON stated the facility had an emergency kit. The ADON stated they expected nurses to call the pharmacy if a resident's medication was unavailable. The ADON stated they also expected nurses to contact the Physician if the pharmacy indicated the resident's medication was unavailable or backordered. The ADON also stated the physician gave instructions to the nurses and nurses followed the instructions. The ADON stated they expected nurses to document notifying the pharmacy or MD whenever a resident's medication was unavailable. The ADON explained nurses could notify them and the DON if a resident's medication was unavailable. The ADON stated they were not sure if a resident could be affected if a resident did not receive medications according to orders. The ADON stated nurses did not notify them or the DON about medication unavailability. The ADON stated they did not know how the DON learned of staff waiting on the pharmacy for Resident #1's medications that resulted in reeducation for the staff. The ADON stated on 05/21/24, Resident #1 fell and went to the hospital. The ADON stated she did not observe Resident #1 before EMS took her to the hospital. The ADON also stated the Pharmacy would notify the nurses if a medication was in the emergency kit. The ADON stated staff (she could not remember who) informed her and the DON that they contacted the MD (did not indicate who nor did staff indicate who) and did not mention if the MD gave any special instructions or medication changes. The ADON also stated residents must be on antibiotics to ensure they did not develop any infections and improve. The ADON stated residents could catch an infection if they were not consistent with their antibiotic orders. Attempted interview with the Pharmacy on 06/05/24 at 4:03 p.m. was unsuccessful. The Pharmacy was advised to email the Pharmacy Director, which was completed. The Pharmacy did not respond to the email and did not call back. During an interview on 06/05/24 at 4:08 p.m., the ADM revealed they were still looking for a policy related to following physician's orders. During an interview on 06/05/24 at 4:17 p.m., LVN E revealed they were trained and in-serviced on medication administration. LVN E stated they learned to notify the pharmacy whenever a residents' medication was unavailable. LVN E also stated Resident #1's medication might have been in the emergency kit . LVN E stated they could not recall that they administered Resident #1's medication on 05/17/24 and 05/18/24 and believed they might have misdocumented on the MAR. LVN E stated residents were given antibiotics for specific diseases and must have full treatment for antibiotics. LVN E stated residents could be affected if they did not receive medication according to their orders. LVN E stated they were trained to call the pharmacy or physician if a medication ran out. LVN E stated they did not document contacting the pharmacy or physician about Resident #1's medication unavailability. LVN E stated they reached out to the physician if the resident needed a substitute or change in medication. LVN E stated they called the physician whenever the pharmacy did not have medications unavailable. LVN E stated they could not recall why they documented administering Resident #1's medications despite Resident #1's medications being unavailable . LVN E stated they must contact the physician so the resident's order could be put on hold or start on the medication when the pharmacy brought out medication or ordered a substitute. LVN E stated they could not recall if they contacted the pharmacy or physician regarding Resident #1's orders. During an interview on 06/05/24 at 4:34 p.m., the DON revealed the ADON and them reviewed residents' clinicals during morning meetings. The DON stated the ADON and them reviewed residents' medications and history and physical records to make sure assessments were in place. The DON also stated they could not recall what happened on 05/20/24 that caused them to overlook Resident #1's medications during Resident #1's clinical review. The DON stated staff were expected to reach out to the physician for a substitution or discontinuation if a medication was back ordered. The DON stated staff could also call a pharmacist and the pharmacist could give a list of medications that could be interchanged with medication on backorder or recommend another medication if a medication was on backorder. During an interview on 06/05/24 at 5:24 p.m., the DON revealed they did notice the ADON and them missed Resident #1's medication during Resident #1's clinical review. The DON stated they initiated a cart and MAR audit for admissions and readmissions and contacted the pharmacy for medications that were missing or not ordered or reordered and STAT medications ordered after Resident #1 went to the hospital. The DON also stated the former DON and ADM were aware of the backordered medications. The DON stated they were not aware of the back-order medication list before stepping into the position. The DON stated they noticed a change occurred and Resident #1's family filed a grievance with the ADM about Resident #1 going to the hospital. During an interview on 06/05/24 at 5:30 p.m., the ADM revealed the hospital notified the facility that Resident #1 was diagnosed with Hepatic Encephalopathy. The ADM stated he and the DON, at the time, discussed the medication backorder list, forwarded the pharmacy communication about the medication backorder list to the MD, the MD acknowledged it, reviewed residents' medications, determined there were no residents who had medications on the back-order list, and communicated the backorder list with staff. The ADM stated they reviewed in-services with staff and had no in-services related to communicating with staff about backordered medications, which they then provided to staff. During an interview on 06/05/24 at 6:16 p.m., Resident #1's POA revealed hospital staff informed them Resident #1 was diagnosed with Hepatic Encephalopathy in the hospital. The POA stated Resident #1 was at another rehabilitation center at the time of the interview and left the hospital on 05/28/24. The POA stated staff did not inform them about anything related to Resident #1's medications, ordering Resident #1's medications, or about the back order of Resident #1's medications. During an interview on 06/06/24 at 11:16 a.m., the DON revealed none of the backordered medications were supposed to be available in the emergency kit. The DON stated staff could contact a pharmacist for a medication recommendation to inform the physician with. The DON also stated they contacted pharmacy if the facility could add a similar medication to the emergency kit, but the pharmacy was not sure because the medication was on back order. The DON stated on 06/05/24, they reached out to the Pharmacy about adding a medication similar to the backorder medication and were waiting to hear back. Attempted interview with the on-call Physician's on 06/06/24 at 1:30 p.m. The Physician on-call Agency advised to speak with their information technology department to determine who the on-call physicians were between 05/17/24 and 05/21/24, which was attempted. A voicemail and call back number was left. The information technology department did not return the call. During an interview on 06/06/24 at 2:37 p.m., The Physician revealed a vital medication was if someone had an infection and needed to take antibiotic or if someone had surgery and needed to take pain medication. The Physician stated Rifaximin was not considered vital despite hospital discharge paperwork which indicated do not skip antibiotics or stop taking antibiotics for Resident #1. The Physician also stated it was hard to determine if medications were vital because Resident #1 was skilled and not long-term. The Physician stated they attended QAPI meeting in May 2024, but could not recall what was discussed. The Physician stated they might have been notified of medications not available following Resident #1, but they could not recall . Record review of an email thread between the ADM, the former DON, and the Pharmacy, dated 03/26/24, reflected the Pharmacy notified the facility that Xifaxan 200 MG was a backordered drug and on shortage that could affect the facility's residents. The Pharmacy also suggested the facility inform the prescribing physician so that an alternative therapy could be evaluated. The ADM notified the Physician on 03/26/24. Record review of an email thread between the Pharmacy and the ADM, dated 06/05/24, reflected the Pharmacy notified the facility that Xifaxan 200 MG tablets were on backorder since the beginning of the year (January 2024) and the Pharmacy tried ordering it on 06/04/24 and the manufacturer was not producing the medication. Record review of an email thread between the Pharmacy and facility, dated 06/06/24, reflected the Pharmacy informed the facility the following, Ekit inventory is determined largely based on average usage of a medication as well as sensitivities regarding initiation of therapy. There are physical limitations of available space that must be factored into deciding what medications are and aren't included in the kit. Ekits are not intended to be a full-service dispensing option. Medications unavailable in the ekit are provided via a standard delivery schedule and if a medication is needed sooner than that would be available can be expedited. Xifaxan 200mg is currently on a long-term manufacturer backorder and is unavailable to be added to an ekit. Record review of the facility's Order Listing Report, from 05/17/24 through 06/05/24, reflected there were no residents who had active, completed, and discontinued orders for Xifaxan 200 MG. Record review of the facility's Physician Notification Manual, dated 06/06/24, reflected staff were required to call the physician whenever there was a new presentation of data, symptoms, findings, lab work, change in condition and assessment, notify the NP immediately, notify the Physician if staff could not reach the NP, or notify on-call Physician if the situation was after hours (6:00 p.m.) or weekends/holidays. Record review of the facility's, undated, Clinical Notification Log, reflected an entry for Resident #1 that was documented by staff, reviewed, and signed by the NP on 05/21/24 which indicated Rifaximin 200 MG was on backorder and expensive and 500 MG was available but expensive. Record review of the facility's In-Services, from 03/01/24 through 05/31/24, reflected staff were trained on Drug Shortages on 03/26/24 at unknown time, 10 staff were trained on POC Orders on 04/02/24 at unknown time, 13 staff were trained on Medication Administration on 04/25/24 at unknown time, 14 staff were trained on Reconciling New Admission Orders on 04/30/24 at unknown time, 9 staff were trained on Antibiotics on 05/08/24 at unknown time, 40 staff were trained on Documentation on 05/23/24 at unknown time, 24 staff were trained on Night Shift staff completing and signing off on MAR on 05/21/24 at unknown time, 23 staff were trained on Following Physician Orders on 05/22/24 at unknown time, and 61 staff were trained on Reconciling Medications and Admission Orders on 05/22/24 at unknown time. Record review of an email thread from the ADM, dated 06/06/24 at 1:00 p.m., reflected the facility did not have a policy on following physician's orders. Record review of the facility's Medication Availability Performance Improvement Plan reflected the MD was notified on 05/22/24, staff completed reviewing residents' current orders to identify any other residents with orders for unavailable medication on 05/22/24, completed a 100% MAR to cart audit for current residents to identify any resident whose medication (including OTCs ) was not available in the facility and/or back ordered on 05/23/24, completed review and reconciliation of orders to validate medication availability for admissions and readmissions from 05/01/24 through 05/22/24, validated facility emergency kits stocks on 05/23/24 and completed reeducation on required communication in the event a medication and/or treatment was not available for a resident, prompt notification to MD/NP, DON and RP, emergency kits on 05/23/24, monitored compliance with medication availability and following physician orders by reviewing new physician orders, including admission and readmission orders daily and include checking to ensure medication was present in facility to validate medication availability, monitor compliance with staff with 10 rights of medication administration by observing medication pass and findings reported to QAPI committee monthly effective 05/24/24. Record review of the facility's Medication Administration Performance Improvement Plan reflected the MD was notified on 05/22/24, staff completed reviewing residents' current orders to identify any other residents with orders for unavailable medication on 05/22/24, completed 100% MAR to cart audit for current residents to identify any resident whose medication (including OTCs) was not available in the facility and/or back ordered on 05/23/24, reviewed and reconciled orders to validate medication availability for admissions and readmissions from 05/01/24 through 05/22/24 on 05/23/24, validated facility emergency kits stocked on 05/23/24, completed medication audit report from 05/01/24 through 05/22/24 to identify residents who refused medication and/or treatments and included validating the MD/NP notification on 05/23/24, reeducated staff on following MD orders for medication administration, notification and/or clarification with the MD with medication availability and 10 rights of medication administration, importance of refusal documentation in residents' electronic health records, use of RP and MD involvement with continued refusals and possible drug alternatives on 05/23/24, reviewed 24 hour reports, order listing report and MARs to identify physician orders not followed related to medication availability on 05/24/24, reviewed resident refusals and documentation on 05/24/24, discussed alternative medications with MD/NP, notification to the pharmacy to obtain STAT medication from the pharmacy on 05/23/24, staff reviewed new orders including admission and readmission orders to validate medication availability and ensuring the medication was present in the facility, and during daily clinical meeting on 05/24/24, monitor compliance with medication availability by reviewing new physician orders including admission and readmission orders daily, checking to ensure the medication was present in the facility, and findings reported to the QAPI committee on 05/24/24. Record review of the facility's Medication Reconciliations Performance Improvement Plan reflected the MD was notified on 05/22/24, staff completed reviewing residents' current orders to identify any other residents with orders for unavailable medication on 05/22/24, completed 100% MAR to cart audit for current residents to identify any resident whose medication (including OTCs) was not available in the facility and/or back ordered on 05/23/24, reviewed and reconciled orders to validate accuracy of medication transcription and medication availability for admissions and readmissions from 05/01/24 through 05/22/24 completed on 05/23/24, validated facility emergency kits stocked on 05/23/24, reeducated staff on accuracy of transcription of admission and readmission orders, validating medication availability for new orders and promptly notifying MD/NP if medication was not available, use of the facility emergency kits, discussing alternative medications with the MD/NP, notifying the pharmacy to obtain STAT medication from the pharmacy on 05/23/24, reviewed new orders including admission or readmission orders to validate accuracy of order transcription and medication availability and ensuring medication was present in the facility during daily clinical meetings on 05/24/24, monitor compliance with accuracy of transcription for admit/readmit orders and medication availability by reviewing new physician orders including admission and readmission orders daily, to validate medication availability and checking to ensure the medication was present in the facility, and findings reported to the QAPI committee on 05/24/24. Record review of the facility's Resident Medication Refusals reflected the MD was notified on 05/23/24, staff completed medication audit report from 05/01/24 through 05/22/24 to identify residents who refused medication and/or treatments that included validating MD/NP notification, MD/NP was notified of any instance notification was not documented on 05/23/24, reeducated staff on the importance of refusal documentation in residents' electronic health records, use of RP and MD involvement with continued refusals and possible drug alternatives on 05/23/24, continued refusal of care needs to be communicated to the Charge Nurse and then ADM for the facility to have the ability to capture refusals in the residents care plan and seek other means of persuasion if at all possible on 05/24/24, refusals of medications communicated to the RP and MD in order to pursue drug alternatives if possible and/or to discontinue when necessary on 05/24/24, review resident refusals and documentation and findings will be reported to the QAPI Committee on 05/24/24. Record review of the facility's Ordering and Receiving Medications from Pharmacy, dated 10/01/19, reflected the following: Procedure: 12. When contacting the attending physician regarding a change in condition where it is likely the physician will order a medication, the nurse is to inform the physician of the availability of remote medications in the facility (i.e., the contents of the remote drug supply). This will facilitate timely drug administration and reduce costs to the resident. Record review of the facility's Ordering and Receiving Medications from Pharmacy policy and procedure, dated 10/01/19, reflected the following under the section, Readmission: A. The Most Original order must be faxed to the pharmacy with a face sheet and cover sheet to clarify a resident's status. B. Nurses must communicate to the pharmacy which medications need to be dispensed based on the readmission medication list. Review current medication stock to avoid duplication and the patient's pay plan upon readmission. C. Use a fax cover sheet and indicate the time that the next doses are due, for the medications that are needed. Record review of the facility's Medication Administration policy and procedure, dated 10/01/19, reflected the following: Medication Administration Guidelines: K. If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g., other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the night box/emergency kit. Documentation (including electronic): F. If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time ( e.g., the resident is not in the facility at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record. If 3 consecutive doses of a vital medication are withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response. The noncompliance was identified as PNC. The IJ began on 05/21/24 and ended 05/24/24. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #24) of 10 residents reviewed for accidents and hazards. The facility failed to ensure Resident #24 was supported when sitting on the edge of her bed on 11/26/2022 and Resident #24 fell and suffered a laceration to her head that required eight sutures. This failure could place residents at risk for injury and decreased quality of life. Findings included: Review of Resident #24's face sheet dated 12/08/2022 revealed Resident #24 was a [AGE] year old female admitted to the facility on [DATE] with a diagnoses of dementia (cognitive and thinking disorder that causes confusion and loss of memory), high blood pressure, history of falls, dysphagia (difficulty swallowing), muscle wasting and atrophy (disorder that causes decreased strength and coordination), contractures (tight muscles) of the left and right lower leg and history of stroke. Review of Resident #24's Physical Therapy Evaluation and Treatment dated 06/10/2020 revealed Resident #24 had fair static sitting balance and required max assistance for bed mobility and transfers. Resident #24 required maximal assistance for lying to sitting on side of bed, sit to lying, sit to stand and chair or bed to chair transfer. Review of Resident #24's care plan dated 08/11/2022 revealed Resident #24 required ETAC [NAME] assistance with 2 staff to move between surfaces as necessary (ETAC [NAME] is a turn aid with a functional design that offers safe patient turning and transfer with standing support). Resident #24 required extensive assistance by two staff to turn and reposition in bed. Resident #24 was at low risk for falls related to confusion, deconditioning, gait/balance problems, incontinence and unaware of safety needs. Interventions included anticipate and meet Resident #24's needs, ensure call light is within reach, ensure Resident #24 is wearing appropriate footwear and Resident #24 needs a safe environment . Review of Resident #24's quarterly MDS assessment dated [DATE] revealed Resident #24 had a BIMS score of zero to indicate severe cognitive impairment. Resident #24 was noted to require extensive assistance by two staff members for transfers and bed mobility. Resident #24 was not steady and only able to stabilize with staff assistance when moving from seated to standing position and moving from surface to surface in a transfer. Review of Resident CNA A's Texas Nurse Aide Performance Record dated 11/10/2022 revealed CNA A satisfactorily completed procedures for assisting with resident to sit up on side of bed, assisting resident to transfer to chair or wheelchair and safety regarding fainting and falls. Review of Resident #24's Incident Report dated 11/26/2022 revealed Resident #24 had an unwitnessed fall with the description CNA alerted this nurse that resident had had a fall and was lying on the floor. CNA stated, I was waiting for a co-worker to come assist me and with the ETAC [NAME] to get the resident into her wheelchair, so I sat the resident up on the side of the bed and turned around to get the wheelchair when fell over onto the floor. Upon entering the room noted resident lying on her left side between her bed and bedside table, gash noted on resident's left forehead above eyebrow, copious amount of blood noted coming from laceration, resident unable to tell this nurse if she was in pain, resident noted holding head with hand, started VS monitoring and neuro checks, no deficits noted, resident able to speak, VS stable, ROM good to extremities, tried to clean wound with gauze and wound cleanser, held pressure to wound, notified DON, called 911, sent resident to ER for further evaluation. Notified RP and MD. Resident description: Resident unable to give description. Resident pain assessment was noted to have a sad, frightened, frown face and tensed, distressed and pacing body language. The report further noted Resident was sitting on the side of the bed and fell over onto the floor. Poor trunk control. Review of Provider Investigation Report dated 11/26/2022 revealed Resident #24 was investigated for an injury of unknown origin revealed the following staff interviews: CNA A: I was getting Resident #24 up for breakfast. She was sitting on the side of the bed, without any issues. I turned to get the wheelchair while I was waiting on another aide and when I turned around, she had fallen between the bed and bedside cabinet. It looked like she hit her head on the cabinet. I called for the charge nurse, who then immediately came to the room. CNA B: was asked to come help with transfer. We didn't do the transfer because Resident #24 had fallen, and they were calling EMS. LVN E: I was called to the room after a resident fall. Resident #24 was noted to be on her side between the bed and her cabinet. She had blood coming from her forehead, after attempting to clean I held pressure to the wound. We then sent her to the ER for treatment. She couldn't explain what happened, but the aide was getting her up from breakfast. Description of injury: 8 forehead sutures to close laceration measuring 3.3 cm. Review of Resident #24 nursing progress notes dated 12/06/2022 revealed nursing progress note by LVN E dated 11/26/2022 at 9:39 AM CNA alerted this nurse that resident had a fall and was lying on the floor. Upon entering room noted resident lying on her left side between her bed and bedside table, gash noted on resident's left forehead above eyebrow, copious amount of blood noted coming from gash, resident unable to tell this nurse if she was in pain, resident noted holding head with hand . Review of Resident #24 nursing progress notes dated 12/06/2022 revealed nursing progress note by LVN E dated 11/26/2022 at 9:43 AM revealed CNA A stated I was waiting for a co-worker to come assist me with the ETAC [NAME] and get the resident up on the side of the bed and turned around to get the wheelchair when she fell over onto the floor. Review of Resident #24 nursing progress notes dated 12/06/2022 revealed nursing progress note by LVN E dated 11/26/2022 at 1:24 PM revealed Resident returned from ER with 8 stitches to left forehead. In an observation on 12/06/2022 at 1:45 PM, Resident #24 was sitting in her wheelchair in the common area and had bruising and a scar to her forehead. In an interview on 12/07/2022 at 3:34 PM CNA A stated she was present when Resident #24 fell . CNA A said she dressed Resident #24 then sat her on the side of Resident #24's bed. She said she was new to the facility and was not sure how Resident #24 was transferred. She said the other CNA B told her Resident #24 required an ETAC [NAME] and went to get the ETAC. She said she sat Resident #24 up on the side of the bed and then stepped away from Resident #24 to get Resident #24 ready for transfer. She stated as she turned away Resident #24 fell and hit her head on the nightstand. She said the wheelchair was on the other side of the nightstand and she was not more than 12-18 inches away from Resident #24. She did not know Resident #24 well and did not realize Resident #24 was not steady enough to sit on the side of bed. She stated she received training on the ETAC transfers and resident safety. She said she found out how residents were transferred or other needs by their care plan or asking other staff members. In an interview on 12/07/2022 at 3:45 PM, the DON stated the fall for Resident #24 was accidental because Resident #24 was stable to sit on the side of her bed. She stated Resident #24 had good core strength and did not require assistance when sitting on the side of the bed. In an interview on 12/08/2022 at 9:05 AM CNA C stated he frequently assisted Resident #24 with transfers to and from her wheelchair to her bed. He stated Resident #24 was not stable enough to sit on the side of her bed without assistance. He stated he would not leave her even briefly just sitting on the side of the bed. He stated Resident #24 was transferred with the ETAC [NAME] with two people without a problem. He stated new staff would know how to transfer and know a resident's ability by their care plan or asking other staff members. In an interview on 12/08/2022 at 9:09 AM, LVN D stated Resident #24 had good core strength and safely sat in a wheelchair, but she would not leave her sitting on side of the bed unattended even for a second because Resident #24 would fall. She stated new staff or unfamiliar staff would know by shift reports from staff or the resident's care plan what and how much assistance a resident required. In an interview on 12/08/2022 at 10:19 AM, the RP for Resident #24 said he was notified of the fall suffered by Resident #24 but not the details of the fall. He said he would not think Resident #24 could sit up on the side of the bed without assistance due to her weakened condition at 96-years-old. He said he would think someone would have to remain by Resident #24 at all times until laying down or in her wheelchair. In a follow-up interview on 12/08/2022 12:32 PM, the DON stated Resident #24 had good trunk control and can sit up on her own. She stated she would not leave Resident #24 alone on side of bed and Resident #24 was not left alone. She stated the aide turned to get the wheelchair and Resident #24 slipped down off the bed and hit her head on the nightstand. She said it was identified as an unwitnessed fall because CNA A did not actually watch Resident #24 slide down off the bed. She stated Resident #24 had no long lasting effects from the fall. When asked if the fall could have been prevented, she said no because normally Resident #24 could sit on the side of the bed. When asked why staff would say Resident #24 was not stable enough to sit on the side of the bed, she said she did not know.

Based on observation, interview and record review the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in the facility during a coronavirus outbreak for the 85 residents that contracted [MEDICAL CONDITION]. A) The Administrator failed to comply with recommendations provided by the facility's Medical Director, the Medical Director of the local health authority and the facility's Nurse Practitioner regarding coronavirus testing for staff and residents to contain and control the spread of Coronavirus to include infection control measures that included cohort and isolation of residents testing positive for the coronavirus, keeping doors of positive residents rooms closed, ensuring the staff had ample PPE (personal protective equipment), monitoring cleaning protocols for the facility. B) The facility Administrator further failed to implement a staffing plan that would ensure there was enough licensed staff on duty to ensure resident assessments and resident monitoring were done to identify changes of condition in medically unstable COVID-19 positive residents, to have sufficient and dedicated staff working on the COVID positive unit and allowed staff to work on both the COVID positive and negative units, and failed to have sufficient direct care staff to meet the residents care needs. The facility Administrator's failure to follow the recommendations provided by the medical professionals at the beginning of the coronavirus outbreak in the facility and the Administrator's failure to ensure there was enough licensed staff on duty to provide resident assessments and practice effective infection control measures led to 85 residents contracting [MEDICAL CONDITION] and the death of 22 of those residents. These failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm at a scope of widespread due to staff needing more time to monitor the plan of removal for effectiveness. These deficient practices could affect all residents and place the residents at risk for mental anguish, prolonged isolation time, coronavirus infections, unidentified changes in condition and death. Findings included: A) In an interview on [DATE] at 2:45 PM the Administrator stated the NP (Nurse Practitioner) had tested another 4 or 5 Residents today. He stated 4 or 5 staff had been tested for Covid-19 (coronavirus disease) and were positive. He stated the facility was unable to obtain tests kits for all the staff (100 plus staff). He stated 30 or 40 tests had been completed at the facility. He stated only 10 staff had been tested for Covid-19. The Administrator stated the first positive tests came back to the facility on [DATE]. He stated the facility contracted a laboratory and they stated they would provide testing for Covid-19. He stated the facility was sent test kits which were collected and then the lab failed to pick them up. Since the failure the corporation had been unsuccessful in finding another testing company. In an interview on [DATE] at 2:55 PM the facility's NP (Nurse Practitioner) stated she was monitoring the COVID residents on the unit and was doing the testing on her own. She stated the facility was not doing testing and stating they did not have the resources. She stated they were not testing staff and until they test everyone she would not be able to get ahead of the infections and stated it was going to get worse without testing. She stated with 100 residents and 100 staff she did not have the supplies to test that many people and the facility was not helping. In an interview on [DATE] at 9:30 AM the facility's NP stated the facility had gotten 20 more positive test for residents. The NP stated the COVID unit would be full after all the positive residents are moved onto the unit. She stated she was concerned about staffing on the unit because the nurse who was working on the 100 hall (the COVID unit) was also working on the 200 hall which had residents who had not tested positive for the coronavirus. She stated as of that day ([DATE]) the number of positive residents had gone up to 43 and the facility still needed to test 80 staff members. In an interview on [DATE] at 1:25 PM the facility MD provided the surveyor with his COVID response plan. He stated he provided this to facility on [DATE] and it was mostly ignored or not fully implemented. He stated if the facility had been more corporative at the beginning with testing and recommendations it might not have reached this point. Review of the Facility MD's Response Plan dated [DATE] reflected that he was recommending the following basic guidelines in an attempt to contain the COVID contagion in the building. The guidelines included but were not limited to quarantine/ isolation of residents with symptoms, implement transmission-based precautions (masks on all residents and anyone in the building), dedicate specific staff to care for only the affected and suspected residents, cohort existing COVID residents to dedicated area, if a resident becomes newly sick with symptoms isolate and test them ASAP, be quick to move to dedicated area, and attempt/encourage testing of all employees in an effort to catch asymptomatic carriers that may inadvertently be spreading [MEDICAL CONDITION]. Observation and interview on [DATE] at 10:15 AM of the facility with DSHS (Department of State Health Services) Epidemiologist revealed hallways and handrails dirty. Trash and gloves noted on floors and wedged into the hand rails. The epidemiologist recommended an increase of housekeeping staff needed. The facility needed to remove items from hallways and alcoves such as lifts, and equipment and the multiple resident use equipment need to be tagged to indicate if it was cleaned after use. Doors to isolation rooms were noted to be open and residents not wearing masks. The facility staff member training the staff on the proper use of PPE was noted not donning his own PPE appropriately. The Epidemiologist stated the donning/ doffing area at the entrance to the isolation unit needed better flow and access to hand sanitizer. All recommendations provided to the facility administration. In an interview on [DATE] at 12:20 PM the NP stated the facility had moved residents on the roster to make them appear to have been moved to a different room but did not actually move the residents. The NP stated the facility did not stop therapy when instructed to. She further stated she repeatedly told the facility and staff to keep isolation room doors closed. She stated she told the facility on [DATE] and instructed them to test all residents and that did not occur. She stated the facility would run out of PPE in the containers outside of isolation rooms and found that isolation rooms did not have biohazard boxes in the rooms. The NP further stated she provided swabs for testing and the facility's Corporate staff took the swabs away from the facility staff because they did not want all residents tested . The NP further stated Corporate did not want employees tested . In an interview on [DATE] at 12:30 PM the Medical Director of the local health authority stated he had made a time line of events that occurred at the facility that concerned him, and he would provide a written statement. Review of the Medical Director of the local health authority statement dated [DATE] reflected I am writing this letter to record my directives to the Medical Director (MD), administration and staff of the facility. As Local Health Authority, I have been monitoring the COVID 19 pandemic in cooperation with DSHS Region 7 and our local emergency management coordinator, since even before the outbreak of [MEDICAL CONDITION] in our county. I was first notified of cases at the facility by the NP on the morning of [DATE]. I had been made aware in passing on or about [DATE] of a PUI (patient under investigation) at the facility that had been sent to the hospital on [DATE]. His test came back positive on 5 April, at which point I was nearly immediately notified. My first call was to the medical director of the facility. At that time, there was a potential staff member that had been tested positive, and by this time there were more suspected cases in the building. My recommendations, which the facility MD and NP relayed to the facility directly, were to immediately isolate all PUI's, and to continue monitoring staff closely for symptoms. At this point, the facility already had stopped all visitors, and there was no communal dining, etc. Within two days, more cases were reported. I was in direct contact with the MD and NP on [DATE] and 7. By [DATE], there were at least 3 (and more PUI's suspected), and I was notified of this by early afternoon. A three-way conference call was arranged, the administrator of the facility, and the NP to discuss recommendations going forward for isolation of residents. My recommendation at that time was to move all positive patients and PUI's to the 300 hall, or if unable to for logistical reasons, to move them all to an isolated area in the 100 hall. I directed them to sequester all positives away from the general population, and to set up an isolation ward to assist with donning/doffing of PPE. Over the next few days cases continued to climb. I spoke with an infectious disease specialist and Local Health Authority to get further suggestions. He and I both agreed that testing all staff was paramount, although due to limited testing ability in the state it would be difficult. I spoke with the facility's MD that afternoon regarding these recommendations, which were to basically stop all unnecessary movement within the facility, stop physical therapy, close all doors that could be closed, and test all staff, and if possible, all patients. He stated he would take the lead on this as he was the medical director for the facility. I continued to follow up with the facility MD and NP daily. The cases unfortunately continued to climb. I was told by the facility MD, and the facility administrator, that corporate doctors did not agree with our recommendations. I did not personally speak with these corporate representatives as the facility MD said he would do so. He related to me that they were very much against testing anyone that did not have symptoms in the facility, for unclear reasons. A plan was made, and orders were written on or about Tuesday, [DATE] or Wednesday [DATE] to test all residents through a lab testing company through the nursing facility. I was told by the facility NP Wednesday [DATE], late in the day, that at the direction of the Corporation, no testing was to be performed on patients that we ordered, and the orders were canceled. The materials necessary to test were reportedly locked in the administrator's office to keep out of the hands of nursing. At this time, the facility MD and I decided that a meeting between corporate and ourselves must be set up as soon as possible due to the risk of continued spread. By this point, there were approximately 10 patients, with multiple PUIs. I drafted control orders for the facility, that clearly laid out a mitigation strategy of testing, complete isolation, closing doors, and assuming all patients had COVID until proven otherwise. These orders were given to the facility MD. On the morning of 16 April, the facility MD gave me his revised version of the control orders, with his signature. These were almost identical to mine in contact, and only different in language. I was told that as LHA (local health authority), I did not have direct authority to impose control orders, as I work through DSHS, and that the medical director and HHS had authority over the facility. The meeting between the facility VPO (Vice present of operations), and several other corporate officers, as well as the facility Administrator, NP, MD and myself occurred at 5:30 PM on Thursday 16 April. There was significant push back during this meeting, during which the facility MD read aloud his orders, regarding the testing of patients. The facility's VPO exact words were what does it matter if we test? What if they all already have it. My impression was that he did not grasp the severity of the situation, and I directly recommended they test everyone and that doors be closed. I also recommended that therapy cease except where absolutely indicated. I was told that was impossible, and that therapy was as important as [MEDICAL TREATMENT]. Again, I recommended it stop immediately. We were promised at this meeting that the isolation wall for the 100 hallway would be up within 24 to 48 hours. During this meeting, the facility NP clearly made administration aware that staff were not [MEDICATION NAME] appropriate distancing, PPE use, or hand hygiene. The facility MD and I both recommended that interventions be made to quickly remedy this. On Monday, 20 April, I was informed that the wall was still not up . By Friday, the number of cases in the facility had risen to over 60, with a total of 11 deaths at the time of this writing. My thoughts on this situation is that, based on the data and discussions with both the facility MD and NP, that numerous times the administration of the facility were given information and the opportunity to lessen the spread of COVID 19. At times, we were directly challenged on how we wanted to proceed, and orders of a physician/FNP that were legally written were disobeyed at the direction of corporate officers. I am saddened by the way this was handled and feel that steps need to be taken to assure that this does not happen in this, or any facility, ever again. In an interview on [DATE] at 6:40 PM the VPO stated he felt the facility followed all the CDC guidelines in regard to the COVID outbreak. The VPO stated the facility tried to test everyone, but the labs would not provide the test kits or would not pick up the test collected and stated the kits taken away from staff were because they were the wrong test kits. The VPO stated residents room doors were not closed and infection control measures might not be followed right now because they are moving residents to get the positive residents away from the negative residents. Observation on [DATE] at 10:50 AM making rounds with the DSHS Epidemiologist and Associate Commissioner for HHSC revealed multiuse equipment still noted in hallways and alcoves without labels to identify if they were clean, residents still not wearing masks, floors remain dirty and residents that were positive needed to be moved to the isolation unit doors were open. Observation/ Interview on [DATE] at 11:20 PM revealed none of the 13 residents on the 300 or 400 hall had been transferred to the isolation unit yet. The VPO stated the staff were making sure equipment and belongings could be secured prior to moving the residents. Observation on [DATE] at 11:40 PM the isolation unit revealed empty rooms to be cleaned and ready to receive residents. In an interview on [DATE] at 10:45 AM a Confidential Staff Member pulled surveyor to side and stated she wanted to talk. She stated she wanted the surveyor to know that Corporate staff took testing swabs away from staff to prevent them from testing and stated she would like to provide a statement and would like to remain anonymous. Review of the Confidential Staff Members statement dated [DATE] reflected Between the dates of [DATE]th and [DATE]th it was never mentioned to the employees that they had a plan in action to begin testing employees, even after employees expressed wanting to be tested . At one-point employees were told if they were tested , they would have to be out of work for 14 days and would have to use their own PTO. [DATE] the VPO and RNC came to the facility to provide lunch for facility staff members. Neither one walked inside facility to ensure that all protocols where being followed. On [DATE] ADON received orders from the FNP to test all remaining residents in the facility. Orders were later given by the facility MD to cover all remaining orders in facility due to his Medical Director status. The Facility spoke with our outside lab company to ask if they would be able to run COVID test for us. They called back to inform facility that they could run the test for us, and a lab tech would deliver the testing kits later that afternoon. On [DATE] Via text message the RNC asked the ADON if there were written orders to test all remaining residents in the facility. When ADON informed her that there were verbal telephone orders that had been entered into PCC the RNC instructed her to hold off on testing. ADON informed her that all orders had been approved by the facility MD and entered into PCC as well as the lab for all specimens to be collected. At that time ADON was instructed to be on a conference call in administrators office. ADON came back into conference room and voiced to me that the VPO stated that the facility will not test all residents. It goes against CDC and CMS guidelines to blanket test all residents. The only way the facility would get over this was to practice proper hand hygiene and social distancing. While talking with the ADON about the phone call, the Administrator came into the conference room and removed all testing kits off the table. At this time, it was the ADONS, and me present in the conference room. A phone conference with CEO, COO, CNO, LHA MD, the facility FNP and MD, the Administrator, RNC and VPO was scheduled for later that evening. One of the ADONs requested to be on the call for added input, the facility MD stated that this would be great thing for any additional input. Later that afternoon ADON was informed that corporate wants no one else in the meeting. [DATE] one of the ADONs reached out to the RNC for help . After reaching out the ADON got no response from the RNC . During this time, I witnessed the VPO instruct other team members to move residents that had a negative test result into a room that a patient with a positive test results without it being properly deep cleaned. [DATE]th while assisting another staff member to identify which test results that were received on [DATE]th were staff members and residents so that she could notify family members of test results. I noticed that there was a COVID positive resident on the south unit and a COVID negative patient on the isolation unit. The VPO instructed staff who needed to be moved and to where. I brought this to his attention. After sitting back down at my computer I overheard him ask the RNC how to move the residents without the state surveyors noticing. At this time the NP asked me for a resident room roster, I walked into the admissions office for a roster at that time and the Admissions Director told me that the VPO had instructed her to NOT give anyone from the state a room roster . In an interview on [DATE] at 12:20 PM the facility NP stated she had made a timeline of events that occurred at the facility and would provide a written statement. The NP stated she had been at the facility everyday since the outbreak started and witnessed facility failures first hand. Review of the facility's NP written statement dated [DATE] reflected This is the statement of events personally witnessed to the best of my recollection at the facility from [DATE]th through 27th 2020. On [DATE] the facility was instructed to close all doors, stop all therapy room to room, and have all staff tested by myself and the LHA (local health authority) MD. This was disregarded by the facility. Again, staff were recommended to be tested , therapy stopped, and doors closed on [DATE] after additional positives were found. Again, this was disregarded by the facility. On [DATE] we attempted to test all the facility residents. These swabs were ordered through a lab. The nursing staff started collecting these specimens and then were told to stop by the Administrator on the direction of the VOP. The swabs were taken away from staff and placed in the Administrators office to prevent them being collected. A meeting was held with LHA MD, the facility MD, me and several corporate members via teleconference on the night of [DATE]. It was stated they did not want to test staff because they were worried they would have too many staff positives and then no staff to manage the facility. This was again requested by LHA MD, facility MD and me despite this concern. It was also requested in writing by the facility MD to keep same staff to isolation hallway- not mix with non-isolation hallway, stop therapy, and to test everyone including staff. This again was disregarded. One corporate official also stated that if this was all over the building then what was the point of testing everyone. On [DATE] at the direction of LHA MD a true isolation unit was recommended. It was said this would be done ASAP at that time. On Monday [DATE] the facility decided to test staff but did not help facilitate this or give staff direction on how to get this done. Staff were told they would have to be out until test results were back even if it was done for screening. We asked for a sign-up list for staff to voluntarily be tested . Then staff were told they would have to be out until test results were back even if it was done for screening, so all the staff removed their names. Therapy continued until [DATE]. Doors remained open until [DATE]. 100 and 200 hall shared one ,[DATE] nurse until [DATE]. Staff took care of positive and negative patients till [DATE]. The residents were all tested at my direction with swabs from state on [DATE], [DATE], [DATE]. I personally witnessed staff asking for additional outside staffing help as early as [DATE]. They were disregarded. I personally witnessed staff entering isolation rooms with masks only on. I also was notified by one family that they did not know their family member was positive for > 48 hrs. post diagnosis. PPE was not adequately stocked outside of isolation rooms and bins were not in rooms to dispose of PPE. Patients with positive results were kept in rooms with negative patients for > 18 hrs. post diagnosis. In an interview on [DATE] at 3:45 PM the VPO came to the surveyor and stated he made a mistake and moved the wrong resident last night and placed a negative resident on the COVID unit and a positive resident remained on the negative side. Observation on [DATE] at 8:25 PM on the isolation unit revealed a trash bag with various contents on the floor outside room [ROOM NUMBER]. Review of the census reflected room [ROOM NUMBER] had housed Resident #6 prior to her going out to hospital this evening (Resident progress notes reflected she left at 6:37 pm. Further observation revealed the double glass doors at the end of 100 hall had a large trash bag outside. This was the second night in a row trash was observed outside this door. The implication was staff are breaking containment to remove trash. A written statement from a facility staff member was received by email on [DATE] at 2:09 AM. The staff member stated they wanted to remain anonymous to protect her job. Review of the written statement reflected .Between the dates of [DATE] and [DATE], there was no effort from our corporate offices to begin testing staff members in spite of multiple requests to do so. The answer that was given from corporate was that if an employee needed to be tested , they were to contact their healthcare provider. There was never mention to the employees that our company was trying to put into a plan of action to begin providing testing for employees even though it was expressed to them (the company) that they wanted to get tested .Sunday [DATE] the first resident from our facility, that was in the hospital was tested for novel coronavirus and had a positive result. There was still no effort from corporate offices to begin testing employees . Up until this date, no effort from Corporate offices were made to fit test N95's for the employees. The only available PPE we had were surgical masks, the yellow disposable gowns, Medium N95 masks, gloves, Hair covers and clear glasses that didn't wrap around our eyes to protect them from the side. No foot covers available at this time. A concern made to the Administrator regarding inappropriate clear glasses, no new clear goggles or face shields made available to staff in facility . [DATE] the VPO and RNC came to facility to provide lunch for facility staff members. Neither one of them entered the facility to assess how protocols were being followed. [DATE] It was relayed to ADON's and Administrator that the Lab could provide 80 testing kits, but the tests could be only be run by the Lab and the results could take at least 5 days for the results. The testing kits were ordered but the lab technician could not bring them to our facility until [DATE] . the Lab technician dropped off testing supplies and instructions on how tests were to be performed and how to store them prior to pick up. Orders for labs were entered into PCC and into the Lab website . I was asked by the Administrator to come to his office to talk to the VPO and RNC. I was told by the VPO that it was against CDC recommendations to blanket test the entire facility. I expressed that I had a verbal order to test all residents from the facility MD and the testing would be started. VPO expressed to me again that it was against CDC recommendations and was told to not test residents but continue social distancing and washing our hands. I left the Administrators office and returned to the conference room where other staff were present and was visibly upset. The Administrator entered the room after me and removed all testing kits from our possession and locked them in his office .[DATE] the facility continues to have orders for testing every resident that has not been tested . No testing kits available except for the Lab testing kits. ADON's continue to have no access to testing kits .[DATE] .the VPO and RNC have finally arrived at the facility and entered our building after 18 days of having multiple residents and staff members positive for the novel coronavirus and 4 days since notifying the RNC of the need for extra staff. Observation/Interview on [DATE] at 9:05 AM during rounds with the Epidemiologist he stated he still had concerns regarding items in the hallways and alcoves, and resident belongings in the halls (which were potentially contaminated). He further stated the house keeping staff need to pick up the pace on getting rooms cleaned out that are empty that had COVID positive residents in them. In an interview on [DATE] at 8:00 AM the ADON stated she would like to provide a statement. Review of the statement dated [DATE] from the ADON reflected . I just have a lot of concerns regarding the VOP and his decisions he's making. In the very beginning we had little PPE to wear, he even said at one point we can wear the N95 masks for 5 days before discarding. Recently I asked if it was safe for me to do wound care on both sides of the building, I try to get south side (negative side) done first but it doesn't always happen this way. I spoke to the VOP and asked if this was safe for the residents and he reassured me it was as long as I wasn't continuously working on the COVID side, which I'm there every day. I'm still very leery of this and wanted clarification I have been treated so poorly by this man, completely booted out of my position because I question him on issues and I speak for the residents which I care about deeply. From the very beginning the facility MD wanted all residents tested and the VOP had the Administrator literally take the swabs out of our hands after we had already collected some and stated it was not necessary. I truly believe that if corporate would have followed orders from doctors we would not have seen as many deaths and other issues from this .I do blame corporate for the deaths we have had. And not only do I, it's just a lot of staff will not speak up .I will probably get fired for even writing this to you, but I had to clear my conscience knowing these decisions, I believe in my heart were very wrong for everyone involved. We asked about testing staff weeks ago before they FINALLY did it. I just can't wrap my head around the thought process . Review of the facility's COVID-19 numbers reflected as of [DATE] 85 residents had contracted [MEDICAL CONDITION] and 22 residents had died . The facility's COVID-19 numbers also reflected 29 staff members had contracted [MEDICAL CONDITION]. Review of the facility's policy Outbreak of Novel Coronavirus (2019-nCoV) dated [DATE] reflected Suspected outbreaks of Novel Coronavirus within the facility will be promptly identified and appropriately handled per the CDC recommendations. The Administrator or Director of Nursing (DON) will notify the local health department in case of an outbreak. Personal Protective equipment (e.g., gowns, gloves, NOISH-certified disposable N95 respirators) will be provided to our employees . Review of the facility's policy Reportable Diseases dated [DATE] reflected .Should any residents or staff suspected or diagnosed as having a reportable communicable/infectious disease according to State-Specific criteria, such information shall be promptly reported to appropriate local and/ or state health department officials . B) In an interview on [DATE] at 9:30 AM the facility NP stated the facility has gotten 20 more positive test for residents and are testing staff and have 12 positive staff. She stated both ADON RN's who were doing the q8hr assessments on the COVID residents tested positive and were sent home. She stated the COVID unit will be full after all the positive residents are moved on the unit. She stated she is concerned about staffing on the unit. She is doing labs and the residents are dehydrated she stated she wanted one staff just hydrating the residents. She stated they did IV's on two of the residents. She also stated the it is not recommended to hydrate to fast because the residents will develop [MEDICAL CONDITIONS]. The NP stated she was concerned that the nurse for 100 hall was also working on 200 hall (100 hall is the COVID) at night. Review of Resident #1's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change Minimum Data Set ((MDS) dated [DATE] reflected Resident #1 had a Brief Interview for Mental Status Score of nine (9) indicating moderate cognitive impairment. Resident #1 was assessed to require supervision for all activities of daily living (ADLs). Review of Resident #1's Comprehensive Care Plan reflected a problem with the start date [DATE] High risk for communicable respiratory infection- influenza/ pneumonia- due to age and resident lives in close proximity to others. Further review of Resident #1's Comprehensive Care plan reflected a problem with the start date [DATE] Resident is at risk for signs and symptoms of COVID-19. Interventions included observe for signs and symptoms of COVID-19, document and promptly report signs and symptoms: fever, coughing, sneezing, sore throat, respiratory issues. Review of Resident #1's Nursing progress notes dated [DATE] reflected an entry at 4:08 AM that the facility received notification that Resident #1 was COVID positive. An entry at 3:45 PM reflected resident returned form the emergency room (ER) at 3:30 PM. The note reflected Resident #1 returned on 2 liters of supplemental oxygen. An entry dated at 5:50 PM reflected a late entry for 10:45 AM on [DATE] that Resident #1was assessed by the NP and her oxygen saturation was 85% on room air and oxygen was started at 2 liters Resident #1 was noted with temperature of 101.4 and a HR of 134. Note indicated Resident #1 was sent to the ER. The next entry in Resident (TRUNCATED)

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for the 85 residents in the facility that contracted the COVID-19 virus. A.) The facility failed to follow recommendations provided by the facility's Medical Director, the Medical Director of the local health authority and the facility's Nurse Practitioner regarding coronavirus testing for staff and residents. B.) The facility failed to follow recommendations provided by the facility's Medical Director, the Medical Director of the local health authority and the facility's Nurse Practitioner regarding infection control measures to prevent the spread of the coronavirus in the facility that included: -cohorting of residents testing positive for the coronavirus (COVID), -keeping doors of positive residents closed to contain the spread of infection. -supply staff with ample PPE (personal protective equipment) to protect residents for cross transmission. -monitoring cleaning and sanitation protocols for the facility and, -cohorting of staff to ensure the staff that provided care for the positive residents did not also provide care to the residents without the coronavirus. The facility's failure to follow these recommendations at the beginning of the coronavirus outbreak in the facility lead to 85 residents contracting [MEDICAL CONDITION] and the death of 22 of those residents. These failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm at a scope of widespread due to staff needing more time to monitor the plan of removal for effectiveness. These deficient practices could affect all residents and place the residents at risk for mental anguish, prolonged isolation time, coronavirus infections and possible death. Findings included: A.) Review of the facility's COVID-19 numbers reflected as of [DATE] 85 residents had contracted [MEDICAL CONDITION] and 22 residents had died . The facility's COVID-19 numbers also reflected 29 staff members had contracted [MEDICAL CONDITION]. In an interview on [DATE] at 2:45 PM the Administrator stated the NP (Nurse Practitioner) had tested another 4 or 5 Residents today. He stated 4 or 5 staff had been tested for Covid-19 (coronavirus disease) and were positive. He stated the facility was unable to obtain tests kits for all the staff (100 plus staff). He stated 30 or 40 tests had been completed at the facility. He stated only 10 staff had been tested for Covid-19. The Administrator stated the first positive tests came back to the facility on [DATE]. He stated the facility's contracted a laboratory and they stated they would provide testing for Covid-19. He stated the facility was sent test kits which were collected and then the lab failed to pick them up and since that failure the corporation had been unsuccessful in finding another testing company. In an interview on [DATE] at 2:55 PM the facility's NP stated she was monitoring the COVID residents on the isolation unit and was doing the testing on her own. She stated the facility was not doing testing and stated they did not have the resources. She stated they were not testing staff and until they test everyone she will not be able to get ahead of the infections and stated it is going to get worse without testing. She stated with 100 residents and 100 staff she does not have the supplies to test that many people and the facility is not helping. In an interview on [DATE] at 9:30 AM the facility's NP stated the facility had gotten 20 more positive test for residents. The NP stated the COVID unit would be full after all the positive residents are moved onto the unit. She stated she is concerned about staffing on the unit because the nurse who is working on the 100 hall (the COVID unit) is also working on the 200 hall which has residents who have not tested positive for the coronavirus. She stated, as of [DATE], the number of positive residents had gone up to 43 and the facility still needed to test 80 staff members. In an interview on [DATE] at 1:25 PM the facility MD provided the surveyor with his COVID response plan. He stated he provided this to the facility on [DATE] and it was mostly ignored or not fully implemented. He stated if the facility had been more cooperative at the beginning with testing and recommendations the spread of [MEDICAL CONDITION] might not have reached this point. Review of the Facility MD's Response Plan dated [DATE] reflected that he was recommending basic guidelines in an attempt to contain the COVID contagion in the building. The guidelines included but were not limited to . if a resident becomes newly sick with symptoms isolate and test them ASAP . attempt/encourage testing of all employees in an effort to catch asymptomatic carriers that may inadvertently be spreading [MEDICAL CONDITION]. In an interview on [DATE] at 12:20 PM the NP stated she told the facility on [DATE] and instructed them to test all residents and that did not occur. The NP further stated she provided swabs for testing and the facility's Corporate staff took the swabs away from the facility staff because they did not want all residents tested . The NP further stated Corporate staff did not want employees tested for fear of sidelining staff. In an interview on [DATE] at 12:30 PM the Medical Director of the local health authority stated he had made a time line of events that occurred at the facility that concerned him, and he would provide a written statement. Review of the Medical Director of the local health authority statement dated [DATE] reflected . I spoke with an infectious disease specialist and Local Health Authority to get further suggestions. He and I both agreed that testing all staff was paramount, although due to limited testing ability in the state it would be difficult .I was told by the facility MD, and the facility administrator, that corporate doctors did not agree with our recommendations. I did not personally speak with these corporate representatives as the facility MD said he would do so. He related to me that they were very much against testing anyone that did not have symptoms in the facility, for unclear reasons. A plan was made, and orders were written on or about Tuesday, [DATE] or Wednesday [DATE] to test all residents through a lab testing company through the nursing facility. I was told by the facility NP Wednesday [DATE], late in the day, that at the direction of the Corporation, no testing was to be performed on patients that we ordered, and the orders were canceled. The materials necessary to test were reportedly locked in the administrator's office to keep out of the hands of nursing. At this time, the facility MD and I decided that a meeting between corporate and ourselves must be set up as soon as possible due to the risk of continued spread. By this point, there were approximately 10 patients, with multiple PUIs. I drafted control orders for the facility, that clearly laid out a mitigation strategy of testing . These orders were given to the facility MD. On the morning of 16 April, the facility MD gave me his revised version of the control orders, with his signature. These were almost identical to mine in context, and only different in language. I was told that as LHA (local health authority), I did not have direct authority to impose control orders, as I work through DSHS, and that the medical director and HHS had authority over the facility. The meeting between the facility VPO (Vice President of Operations), and several other corporate officers, as well as the facility Administrator, NP, MD and myself occurred at 5:30 PM on Thursday 16 April. There was significant push back during this meeting, during which the facility MD read aloud his orders, regarding the testing of patients. The facility's VPO exact words were what does it matter if we test? What if they all already have it. My impression was that he did not grasp the severity of the situation, and I directly recommended they test everyone .The facility MD and I both recommended that interventions be made to quickly remedy this. On Monday, 20 April, I was informed that the wall was still not up . By Friday, the number of cases in the facility had risen to over 60, with a total of 11 deaths at the time of this writing. My thoughts on this situation is that, based on the data and discussions with both the facility MD and NP, that numerous times the administration of the facility were given information and the opportunity to lessen the spread of COVID 19. At times, we were directly challenged on how we wanted to proceed, and orders of a physician/FNP that were legally written were disobeyed at the direction of corporate officers. I am saddened by the way this was handled and feel that steps need to be taken to assure that this does not happen in this, or any facility, ever again. In an interview on [DATE] at 6:40 PM the VPO stated he felt the facility followed all the CDC guidelines in regard to the COVID outbreak. The VPO stated the facility tried to test everyone, but the labs would not provide the test kits or would not pick up the test collected and stated the kits taken away from staff were because they were the wrong test kits. In an interview on [DATE] at 10:45 AM a Confidential Staff Member pulled surveyor to side and stated she wanted to talk. She stated she wanted the surveyor to know that Corporate staff took testing swabs away from staff to prevent them from testing and stated she would like to provide a statement and would like to remain anonymous. Review of the Confidential Staff Members statement dated [DATE] reflected Between the dates of [DATE] and [DATE]th it was never mentioned to the employees that they had a plan in action to begin testing employees, even after employees expressed wanting to be tested . At one-point employees were told if they were tested , they would have to be out of work for 14 days and would have to use their own PTO . On [DATE] ADON received orders from the FNP to test all remaining residents in the facility. Orders were later given by the facility MD to cover all remaining orders in facility due to his Medical Director status. The Facility spoke with our outside lab company to ask if they would be able to run COVID test for us. They called back to inform facility that they could run the test for us, and a lab tech would deliver the testing kits later that afternoon. On [DATE] Via text message the RNC asked the ADON if there were written orders to test all remaining residents in the facility. When ADON informed her that there were verbal telephone orders that had been entered into PCC the RNC instructed her to hold off on testing. ADON informed her that all orders had been approved by the facility MD and entered into PCC as well as the lab for all specimens to be collected. At that time ADON was instructed to be on a conference call in administrators office. ADON came back into conference room and voiced to me that the VPO stated that the facility will not test all residents. It goes against CDC and CMS guidelines to blanket test all residents. The only way the facility would get over this was to practice proper hand hygiene and social distancing. While talking with the ADON about the phone call, the Administrator came into the conference room and removed all testing kits off the table. At this time, it was the ADONS, and me present in the conference room. A phone conference with CEO, COO, CNO, LHA MD, the facility FNP and MD, the Administrator, RNC and VPO was scheduled for later that evening. One of the ADONs requested to be on the call for added input, the facility MD stated that this would be great thing for any additional input. Later that afternoon ADON was informed that corporate wants no one else in the meeting . In an interview on [DATE] at 12:20 PM the facility NP stated she had made a timeline of events that occurred at the facility and would provide a written statement. The NP stated she had been at the facility every day since the outbreak started and witnessed facility failures first hand. Review of the facility's NP written statement dated [DATE] reflected This is the statement of events personally witnessed to the best of my recollection at the facility from [DATE]th through 27th 2020 . Again, staff were recommended to be tested . On [DATE] we attempted to test all the facility residents. These swabs were ordered through a lab. The nursing staff started collecting these specimens and then were told to stop by the Administrator on the direction of the VOP. The swabs were taken away from staff and placed in the Administrators office to prevent them being collected. A meeting was held with LHA MD, the facility MD, me and several corporate members via teleconference on the night of [DATE]. It was stated they did not want to test staff because they were worried they would have too many staff positives and then no staff to manage the facility. This was again requested by LHA MD, facility MD and me despite this concern . It was also requested in writing by the facility MD . to test everyone including staff. This again was disregarded. One corporate official also stated that if this was all over the building then what was the point of testing everyone. On Monday [DATE] the facility decided to test staff but did not help facilitate this or give staff direction on how to get this done. Staff were told they would have to be out until test results were back even if it was done for screening. We asked for a sign-up list for staff to voluntarily be tested . Then staff were told they would have to be out until test results were back even if it was done for screening, so all the staff removed their names . A written statement from a facility staff member was received by email on [DATE] at 2:09 AM. The staff member stated they wanted to remain anonymous to protect her job. Between the dates of [DATE] and [DATE], there was no effort from our corporate offices to begin testing staff members in spite of multiple requests to do so. The answer that was given from corporate was that if an employee needed to be tested , they were to contact their healthcare provider. There was never mention to the employees that our company was trying to put into a plan of action to begin providing testing for employees even though it was expressed to them (the company) that they wanted to get tested .Sunday [DATE] the first resident from our facility, that was in the hospital was tested for novel coronavirus and had a positive result. There was still no effort from corporate offices to begin testing employees . [DATE] It was relayed to ADON's and Administrator that the Lab could provide 80 testing kits, but the tests could be only be run by the Lab and the results could take at least 5 days for the results. The testing kits were ordered but the lab technician could not bring them to our facility until [DATE] . the Lab technician dropped off testing supplies and instructions on how tests were to be performed and how to store them prior to pick up. Orders for labs were entered into PCC and into the Lab website . I was asked by the Administrator to come to his office to talk to the VPO and RNC. I was told by the VPO that it was against CDC recommendations to blanket test the entire facility. I expressed that I had a verbal order to test all residents from the facility MD and the testing would be started. VPO expressed to me again that it was against CDC recommendations and was told to not test residents but continue social distancing and washing our hands. I left the Administrators office and returned to the conference room where other staff were present and was visibly upset. The Administrator entered the room after me and removed all testing kits from our possession and locked them in his office .[DATE] the facility continues to have orders for testing every resident that has not been tested . No testing kits available except for the Lab testing kits. ADON's continue to have no access to testing kits . In an interview on [DATE] at 8:00 AM the ADON stated she would like to provide a statement. Review of the statement dated [DATE] from the ADON reflected . From the very beginning the facility MD wanted all residents tested and the VOP had the Administrator literally take the swabs out of our hands after we had already collected some and stated it was not necessary. I truly believe that if corporate would have followed orders from doctors we would not have seen as many deaths and other issues from this .I do blame corporate for the deaths we have had. And not only do I, it's just a lot of staff will not speak up .I will probably get fired for even writing this to you, but I had to clear my conscience knowing these decisions, I believe in my heart were very wrong for everyone involved. We asked about testing staff weeks ago before they FINALLY did it. I just can't wrap my head around the thought process . B.) In an interview on [DATE] at 1:25 PM the facility MD provided the surveyor with his COVID response plan. He stated he provided this to the facility on [DATE] and it was mostly ignored or not fully implemented. Review of the Facility MD's Response Plan dated [DATE] reflected that he was recommending basic guidelines in an attempt to contain the COVID contagion in the building. The guidelines included but were not limited to quarantine/ isolation of residents with symptoms, implement transmission-based precautions (masks on all residents and anyone in the building), dedicate specific staff to care for only the affected and suspected residents, cohort existing COVID residents to dedicated area, if a resident becomes newly sick with symptoms isolate and test them ASAP, be quick to move to dedicated area, and attempt/encourage testing of all employees in an effort to catch asymptomatic carriers that may inadvertently be spreading [MEDICAL CONDITION]. Observation and interview on [DATE] at 10:15 AM of the facility with DSHS (Department of State Health Services) Epidemiologist revealed hallways and handrails dirty. Trash and gloves noted on floors and wedged into the hand rails. The epidemiologist recommended an increase of housekeeping staff. The facility needed to remove items from hallways and alcoves such as lifts, and equipment and the multiple resident use equipment needed to be tagged to indicate if it was cleaned after use. Doors to isolation rooms were noted to be open and residents were not wearing masks. The facility staff member training the staff on the proper use of PPE was noted not donning his own PPE appropriately. The Epidemiologist stated the donning/ doffing area at the entrance to the isolation unit needed better flow and access to hand sanitizer. All recommendations had been provided to the facility administration. In an interview on [DATE] at 12:20 PM the NP stated the facility had moved residents on the roster to make them appear to have been moved to a different room but did not actually move the residents. The NP stated the facility did not stop therapy when instructed to. She further stated she repeatedly told the facility and staff to keep isolation room doors closed. She stated the facility would run out of PPE in the containers outside of isolation rooms and found that isolation rooms did not have biohazard boxes in the rooms. In an interview on [DATE] at 12:30 PM the Medical Director of the local health authority stated he had made a time line of events that occurred at the facility that concerned him, and he would provide a written statement. Review of the Medical Director of the local health authority statement dated [DATE] reflected I am writing this letter to record my directives to the Medical Director (MD), administration and staff of the facility. As Local Health Authority, I have been monitoring the COVID 19 pandemic in cooperation with DSHS Region 7 and our local emergency management coordinator, since even before the outbreak of [MEDICAL CONDITION] in our county. I was first notified of cases at the facility by the NP on the morning of [DATE]. I had been made aware in passing on or about [DATE] of a PUI (patient under investigation) at the facility that had been sent to the hospital on [DATE]. His test came back positive on 5 April, at which point I was nearly immediately notified. My first call was to the medical director of the facility. At that time, there was a potential staff member that had been tested positive, and by this time there were more suspected cases in the building. My recommendations, which the facility MD and NP relayed to the facility directly, were to immediately isolate all PUI's, and to continue monitoring staff closely for symptoms. At this point, the facility already had stopped all visitors, and there was no communal dining, etc. Within two days, more cases were reported. I was in direct contact with the MD and NP on [DATE] and 7. By [DATE], there were at least 3 (and more PUI's suspected), and I was notified of this by early afternoon. A three-way conference call was arranged, the administrator of the facility, and the NP to discuss recommendations going forward for isolation of residents. My recommendation at that time was to move all positive patients and PUI's to the 300 hall, or if unable to for logistical reasons, to move them all to an isolated area in the 100 hall. I directed them to sequester all positives away from the general population, and to set up an isolation ward to assist with donning/doffing of PPE. Over the next few days cases continued to climb . I spoke with the facility's MD that afternoon regarding these recommendations, which were to basically stop all unnecessary movement within the facility, stop physical therapy, close all doors that could be closed, and test all staff, and if possible, all patients. He stated he would take the lead on this as he was the medical director for the facility. I continued to follow up with the facility MD and NP daily. The cases unfortunately continued to climb . I drafted control orders for the facility, that clearly laid out a mitigation strategy of complete isolation, closing doors, and assuming all patients had COVID until proven otherwise . My impression was that he did not grasp the severity of the situation, and I directly recommended . that doors be closed. I also recommended that therapy cease except where absolutely indicated. I was told that was impossible, and that therapy was as important as [MEDICAL TREATMENT]. Again, I recommended it stop immediately. We were promised at this meeting that the isolation wall for the 100 hallway would be up within 24 to 48 hours. During this meeting, the facility NP clearly made administration aware that staff were not [MEDICATION NAME] appropriate distancing, PPE use, or hand hygiene . In an interview on [DATE] at 6:40 PM the VPO stated residents room doors were not closed and infection control measures might not be followed right now because they are moving residents to get the positive residents away from the negative residents. Observation on [DATE] at 10:50 AM making rounds with the DSHS Epidemiologist and Associate Commissioner for HHSC revealed multiuse equipment still noted in hallways and alcoves without labels to identify if they were clean, residents still not wearing masks, floors remain dirty and residents that were positive and needed to be moved to the isolation unit doors were open. Observation/ Interview on [DATE] at 11:20 PM revealed none of the 13 COVID positive residents on the 300 or 400 hall had been transferred to the isolation unit yet. The positive and negative residents were still intermingled. The VPO stated the staff were making sure equipment and belongings could be secured prior to moving the residents. Observation on [DATE] at 11:40 PM revealed the isolation units empty rooms were clean and ready to receive residents. In an interview on [DATE] at 10:45 AM a Confidential Staff Member pulled surveyor to side and stated she wanted to talk and stated she would like to provide a statement and would like to remain anonymous. Review of the Confidential Staff Members statement dated [DATE] reflected .[DATE] the VPO and RNC came to the facility to provide lunch for facility staff members. Neither one walked inside facility to ensure that all protocols where being followed . [DATE] one of the ADONs reached out to the RNC for help . After reaching out the ADON got no response from the RNC . During this time, I witnessed the VPO instruct other team members to move residents that had a negative test result into a room that a patient with a positive test results without it being properly deep cleaned. [DATE]th while assisting another staff member to identify which test results that were received on [DATE]th were staff members and residents so that she could notify family members of test results. I noticed that there was a COVID positive resident on the south unit and a COVID negative patient on the isolation unit. The VPO instructed staff who needed to be moved and to where. I brought this to his attention. After sitting back down at my computer I overheard him ask the RNC how to move the residents without the state surveyors noticing. At this time the NP asked me for a resident room roster, I walked into the admissions office for a roster at that time and the Admissions Director told me that the VPO had instructed her to NOT give anyone from the state a room roster . In an interview on [DATE] at 12:20 PM the facility NP stated she had made a timeline of events that occurred at the facility and would provide a written statement. The NP stated she had been at the facility everyday since the outbreak started and witnessed facility failures first hand. Review of the facility's NP written statement dated [DATE] reflected This is the statement of events personally witnessed to the best of my recollection at the facility from [DATE]th through 27th 2020. On [DATE] the facility was instructed to close all doors, stop all therapy room to room, and have all staff tested by myself and the LHA (local health authority) MD. This was disregarded by the facility. Again, staff were recommended to be tested , therapy stopped, and doors closed on [DATE] after additional positives were found. Again, this was disregarded by the facility. Again, staff were recommended therapy stopped, and doors closed on [DATE] after additional positives were found. Again, this was disregarded by the facility . It was also requested in writing by the facility MD to keep same staff to isolation hallway- not mix with non-isolation hallway, stop therapy .This again was disregarded . On [DATE] at the direction of LHA MD a true isolation unit was recommended. It was said this would be done ASAP at that time . Therapy continued until [DATE]. Doors remained open until [DATE]. 100 and 200 hall shared one ,[DATE] nurse until [DATE]. Staff took care of positive and negative patients till [DATE]. The residents were all tested at my direction with swabs from state on [DATE], [DATE], [DATE]. I personally witnessed staff asking for additional outside staffing help as early as [DATE]. They were disregarded. I personally witnessed staff entering isolation rooms with masks only on. I also was notified by one family that they did not know their family member was positive for > 48 hrs. post diagnosis. PPE was not adequately stocked outside of isolation rooms and bins were not in rooms to dispose of PPE. Patients with positive results were kept in rooms with negative patients for > 18 hrs. post diagnosis. In an interview on [DATE] at 3:45 PM the VPO came to the surveyor and stated he made a mistake and moved the wrong resident last night and placed a negative resident on the COVID unit and a positive resident remained on the negative side. Observation on [DATE] at 8:25 PM on the isolation unit revealed a trash bag with various contents on the floor outside room [ROOM NUMBER]. Review of the census reflected room [ROOM NUMBER] had housed Resident #6 prior to her going out to hospital this evening (Resident progress notes reflected she left at 6:37 pm. Further observation revealed the double glass doors at the end of 100 hall had a large trash bag outside. This was the second night in a row trash was observed outside this door. The staff are breaking containment to remove trash. A written statement from a facility staff member was received by email on [DATE] at 2:09 AM. The staff member stated they wanted to remain anonymous to protect her job.Up until [DATE] , no effort from Corporate offices were made to fit test N95's for the employees. The only available PPE we had were surgical masks, the yellow disposable gowns, Medium N95 masks, gloves, Hair covers and clear glasses that didn't wrap around our eyes to protect them from the side. No foot covers available at this time. A concern made to the Administrator regarding inappropriate clear glasses, no new clear goggles or face shields made available to staff in facility . [DATE] the VPO and RNC came to facility to provide lunch for facility staff members. Neither one of them entered the facility to assess how protocols were being followed.[DATE] .the VPO and RNC have finally arrived at the facility and entered our building after 18 days of having multiple residents and staff members positive for the novel coronavirus and 4 days since notifying the RNC of the need for extra staff. Observation/Interview on [DATE] at 9:05 AM during rounds with the Epidemiologist revealed he stated he still had concerns regarding items in the hallways and alcoves, and resident belongings in the halls (which were potentially contaminated). He further stated the house keeping staff need to pick up the pace on getting rooms cleaned out that are empty that had COVID positive residents in them. In an interview on [DATE] at 8:00 AM the ADON stated she would like to provide a statement. Review of the statement dated [DATE] from the ADON reflected . I just have a lot of concerns regarding the VOP and his decisions he's making. In the very beginning we had little PPE to wear, he even said at one point we can wear the N95 masks for 5 days before discarding. Recently I asked if it was safe for me to do wound care on both sides of the building, I try to get south side (negative side) done first but it doesn't always happen this way. I spoke to the VOP and asked if this was safe for the residents and he reassured me it was as long as I wasn't continuously working on the COVID side, which I'm there every day. I'm still very leery of this and wanted clarification Review of the facility's policy Outbreak of Novel Coronavirus (2019-nCoV) dated [DATE] reflected Suspected outbreaks of Novel Coronavirus within the facility will be promptly identified and appropriately handled per the CDC recommendations. The Administrator or Director of Nursing (DON) will notify the local health department in case of an outbreak. Personal Protective equipment (e.g., gowns, gloves, NOISH-certified disposable N95 respirators) will be provided to our employees . Review of the facility's policy Reportable Diseases dated [DATE] reflected .Should any residents or staff suspected or diagnosed as having a reportable communicable/infectious disease according to State-Specific criteria, such information shall be promptly reported to appropriate local and/ or state health department officials . On [DATE] at 6:40 PM the VPO, Administrator and RNC were notified the facility had an IJ situation for the above failures. The facility's first Plan of Removal (POR) was submitt (TRUNCATED)

Based on observation, interview and record review, the governing body failed to implement policies regarding the management and operation of the facility for the 85 residents in the facility that contracted the COVID-19 virus and for one (1) of ten (10) residents reviewed for assessment. -The Vice President of Operations (VPO) and Regional Nurse Consultant (RNC) failed to provide instruction and oversight for the facility when the facility failed to follow recommendations provided by the facility's Medical Director, the Medical Director of the local health authority and the facility's Nurse Practitioner regarding coronavirus testing for staff and residents and followed the recommended infection control measures to prevent the spread of the coronavirus in the facility. -The VPO and RNC failed to assist the facility in modifying their staffing ratios to ensure the facility had enough licensed staff on duty to provide resident assessments, monitoring and care for the clinically unstable COVID-19 positive residents. -The RNC failed to develop and implemented assessment protocols for the facility to monitor and identify changes in clinically unstable COVID-19 positive residents. These failures led to 85 residents contracting the COVID-19 virus and the death of 22 of those residents. These failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm at isolated and a severity level of no actual harm with potential for more than minimal harm at a scope of widespread due to staff needing more time to monitor the plan of removal for effectiveness. These deficient practices could affect all residents and place the residents at risk for mental anguish, prolonged isolation time, coronavirus infections, unidentified changes in condition and death. Finding included: In an interview on [DATE] at 2:45 PM the Administrator stated the NP (Nurse Practitioner) had tested another 4 or 5 Residents today. He stated 4 or 5 staff had been tested for Covid-19 (coronavirus disease) and were positive. He stated the facility was unable to obtain tests kits for all the staff (100 plus staff). He stated 30 or 40 tests had been completed at the facility. He stated only 10 staff had been tested for Covid-19. The Administrator stated the first positive tests came back to the facility on [DATE]. He stated the facility's contracted a laboratory and they stated they would provide testing for Covid-19. He stated the facility was sent test kits which were collected and then the lab failed to pick them up. Since the failure the corporation had been unsuccessful in finding another testing company. In an interview on [DATE] at 2:55 PM the facility's NP (Nurse Practitioner) stated she is monitoring the COVID residents on the unit and is doing the testing on her own. She stated the facility is not doing testing and stating they do not have the resources. She stated they are not testing staff and until they test everyone she will not be able to get ahead of the infections and stated it is going to get worse without testing. She stated with 100 residents and 100 staff she does not have the supplies to test that many people and the facility is not helping. In an interview on [DATE] at 9:30 AM the facility NP stated the facility has gotten 20 more positive test for residents and are testing staff and have 12 positive staff. She stated both ADON RN's who were doing the q8hr assessments on the COVID residents tested positive and were sent home. She stated the COVID unit will be full after all the positive residents are moved on the unit. She stated she is concerned about staffing on the unit. She is doing labs and the residents are dehydrated she stated she wanted one staff just hydrating the residents. She stated they did IV's on two of the residents. She also stated the it is not recommended to hydrate to fast because the residents will develop [MEDICAL CONDITIONS]. The NP stated she was concerned that the nurse for 100 hall was also working on 200 hall (100 hall is the COVID) at night. She stated as of today the number of positive residents had go up to 43 and the facility still needs to test 80 staff members. Review of Resident #1's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change Minimum Data Set ((MDS) dated [DATE] reflected Resident #1 had a Brief Interview for Mental Status Score of nine (9) indicating moderate cognitive impairment. Resident #1 was assessed to require supervision for all activities of daily living (ADLs). Review of Resident #1's Comprehensive Care Plan reflected a problem with the start date [DATE] High risk for communicable respiratory infection- influenza/ pneumonia- due to age and resident lives in close proximity to others. Further review of Resident #1's Comprehensive Care plan reflected a problem with the start date [DATE] Resident is at risk for signs and symptoms of COVID-19. Interventions included observe for signs and symptoms of COVID-19, document and promptly report signs and symptoms: fever, coughing, sneezing, sore throat, respiratory issues. Review of Resident #1's Nursing progress notes dated [DATE] reflected an entry at 4:08 AM that the facility received notification that Resident #1 was COVID positive. An entry at 3:45 PM reflected resident returned form the emergency room (ER) at 3:30 PM. The note reflected Resident #1 returned on 2 liters of supplemental oxygen. An entry dated at 5:50 PM reflected a late entry for 10:45 AM on [DATE] that Resident #1was assessed by the NP and her oxygen saturation was 85% on room air and oxygen was started at 2 liters Resident #1 was noted with temperature of 101.4 and a HR of 134. Note indicated Resident #1 was sent to the ER. The next entry in Resident #1's Nursing progress notes dated [DATE] was at 10:40 PM indicating Resident #1 was sent to the ER with [MEDICAL CONDITION] and respiratory distress. Review of Resident #1's Hospital Record dated [DATE] at 11:27 PM reflected DOS [DATE], Chief complaint SOB with [MEDICAL CONDITION], lethargy, resident is a DNR, EMS assessment oxygen saturation 50%, 6L NC ,[DATE]%; [MEDICATION NAME] 0.3 IM administered. She was found to have a saturation of 50% on room air she was recently diagnosed with [REDACTED].she does have history of [MEDICAL CONDITION], but in not on home oxygen at baseline. Vital signs BP: ,[DATE], Pulse 38, Temp 97.2 Resp 35, Sp02 90%. Critical Care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: [MEDICAL CONDITION]. Patient progress listed as Critical. Further review of Resident #1's hospital record reflected Resident #1 expired at on [DATE] at 12:50 AM in the ER with finial [DIAGNOSES REDACTED]. Review of Resident #1's Electronic Medical Record (EMR) reflected Resident #1 did not have an assessment completed upon her return to the facility at 3:30 PM on [DATE]. The EMR further reflected no vital signs documented for Resident #1 from the time she returned to the facility at 3:30 PM until the time she was sent back to the hospital at 10:40 PM (7 hours and 10 min later). Record review of Resident #1's EMR reflected that no progress notes were charted for Resident #1 from [DATE] to [DATE]. No documented temperature on 3 days: ,[DATE], ,[DATE], ,[DATE]. No documented BP for 4 days: ,[DATE], ,[DATE], ,[DATE], ,[DATE]. No pulse documented on 4 days: ,[DATE], ,[DATE], ,[DATE], ,[DATE]. No RR documented for 6 days: ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE]. No O2 sat documented for 4 days: ,[DATE], ,[DATE], ,[DATE], ,[DATE]. No skilled assessments were documented for 8 days: ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE]. Resident COVID positive on [DATE]. Review of the facility census for [DATE] reflected 36 residents on the COVID unit. Review of the facility staffing for [DATE] reflected one (1) LVN on the COVID unit and no RN. In an interview on [DATE] at 1:25 PM the facility MD provided the surveyor with his COVID response plan. He stated he provided this to facility on [DATE] and it was mostly ignored or not fully implemented. He stated if the facility had been more corporative at the beginning with testing and recommendations it might not have reached this point. Review of the Facility MD's Response Plan dated [DATE] reflected that he was recommending the following basic guidelines in an attempt to contain the COVID contagion in the building. The guidelines included but were not limited to quarantine/ isolation of residents with symptoms, implement transmission-based precautions (masks on all residents and anyone in the building), dedicate specific staff to care for only the affected and suspected residents, cohort existing COVID residents to dedicated area, if a resident becomes newly sick with symptoms isolate and test them ASAP, be quick to move to dedicated area, and attempt/encourage testing of all employees in an effort to catch asymptomatic carriers that may inadvertently be spreading [MEDICAL CONDITION]. In an interview on [DATE] at 2:45 PM the RNC and VPO stated they were working on a plan for staffing once the unit was completed. Observation and interview on [DATE] at 10:15 AM of the facility with DSHS (Department of State Health Services) Epidemiologist revealed hallways and handrails dirty. Trash and gloves noted on floors and wedged into the hand rails. The epidemiologist recommended an increase of housekeeping staff needed. The facility needed to remove items from hallways and alcoves such as lifts, and equipment and the multiple resident use equipment need to be tagged to indicate if it was cleaned after use. Doors to isolation rooms were noted to be open and residents not wearing masks. The facility staff member training the staff on the proper use of PPE was noted not donning his own PPE appropriately. The Epidemiologist stated the donning/ doffing area at the entrance to the isolation unit needed better flow and access to hand sanitizer. All recommendations provided to the facility administration. In an interview on [DATE] at 12:20 PM the NP stated the facility had moved residents on the roster to make them appear to have been moved to a different room but did not actually move the residents. The NP stated the facility did not stop therapy when instructed to. She further stated she repeatedly told the facility and staff to keep isolation room doors closed. She stated she told the facility on [DATE] and instructed them to test all residents and that did not occur. She stated the facility would run out of PPE in the containers outside of isolation rooms and found that isolation rooms did not have biohazard boxes in the rooms. The NP further stated she provided swabs for testing and the facility's Corporate staff took the swabs away from the facility staff because they did not want all residents tested . The NP further stated Corporate did not want employees tested . The facility NP stated the facility had been understaffed for two weeks and Corporate was asked for more staffing, but they refused. She stated she did not feel like the residents were getting the care they need such as hydration, feeding assist and just care in general. In an interview on [DATE] at 12:30 PM the Medical Director of the local health authority stated he had made of time line of events that occurred at the facility that concerned him, and he would provide a written statement. Review of the Medical Director of the local health authority statement dated [DATE] reflected I am writing this letter to record my directives to the Medical Director (MD), administration and staff of the facility. As Local Health Authority, I have been monitoring the COVID 19 pandemic in cooperation with DSHS Region 7 and our local emergency management coordinator, since even before the outbreak of [MEDICAL CONDITION] in our county. I was first notified of cases at the facility by the NP on the morning of [DATE]. I had been made aware in passing on or about [DATE] of a PUI (patient under investigation) at the facility that had been sent to the hospital on [DATE]. His test came back positive on 5 April, at which point I was nearly immediately notified. My first call was to the medical director of the facility. At that time, there was a potential staff member that had been tested positive, and by this time there were more suspected cases in the building. My recommendations, which the facility MD and NP relayed to the facility directly, were to immediately isolate all PUI's, and to continue monitoring staff closely for symptoms. At this point, the facility already had stopped all visitors, and there was no communal dining, etc. Within two days, more cases were reported. I was in direct contact with the MD and NP on [DATE] and 7. By [DATE], there were at least 3 (and more PUI's suspected), and I was notified of this by early afternoon. A three-way conference call was arranged, the administrator of the facility, and the NP to discuss recommendations going forward for isolation of residents. My recommendation at that time was to move all positive patients and PUI's to the 300 hall, or if unable to for logistical reasons, to move them all to an isolated area in the 100 hall. I directed them to sequester all positives away from the general population, and to set up an isolation ward to assist with donning/doffing of PPE. Over the next few days cases continued to climb. I spoke with an infectious disease specialist and Local Health Authority to get further suggestions. He and I both agreed that testing all staff was paramount, although due to limited testing ability in the state it would be difficult. I spoke with the facility's MD that afternoon regarding these recommendations, which were to basically stop all unnecessary movement within the facility, stop physical therapy, close all doors that could be closed, and test all staff, and if possible, all patients. He stated he would take the lead on this as he was the medical director for the facility. I continued to follow up with the facility MD and NP daily. The cases unfortunately continued to climb. I was told by the facility MD, and the facility administrator, that corporate doctors did not agree with our recommendations. I did not personally speak with these corporate representatives as the facility MD said he would do so. He related to me that they were very much against testing anyone that did not have symptoms in the facility, for unclear reasons. A plan was made, and orders were written on or about Tuesday, [DATE] or Wednesday [DATE] to test all residents through a lab testing company through the nursing facility. I was told by the facility NP Wednesday [DATE], late in the day, that at the direction of the Corporation, no testing was to be performed on patients that we ordered, and the orders were canceled. The materials necessary to test were reportedly locked in the administrator's office to keep out of the hands of nursing. At this time, the facility MD and I decided that a meeting between corporate and ourselves must be set up as soon as possible due to the risk of continued spread. By this point, there were approximately 10 patients, with multiple PUIs. I drafted control orders for the facility, that clearly laid out a mitigation strategy of testing, complete isolation, closing doors, and assuming all patients had COVID until proven otherwise. These orders were given to the facility MD. On the morning of 16 April, the facility MD gave me his revised version of the control orders, with his signature. These were almost identical to mine in contact, and only different in language. I was told that as LHA (local health authority), I did not have direct authority to impose control orders, as I work through DSHS, and that the medical director and HHS had authority over the facility. The meeting between the facility VPO (Vice present of operations), and several other corporate officers, as well as the facility Administrator, NP, MD and myself occurred at 5:30 PM on Thursday 16 April. There was significant push back during this meeting, during which the facility MD read aloud his orders, regarding the testing of patients. The facility's VPO exact words were what does it matter if we test? What if they all already have it. My impression was that he did not grasp the severity of the situation, and I directly recommended they test everyone and that doors be closed. I also recommended that therapy cease except where absolutely indicated. I was told that was impossible, and that therapy was as important as [MEDICAL TREATMENT]. Again, I recommended it stop immediately. We were promised at this meeting that the isolation wall for the 100 hallway would be up within 24 to 48 hours. During this meeting, the facility NP clearly made administration aware that staff were not [MEDICATION NAME] appropriate distancing, PPE use, or hand hygiene. The facility MD and I both recommended that interventions be made to quickly remedy this. On Monday, 20 April, I was informed that the wall was still not up . By Friday, the number of cases in the facility had risen to over 60, with a total of 11 deaths at the time of this writing. My thoughts on this situation is that, based on the data and discussions with both the facility MD and NP, that numerous times the administration of the facility were given information and the opportunity to lessen the spread of COVID 19. At times, we were directly challenged on how we wanted to proceed, and orders of a physician/FNP that were legally written were disobeyed at the direction of corporate officers. I am saddened by the way this was handled and feel that steps need to be taken to assure that this does not happen in this, or any facility, ever again. In an interview on [DATE] at 5:15 PM the RNC (Reginal Nurse Consultant) stated that Resident's VS (vital sings) were on paper sheets. The RNC stated the VS for Resident #1 regarding the time period in question were not present. She stated her expectation of assessments were that they were to be done every time there was a change of condition. She stated that her expectation was that vital signs were done every shift. There are 3 eight-hour shifts. She stated that this has always been her expectation. In an interview on [DATE] at 5:27 PM the nurse on duty LVN A stated she was not the nurse on duty taking care of Resident #1 when she arrived back to the facility at 3:30 pm or was sent back out to the hospital at 10:40 pm. She stated she was in the facility at the time the patient needed to be sent to the hospital, but she was not the nurse on duty. LVN A stated she put the notes in the chart for the night nurse, which is why her name was in the chart. She stated she called the family, the nurse practitioner, charted, and did the paperwork for the resident to be sent out of the facility. LVN A stated she was the 6 am-2 pm nurse for the resident. She stated during the 6 am- 2 pm shift, the NP asked her if she had taken vitals yet on the resident on [DATE] and she stated that she did not have time to yet. The nurse practitioner took the O2 sat and it was at 84% at 11:05 AM. The nurse took the rest of the vital signs and the nurse practitioner after assessing Resident #1 sent her to the hospital. In an interview on [DATE] at 5:53 PM the 2 pm-10 pm shift nurse LVN B stated on [DATE] that she was the only nurse working that night. She stated that vital signs should be taken every shift and that assessments should be done before a resident gets sent out and when a resident comes back. Assessments should also be done when a resident is critical or is a priority. She stated that managed patients(Medicare/Medicaid) get assessments with vitals. She stated that in the case of Resident #1, she was not able to get a set of vitals because she had a lot going on. She stated that an aide came and told her around 10:00 PM that Resident #1 did not look good. LVN B stated she went in to look at Resident #1 and put her nasal cannula back on, but she was not able to obtain a O2 saturation level on the resident and that her pulse was 111 bpm and her BP was 115 over something she stated the resident was starting to appear cyanotic. A nonrebreather mask was placed on resident on 10Liters, and she called the nurse manager. She stated at that point Resident #1's pulse was 156. Nurse practitioner was called, and resident was sent to ER, where she was told the resident died . In an interview on [DATE] at 6:30 PM the RNC stated the facility only had one nurse on the COVID unit on [DATE] and Resident #1's assessment after her return from the hospital was not completed. The RNC stated she was not aware there was only one nurse on the unit and that there was not an RN on the unit. In an interview on [DATE] at 6:40 PM the VPO stated he felt the facility followed all the CDC guidelines in regard to the COVID outbreak. The VPO stated the facility tried to test everyone, but the labs would not provide the test kits or would not pick up the test collected and stated the kits taken away from staff were because they were the wrong test kits. The VPO stated residents room doors were not closed and infection control measures might not be followed right now because they are moving residents to get the positive residents away from the negative residents. Observation on [DATE] at 11:15 PM revealed the State Task force staff arrive at facility. 13 staff were observed undergoing orientation to the facility. No staffing plan received from facility. Observation on [DATE] at 10:50 AM making rounds with the DSHS Epidemiologist and Associate Commissioner revealed multiuse equipment still noted in hallways and alcoves without labels to identify if they were clean, residents still not wearing masks, floors remain dirty and residents that were positive needed to be moved to the isolation unit doors were open. In an interview on [DATE] at 1:40 PM the RNC stated the facility's COVID response plan did not have standing orders for assessments and care of COVID positive residents to guide the staff on their care and agreed that the COVID positive residents were clinically unstable and required close monitoring. Observation/ Interview on [DATE] at 11:20 PM revealed none of the 13 residents on the 300 or 400 hall had been transferred to the isolation unit yet. The VPO stated the staff were making sure equipment and belongings could be secured prior to moving the residents. Observation on [DATE] at 11:40 PM the isolation unit revealed empty rooms to be cleaned and ready to receive residents. In an interview on [DATE] at 10:40 AM with 2 CNA's on the 400 hall CNA E and CNA F both stated they often worked short staffed. They said they both worked the day shift 6:00 AM to 2:00 PM, and often stayed late sometimes until after supper meal, to help care for residents because many times the next shift didn't show up or showed up late. They said they had been very concerned about residents not getting the care they needed because there wasn't enough CNA's working. Observation and interview on [DATE] at 10:43 AM revealed Resident #2 sitting in his doorway, he was wearing a mask. He was dressed for the day, slightly disheveled. He said he was concerned he had not been given his early AM medications. When asked if he received good care he said he had not received his morning medication. He said he had not received a shower in 6 days, he said he used an electric razor to shave himself. He said he slept in his recliner, as was his preference and had done so for several years. Surveyor asked the nurse on the hall about Resident #2 morning medications. She said he had not yet received medications which were scheduled for 07:00 AM, she said she was trying to figure things out which had placed her behind. She agreed she would give his morning medications now. In an interview on [DATE] at 10:45 AM a Confidential Staff Member pulled surveyor to side and stated she wanted to talk. She stated she wanted the surveyor to know that Corporate staff took testing swabs away from staff to prevent them from testing and stated she would like to provide a statement and would like to remain anonymous. Review of the Confidential Staff Members statement dated [DATE] reflected . On [DATE] the facility was instructed by our corporate office that the facility would no longer be receiving visitors into the facility at this time, except for private sitters. On [DATE] we informed families that there could no longer be any private sitters at this point. Between the dates of [DATE]th and [DATE]th there was never mentioned to the employees that they had a plan in action to begin testing employees, even after employees expressed wanting to be tested . At one-point employees were told if they were tested , they would have to be out of work for 14 days and would have to use their own PTO. [DATE] VPO and the RNC came to the facility to provide lunch for facility staff members. Neither one walked inside facility to ensure that all protocols where being followed. On [DATE] ADON received orders from the NP to test all remaining residents in the facility. Orders were later given by the facilely MD to cover all remaining orders in facility due to Medical Director status. Facility spoke with our outside lab company to ask if they would be able to run COVID test for us. They called back to inform facility that they could run the test for us, and a lab tech would deliver the testing kits later that afternoon. On [DATE] Via text message the RNC asked the ADON if there were written orders to test all remaining residents in the facility. When ADON informed her that there were verbal telephone orders that had been entered into PCC (point click care) instructed her to hold off on testing. ADON informed her that all orders had been approved by the MD and entered into PCC as well as the lab for all specimens to be collected. At that time ADON was instructed to be on a conference call in administrators office. ADON came back into conference and voiced to me that the VPO stated that the facility will not test all residents. It goes against CDC and CMS guidelines to blanket test all residents. The only way the facility would get over this was to practice proper hand hygiene and social distancing. While talking with the ADON about the phone call, the Administrator came into the conference room and removed all testing kits off the table. At this time, it the ADONs, and myself were present in the conference room. A phone conference with CEO, COO, CNO, MD (LHA), the facility NP, the facility MD, the Administrator, the RNC and the VPO was scheduled for later that evening. ADON requested to be on the call for added input, the facility MD stated that this would be great thing for any additional input. Later that afternoon the ADON was informed that corporate wants no one else in the meeting. [DATE] ADON reached out to the RNC for help. Our DON is out on medical leave, ADON out on maternity leave, and another ADON out for 14 days. This would leave only 2 ADONs in the facility to complete all required tasks and staffing. After reaching out ADON got no response from the RNC. [DATE]rd while assisting VPO with moving residents with positive test results to the isolation unit I was asked by a resident to fix his tv. While fixing it VPO asked me to continue with the room move and that hooking up a tv at this point was not important. [DATE]th while moving residents with positive results over to the isolation unit I was unhooking a tv, and the VPO again stopped me and stated don't worry about the tv they will not need it. Just bring the resident, they do not need a tv in their room while on the unit. During this time, I witnessed the VPO instruct other team members to move residents that had a negative test result into a room that a patient with a positive test results without it being properly deep cleaned. [DATE]th while assisting another staff member identify which test results that were received on [DATE]th were staff members and residents so that she could notify family members of test results. I noticed that there was a COVID positive resident on the south unit (negative side) and a COVID negative patient on the isolation unit. The VPO instructed staff who needed to be moved and to where. I brought this to his attention. After sitting back down at my computer I overheard him ask the RNC how to move the residents without the state surveyors noticing. At this time the NP asked me for a resident room roster, I walked into the admissions office for a roster at that time Admissions Director told me that the VPO had instructed her to NOT give anyone from the state a room roster. As I am not an ADON and do not have much involvement with staffing, I cannot give accurate information on staffing other than being aware that the facility has been understaffed for some time now. I can only speak on what I have witnessed. When asked if corporate would call in a staffing agency to fill in some of the open shifts the VPO reminds facility that we must be down 12 aides on one shift before calling in agency. When request for staffing were given by multiple ADONs to administration ADONs were told that the facility did not have enough openings to request staffing agencies. In an interview on [DATE] at 12:20 PM the facility NP stated she had made a timeline of events that occurred at the facility and would provide a written statement. The NP stated she had been at the facility every day since the outbreak started and witnessed facility failures first hand. Review of the facility's NP written statement dated [DATE] reflected This is the statement of events personally witnessed to the best of my recollection at the facility from [DATE]th through 27th 2020. On [DATE] the facility was instructed to close all doors, stop all therapy room to room, and have all staff tested by myself and the LHA (local health authority) MD. This was disregarded by the facility. Again, staff were recommended to be tested , therapy stopped, and doors closed on [DATE] after additional positives were found. Again, this was disregarded by the facility. On [DATE] we attempted to test all the facility residents. These swabs were ordered through a lab. The nursing staff started collecting these specimens and then were told to stop by the Administrator on the direction of the VOP. The swabs were taken away from staff and placed in the Administrators office to prevent them being collected. A meeting was held with LHA MD, the facility MD, me and several corporate members via teleconference on the night of [DATE]. It was stated they did not want to test staff because they were worried they would have too many staff positives and then no staff to manage the facility. This was again requested by LHA MD, facility MD and me despite this concern. It was also requested in writing by the facility MD to keep same staff to isolation hallway- not mix with non-isolation hallway, stop therapy, and to test everyone including staff. This again was disregarded. One corporate official also stated that if this was all over the building then what was the point of testing everyone. On [DATE] at the direction of LHA MD a true isolation unit was recommended. It was said this would be done ASAP at that time. On Monday [DATE] the facility decided to test staff but did not help facilitate this or give staff direction on how to get this done. Staff were told they would have to be out until test results were back even if it was done for screening. We asked for a sign-up list for staff to voluntarily be tested . Then staff were told they would have to be out until test results were back even if it was done for screening, so all the staff removed their names. Therapy continued until [DATE]. Doors remained open until [DATE]. 100 and 200 hall shared one ,[DATE] nurse until [DATE]. Staff (TRUNCATED)

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure and attain or maintain the highest practicable physical, mental and psychological well-being of each resident related to sufficient staffing during a coronavirus outbreak for one of four residents (Resident #1) reviewed for assessments and 85 residents reviewed for COVID-19. The facility failed to ensure there was enough licensed staff on duty to ensure resident assessments and resident monitoring were done to identify changes of condition in a medically unstable COVID-19 positive resident. Resident #1 was not assessed after she returned from the hospital on [DATE] at 3:30 PM until 7 hours later on the next shift when she was sent back to the hospital at 10:40 PM where the resident died in the ER. The facility further failed to have sufficient and dedicated staff working on the COVID positive unit and allowed staff to work on both the COVID positive and negative units, and failed to have sufficient direct care staff to meet the residents care needs. These failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. These deficient practices could affect all residents and place the residents at risk for mental anguish, prolonged isolation time, coronavirus infections and death. Findings included: In an interview on [DATE] at 9:30 AM the facility NP stated the facility had gotten 20 more positive test for residents and were testing staff and had 12 positive staff. She stated both ADON RN's who were doing the q8hr assessments on the COVID residents tested positive and were sent home. She stated the COVID unit would be full after all the positive residents were moved on the unit. She stated she was concerned about staffing on the unit. She was doing labs and the residents were dehydrated. She stated she wanted one staff just hydrating the residents. She stated they did IV's on two of the residents. She also stated the it was not recommended to hydrate too fast because the residents would develop [MEDICAL CONDITIONS]. The NP stated she was concerned that the nurse for 100 hall was also working on 200 hall (100 hall is the COVID) at night. Review of Resident #1's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #1's Significant Change Minimum Data Set ((MDS) dated [DATE] reflected Resident #1 had a Brief Interview for Mental Status Score of nine (9) indicating moderate cognitive impairment. Resident #1 was assessed to require supervision for all activities of daily living (ADLs). Review of Resident #1's Comprehensive Care Plan reflected a problem with the start date [DATE] High risk for communicable respiratory infection- influenza/ pneumonia- due to age and resident lives in close proximity to others. Further review of Resident #1's Comprehensive Care plan reflected a problem with the start date [DATE] Resident is at risk for signs and symptoms of COVID-19. Interventions included observe for signs and symptoms of COVID-19, document and promptly report signs and symptoms: fever, coughing, sneezing, sore throat, respiratory issues. Review of Resident #1's Nursing progress notes dated [DATE] reflected an entry at 4:08 AM that the facility received notification that Resident #1 was COVID positive. An entry at 3:45 PM reflected resident returned from the emergency room (ER) at 3:30 PM. The note reflected Resident #1 returned on 2 liters of supplemental oxygen. An entry dated at 5:50 PM reflected a late entry for 10:45 AM on [DATE] that Resident #1 was assessed by the NP and her oxygen saturation was 85% on room air and oxygen was started at 2 liters Resident #1 was noted with temperature of 101.4 and a HR of 134. Note indicated Resident #1 was sent to the ER. The next entry in Resident #1's Nursing progress notes dated [DATE] was at 10:40 PM indicating Resident #1 was sent to the ER with [MEDICAL CONDITION] and respiratory distress. Review of Resident #1's Hospital Record dated [DATE] at 11:27 PM reflected DOS [DATE], Chief complaint SOB with [MEDICAL CONDITION], lethargy, resident is a DNR, EMS assessment oxygen saturation 50%, 6L NC ,[DATE]%; [MEDICATION NAME] 0.3 IM administered. She was found to have a saturation of 50% on room air she was recently diagnosed with [REDACTED].she does have history of [MEDICAL CONDITION], but in not on home oxygen at baseline. Vital signs BP: ,[DATE], Pulse 38, Temp 97.2 Resp 35, Sp02 90%. Critical Care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: [MEDICAL CONDITION]. Patient progress listed as Critical. Further review of Resident #1's hospital record reflected Resident #1 expired at on [DATE] at 12:50 AM in the ER with finial [DIAGNOSES REDACTED]. Review of Resident #1's Electronic Medical Record (EMR) reflected Resident #1 did not have an assessment completed upon her return to the facility at 3:30 PM on [DATE]. The EMR further reflected no vital signs documented for Resident #1 from the time she returned to the facility at 3:30 PM until the time she was sent back to the hospital at 10:40 PM (7 hours and 10 min later). Record review of Resident #1's EMR reflected that no progress notes were charted for Resident #1 from [DATE] to [DATE]. No documented temperature on 3 days: ,[DATE], ,[DATE], ,[DATE]. No documented BP for 4 days: ,[DATE], ,[DATE], ,[DATE], ,[DATE]. No pulse documented on 4 days: ,[DATE], ,[DATE], ,[DATE], ,[DATE]. No RR documented for 6 days: ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE]. No O2 sat documented for 4 days: ,[DATE], ,[DATE], ,[DATE], ,[DATE]. No skilled assessments were documented for 8 days: ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE]. Resident COVID positive on [DATE]. Review of the facility census for [DATE] reflected 36 residents on the COVID unit. Review of the facility staffing for [DATE] reflected one (1) LVN on the COVID unit and no RN. In an interview on [DATE] at 2:45 PM the RNC and VPO stated they were working on a plan for staffing once the unit was completed. Observation and interview on [DATE] at 9:51 AM with DSHS Epidemiologist revealed the facility halls dirty and in need of increased housekeeping. Call lights going off and isolation room doors open. The Epidemiologist stated the facility was in need of more staff for resident care. In an interview on [DATE] at 12:20 PM the facility NP stated the facility had been understaffed for two weeks and Corporate was asked for more staffing, but they refused. She stated she did not feel like the residents were getting the care they need such as hydration, feeding assist and just care in general. In an interview on [DATE] at 5:27 PM the nurse on duty LVN A stated she was not the nurse on duty taking care of Resident #1 when she arrived back to the facility at 3:30 pm or was sent back out to the hospital at 10:40 pm. She stated she was in the facility at the time the patient needed to be sent to the hospital, but she was not the nurse on duty. LVN A stated she put the notes in the chart for the night nurse, which is why her name was in the chart. She stated she called the family, the nurse practitioner, charted, and did the paperwork for the resident to be sent out of the facility. LVN A stated she was the 6 am-2 pm nurse for the resident. She stated during the 6 am- 2 pm shift, the NP asked her if she had taken vitals yet on the resident on [DATE] and she stated that she did not have time to yet. The nurse practitioner took the O2 sat and it was at 84% at 11:05 AM. The nurse took the rest of the vital signs and the nurse practitioner after assessing Resident #1 sent her to the hospital. In an interview on [DATE] at 5:53 PM the 2 pm-10 pm shift nurse LVN B stated on [DATE] that she was the only nurse working that night. She stated that vital signs should be taken every shift and that assessments should be done before a resident gets sent out and when a resident comes back. Assessments should also be done when a resident is critical or is a priority. She stated that managed patients (Medicare/Medicaid) get assessments with vitals. She stated that in the case of Resident #1, she was not able to get a set of vitals because she had a lot going on. She stated that an aide came and told her around 10:00 PM that Resident #1 did not look good. LVN B stated she went in to look at Resident #1 and put her nasal cannula back on, but she was not able to obtain a O2 saturation level on the resident and that her pulse was 111 bpm and her BP was 115 over something she stated the resident was starting to appear cyanotic. A nonrebreather mask was placed on resident on 10Liters, and she called the nurse manager. She stated at that point Resident #1's pulse was 156. Nurse practitioner was called, and resident was sent to ER, where she was told the resident died . In an interview on [DATE] at 6:30 PM the RNC stated the facility only had one nurse on the COVID unit on [DATE] and Resident #1's assessment after her return from the hospital was not completed. The RNC stated she was not aware there was only one nurse on the unit and that there was not an RN on the unit. Observation on [DATE] at 11:15 PM revealed the State Task Force staff arrive at facility. 13 staff were observed undergoing orientation to the facility. No staffing plan received from facility. In an interview on [DATE] at 10:40 AM with 2 CNA's on the 400 hall CNA E and CNA F both stated they often worked short staffed. They said they both worked the day shift 6:00 AM to 2:00 PM, and often stayed late sometimes until after supper meal, to help care for residents because many times the next shift didn't show up or showed up late. They said they had been very concerned about residents not getting the care they needed because there wasn't enough CNA's working (i.e bathing, incontinent care) Observation and interview on [DATE] at 10:43 AM revealed Resident #2 sitting in his doorway, he was wearing a mask. He was dressed for the day, slightly disheveled. He said he was concerned he had not been given his early AM medications. When asked if he received good care he said he had not received his morning medication. He said he had not received a shower in 6 days, he said he used an electric razor to shave himself. He said he slept in his recliner, as was his preference and had done so for several years. Surveyor asked the nurse on the hall about Resident #2 morning medications. She said he had not yet received medications which were scheduled for 07:00 AM, she said she was trying to figure things out which had placed her behind. She agreed she would give his morning medications. In an interview on [DATE] at 10:45 AM a Confidential Staff Member pulled surveyor to side and stated she wanted to talk. She stated she wanted the surveyor to know what Corporate staff were doing and stated she would like to provide a statement and would like to remain anonymous. Review of the Confidential Staff Members statement dated [DATE] reflected .[DATE] an ADON reached out to the RNC for help. Our DON is out on medical leave, an ADON is out on maternity leave, and another ADON out for 14 days. This would leave only 2 ADONs in the facility to complete all required tasks and staffing. After reaching out ADON got no response from the RNC . As I am not an ADON and do not have much involvement with staffing, I cannot give accurate information on staffing other than being aware that the facility has been understaffed for some time now. I can only speak on what I have witnessed. When asked if corporate would call in a staffing agency to fill in some of the open shifts the VPO reminded the facility that we must be down 12 aides on one shift before calling in agency. When request for staffing were given by multiple ADONs to administration ADONs were told that the facility did not have enough openings to request staffing agencies. In an interview on [DATE] at 12:20 PM Resident #3 stated she had breakfast and that staff have been much nicer today. She told me that before she has not had good care and that aides have been rude to her and acting like they knew more than her. She also stated they have been rough with her. She states that if they pay money for a place they should get good care. Observation on [DATE] at 12:45 PM revealed Resident #6 in room eating lunch. Resident #6's dinner tray from [DATE] was still in her room. Observation/ Interviews on [DATE] at 1:15 PM revealed 3 call lights going off on the COVID unit. The call lights continued to go off for 15 minutes. Surveyor observed Resident #2 in her doorway yelling hey to someone who passed her room and she finally got some help. A RN asked surveyor if she needed helped. Surveyor asked who was responsible for answering call lights and the RN stated anyone could answer them and asked Surveyor to tell the nurses at the nurse's station. Surveyor went to the nurse's station and asked multiple staff, who was responsible for answering call lights. The staff stated anyone could answer them. Surveyor informed then that the call lights had been going off for more than 15 minutes. Residents finally started to get assistance at this point. A written statement from a facility staff member was received by email on [DATE] at 2:09 AM. The staff member stated they wanted to remain anonymous to protect her job. Review of the written statement reflected .[DATE] multiple department heads worked on COVID unit in a CNA role due to low staffing. These staff also work with the residents off the COVID unit. On [DATE] the following was communicated to the RNC .we need some help. We just found out that another ADON is positive and since the DON can't be here, it's just one other staff besides myself. We are struggling with staff picking up extra. Is there a plan in motion to help with extra staff? No response was received from the RNC. In an interview on [DATE] at 11:00 AM Resident #3 stated she wanted to get up in her wheelchair and stated she had asked multiple people to get her up and no one would assist her. Review of the written statement dated [DATE] from the ADON reflected . I just have a lot of concerns regarding the VOP and his decisions he's making. In the very beginning we had little PPE to wear, he even said at one point we can wear the N95 masks for 5 days before discarding. Recently I asked if it was safe for me to do wound care on both sides of the building, I try to get south side (negative side) done first but it doesn't always happen this way. I spoke to the VOP and asked if this was safe for the residents and he reassured me it was as long as I wasn't continuously working on the COVID side, which I'm there every day. I'm still very leery of this and wanted clarification . On [DATE] at 6:40 PM the VPO, Administrator and RNC were notified the facility had an IJ situation for the above failures. The facility's first Plan of Removal (POR) was submitted by the VPO on [DATE] at 8:20 PM. The final POR was accepted by the survey team on [DATE] at 2:00 PM. Accepted Plan of Removal: Plan of Removal On [DATE], a complaint survey was initiated at Brenham Nursing and Rehabilitation Center at 400 E Sayles Street, Brenham TX . On [DATE], the facility was notified by the surveyor that a jeopardy had been called and needed to submit a letter of credible allegation. The Facility respectfully submits this Letter of Credible Allegation pursuant to Federal and State regulatory requirements. Submission of the Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiencies. The alleged immediate jeopardy allegations are as follows: Issue: The facility failed to ensure there was a sufficient number of skilled licensed nurses to provide care and respond to each resident's needs. *Effective [DATE], the Director of Nursing and/ or designee reviewed the licensed nurse staffing patterns for the facility. The review included the staff assignments for the Isolation Unit designated for COVID 19 residents, as well as the unit designated for the COVID 19 negative residents to determine facility staffing needs. This will be completed by [DATE]. *Effective [DATE], Brenham Nursing and Rehab identified alternate sources to secure licensed nursing staff for the facility. This will be completed by [DATE]. *Effective [DATE], the Director of Nursing and/ or designee reviewed licensed nursing and ancillary nursing staffing patterns to take into consideration residents' assessment and care needs related COVID 19 up to and including revision in the current shifts from eight hour shifts to twelve-hour shift to maximize staff availability. This will be completed by [DATE]. *Effective [DATE], the Administrator and/ or designee established a four-month recruitment plan designed in four thirty-day increments to recruit and training staff needed to meet the changing needs of the facility based on the status of the COVID 19 positive and negative residents. This will be completed by [DATE]. *Effective [DATE], the Director of Nursing and/ or designee reviewed the process for supervision of care provided to the residents by licensed nurses and ancillary nursing staff and established shift supervision structures to coordinate the provision of care and meeting of resident needs. This will be completed by [DATE]. *Effective [DATE], the Director of Nursing and/ or designee reeducated Licensed Nurses on the COVID-19 Assessment and Reporting Protocols related to the care, management and intervention for COVID 19 positive and COVID 19 negative residents. This will be completed by [DATE]. *Effective [DATE], the Director of Nursing and/ or designee will monitor compliance with vital signs and assessments and interventions through reconciliation of vital sign and assessment data/ documentation, as well as applicable interventions daily for seven days, then every other day for fourteen days three times weekly for three weeks and weekly for six weeks. *Effective [DATE], the Director of Nursing and/ or designee will monitor compliance with licensed nurse staffing by reviewing the staffing schedules for all shift for licensed nurse to resident ratios based on resident acuity and unit needs daily for fourteen days, then every other day for two weeks, then weekly for two months. On [DATE] an Quality Assurance Performance Improvement Meeting was held with the Administrator, Assistant Director of Nursing, Medical Director and two other persons present to discuss the above plan. The facility respectfully requests that the plan of removal be accepted, and immediate jeopardy be lifted. Monitoring for the Plan of Removal began on [DATE] at 2:00 PM. Staff were interviewed for understanding regarding the new procedure resident assessment, and assessment protocols. All staff interviewed had a good understanding of the training. Staffing sheets, and staffing ratios were reviewed for sufficient staffing. Staffing was observed to ensure sufficient staff were assisting residents and residents needs were being met. The facility was monitored for adequate staffing. On [DATE] at 2:45 PM the facility Administrator was notified that the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of widespread due to the facility requiring time to train all staff and monitor their plan of removal.

Based on observation, interview and record review, the facility failed to ensure that based on the comprehensive assessment of a resident, the facility ensured residents received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered plan of care for one (1) of ten (10) residents reviewed for quality of care during a coronavirus outbreak. (Resident #1) The facility failed to ensure Resident #1, who was medically unstable due to the coronavirus, was assessed and monitored after she returned from the hospital on [DATE] at 3:30 PM until 7 hours later when she was sent back to the hospital with [MEDICAL CONDITION] and respiratory distress and died in the ER. This failure resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm at a scope of isolated due to staff needing more time to monitor the plan of removal for effectiveness. This deficient practice could affect residents with the coronavirus and place them at risk for unidentified changes in condition, delay of necessary treatment and death. Findings included: Review of Resident #1's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #1's Significant Change Minimum Data Set ((MDS) dated [DATE] reflected Resident #1 had a Brief Interview for Mental Status Score of nine (9) indicating moderate cognitive impairment. Resident #1 was assessed to require supervision for all activities of daily living (ADLs). Review of Resident #1's Comprehensive Care Plan reflected a problem with the start date of [DATE] High risk for communicable respiratory infection- influenza/ pneumonia- due to age and resident lives in close proximity to others. Further review of Resident #1's Comprehensive Care plan reflected a problem with the start date [DATE] Resident is at risk for signs and symptoms of COVID-19. Interventions included observe for signs and symptoms of COVID-19, document and promptly report signs and symptoms: fever, coughing, sneezing, sore throat, respiratory issues. Review of Resident #1's Nursing progress notes dated [DATE] reflected an entry at 4:08 AM that the facility received notification that Resident #1 was COVID positive. An entry at 3:45 PM reflected resident returned from the emergency room (ER) at 3:30 PM. The note reflected Resident #1 returned on 2 liters of supplemental oxygen. An entry dated at 5:50 PM reflected a late entry for 10:45 AM on [DATE] that Resident #1 was assessed by the NP and her oxygen saturation was 85% on room air and oxygen was started at 2 liters Resident #1 was noted with temperature of 101.4 and a HR of 134. The nursing progress note indicated Resident #1 was sent to the ER and returned at 3:30 PM. The next entry in Resident #1's Nursing progress notes dated [DATE] was at 10:40 PM indicating Resident #1 was sent to the ER with [MEDICAL CONDITION] and respiratory distress. Review of Resident #1's Hospital Record dated [DATE] at 11:27 PM reflected DOS [DATE], Chief complaint SOB with [MEDICAL CONDITION], lethargy, resident is a DNR, EMS assessment oxygen saturation 50%, 6L NC ,[DATE]%; [MEDICATION NAME] 0.3 IM administered. She was found to have a saturation of 50% on room air she was recently diagnosed with [REDACTED].she does have history of [MEDICAL CONDITION], but in not on home oxygen at baseline. Vital signs BP: ,[DATE], Pulse 38, Temp 97.2 Resp 35, Sp02 90%. Critical Care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: [MEDICAL CONDITION]. Patient progress listed as Critical. Further review of Resident #1's hospital record reflected Resident #1 expired at on [DATE] at 12:50 AM in the ER with final [DIAGNOSES REDACTED]. Review of Resident #1's Electronic Medical Record (EMR) reflected Resident #1 did not have a nursing assessment completed upon her return to the facility at 3:30 PM on [DATE]. The EMR further reflected no vital signs documented for Resident #1 from the time she returned to the facility at 3:30 PM until the time she was sent back to the hospital at 10:40 PM (7 hours and 10 min later). In an interview on [DATE] at 6:30 PM the RNC stated the facility only had one nurse on the COVID unit on [DATE] and Resident #1's assessment after her return from the hospital was not completed. Record review of Resident #1's EMR reflected that no progress notes were charted for Resident #1 from [DATE] to [DATE]. No documented temperature on 3 days: ,[DATE], ,[DATE], ,[DATE]. No documented BP for 4 days: ,[DATE], ,[DATE], ,[DATE], ,[DATE]. No pulse documented on 4 days: ,[DATE], ,[DATE], ,[DATE], ,[DATE]. No RR documented for 6 days: ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE]. No O2 sat documented for 4 days: ,[DATE], ,[DATE], ,[DATE], ,[DATE]. No skilled assessments were documented for 8 days: ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE]. Resident COVID positive on [DATE]. In an interview on [DATE] at 9:30 AM the facility NP stated the facility had gotten 20 more positive test for residents and were testing staff and had 12 positive staff. She stated both ADON RN's who were doing the q8hr assessments on the COVID residents tested positive and were sent home. She stated she was concerned about staffing on the unit. She was doing labs and the residents were dehydrated and she stated she wanted one staff just for hydrating the residents. The NP stated she was concerned that the nurse for 100 hall was also working on 200 hall (100 hall is the COVID) at night. Review of the facility census for [DATE] reflected 36 residents on the COVID unit. Review of the facility staffing for [DATE] reflected one (1) LVN on the COVID unit and no RN. In an interview on [DATE] at 5:15 PM the RNC (Reginal Nurse Consultant) stated that Resident's VS (vital sings) were on paper sheets. The RNC stated the VS for Resident #1 regarding the time period in question were not present. She stated her expectation of assessments were that they were to be done every time there was a change of condition. She stated that her expectation was that vital signs were done every shift. There are 3 eight-hour shifts. She stated that this has always been her expectation. In an interview on [DATE] at 5:27 PM the nurse on duty LVN A stated she was not the nurse on duty taking care of Resident #1 when she arrived back to the facility at 3:30 PM or was sent back out to the hospital at 10:40 PM. She stated she was in the facility at the time the patient needed to be sent to the hospital, but she was not the nurse on duty. LVN A stated she put the notes in the chart for the night nurse, which is why her name was in the chart. She stated she called the family, the nurse practitioner, charted, and did the paperwork for the resident to be sent out of the facility. LVN A stated she was the 6:00 AM-2:00 PM nurse for the resident. She stated during the 6:00 AM- 2:00 PM shift, the NP asked her if she had taken vitals yet on the resident on [DATE] and she stated that she did not have time to yet. The nurse practitioner took the O2 sat and it was at 84% at 11:05 AM. The nurse took the rest of the vital signs and the nurse practitioner after assessing Resident #1 sent her to the hospital. In an interview on [DATE] at 5:53 PM the 2:00 PM-10:00 PM shift nurse LVN B stated on [DATE] that she was the only nurse working that night. She stated that vital signs should be taken every shift and that assessments should be done before a resident gets sent out and when a resident comes back. Assessments should also be done when a resident is critical or is a priority. She stated that managed patients(Medicare/Medicaid) get assessments with vitals. She stated that in the case of Resident #1, she was not able to get a set of vitals because she had a lot going on. She stated that an aide came and told her around 10:00 PM that Resident #1 did not look good. LVN B stated she went in to look at Resident #1 and put her nasal cannula back on, but she was not able to obtain a O2 saturation level on the resident and that her pulse was 111 bpm and her BP was 115 over something she stated the resident was starting to appear cyanotic. A nonrebreather mask was placed on resident on 10Liters, and she called the nurse manager. She stated at that point Resident #1's pulse was 156. Nurse practitioner was called, and resident was sent to ER, where she was told the resident died . In an interview on [DATE] at 1:40 PM the RNC stated the facility's COVID response plan did not have standing orders for assessments and care of COVID positive residents to guide the staff on their care and agreed that the COVID positive residents were clinically unstable and required close monitoring. Review of the facility's policy Change in a Residents Condition dated [DATE] reflected Our facility shall promptly notify the resident, his or her attending Physician .of changes in the resident's medical/ mental condition .prior to notifying the physician the nurse will make observations and gather pertinent information for the physician including information prompted by change of condition. On [DATE] at 6:40 PM the VPO, Administrator and RNC were notified the facility had an IJ situation for the above failures. The facility's first Plan of Removal (POR) was submitted by the VPO on [DATE] at 8:20 PM. The final POR was accepted by the survey team on [DATE] at 2:00 PM. Accepted Plan of Removal: Plan of Removal On [DATE], a complaint survey was initiated at Brenham Nursing and Rehabilitation Center at 400 E Sayles Street, Brenham TX . On [DATE], the facility was notified by the surveyor that a jeopardy had been called and needed to submit a letter of credible allegation. The Facility respectfully submits this Letter of Credible Allegation pursuant to Federal and State regulatory requirements. Submission of the Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiencies. The alleged immediate jeopardy allegations are as follows: Issue: Facility failed to provide needed care or services resulting in an actual decline in resident's physical wellbeing. Resident #1 was discharged from the facility on [DATE] and admitted to the hospital on [DATE]. *Effective [DATE], the Registered Nurse will reassess COVID 19 positive and COVID19 negative residents to identify residents with a potential change in condition related to COVID 19. Reassessment will include blood pressure, pulse, temperature, respirations, oxygen saturations. Deviations based on MD/ NP parameters will reported to the MD/NP. This will be completed by [DATE]. *Effective [DATE], the Director of Nursing and/ or designee reeducated Licensed Nurses on the COVID-19 Assessment and Reporting Protocols related to the care, management and interventions for COVID 19 positive and COVID 19 negative residents. This will be completed by [DATE]. *Effective [DATE], the Director of Nursing and/ or designee reeducated all facility staff on COVID 19 Symptom Reduction Protocols. COVID 19 Symptom Reduction Protocols include signs and symptoms reported to manifest with COVID 19 and measures to improve circumstance in resident conditions. This will be completed by [DATE]. *Effective [DATE], the Director of Nursing and/ or designee will monitor compliance with vital signs, assessments and interventions through reconciliation of vital sign and assessment data/ documentation, as well as applicable interventions daily for seven days, then every other day for fourteen days, then three times weekly for three weeks and weekly for six weeks. *Effective [DATE], the Director of Nursing and/ or designee will monitor compliance with provision of needed care and services through rounding to observe for resident hydration, meal service and ADL care by observing facility and support staff provide care for five residents on each hall daily for seven days, then every other day for fourteen days, then three times weekly for three weeks and weekly for six weeks. On [DATE] an Quality Assurance Performance Improvement Meeting was held with the Administrator, Assistant Director of Nursing, Medical Director and two other persons present to discuss the above plan. The facility respectfully requests that the plan of removal be accepted, and immediate jeopardy be lifted. Monitoring for the Plan of Removal began on [DATE] at 2:00 PM. Staff were interviewed for understanding regarding the new procedure resident assessment, and assessment protocols for COVID positive residents. All staff interviewed had a good understanding of the training. The facility was monitored for adequate staffing. Resident charts were reviewed for assessments. On [DATE] at 2:45 PM the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility requiring time to train all staff and monitor their plan of removal.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of six (6) residents (Resident #6) reviewed for pain management with wound care. Treatment Nurse A did not address Resident #6's pain during wound care resulting in Resident #6 enduring painful wound treatments. This deficient practice placed 21 residents at risk for enduring painful wound care and unrelieved pain. Findings include: Review of Resident #6's Face Sheet reflected an [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly MDS assessment dated [DATE] reflected Resident #6 had a BIMS score of four (4) indicating he had severe cognitive impairment. Resident #6 was assessed to be totally dependent on staff for all ADL's and to have contractures of his bilateral lower extremities. Resident #6 was assessed to have pain occasionally that made it hard to sleep and limited daily activities. Resident #6 pain intensity rating was assessed to be a seven (7) out of 10. Resident #6 was assessed to have three (3) arterial ulcers. Review of Resident #6's Comprehensive Care Plan reflected a care plan dated 04/15/2014 which reflected "Arterial Ulcers: top of right foot, top of left foot and second toe right foot." Further review of Resident #6's Care Plan reflected a plan of care dated 05/30/2014 which reflected "is at risk for pain related to arterial wounds." Approaches included "evaluate pain daily using 1-10 scale; pain goal is three (3); assist to change positions slowly; Monitor for worsening of pain symptoms and report to physician; Monitor for effectiveness of pain medications." Review of Resident #6's Readmission Physician orders [REDACTED].#6's arterial ulcers on the top of his right, top of left foot and second toe right foot with wound cleanser, swab with [MEDICATION NAME], pat dry and cover with foam dressing. Further review of Resident #6's readmission Physician orders [REDACTED]. Review of Resident #6's Wound Care Physician's Progress note dated 05/16/2014 reflected that Resident #6 had chronic full thickness (A full-thickness wound extends into deeper tissues which may involve subcutaneous tissue, muscle, bone, or other supporting structures.) arterial ulcers to the top of his left foot, top of right foot and second toe right foot. The progress note further reflected that Resident #6 reported pain in wounds of level four (4). Review of Resident #6's Treatment Administration Record (TAR) for June 2014 reflected an entry "Treatment: any/ pain reported before treatment, 0= no 1= yes, if pain needs to be addressed." The TAR was initialed from 06/17/2014 through 06/30/2014 and a zero was documented indicating Resident #6 had no pain. Review of Resident #6's Medication Administration Record [REDACTED]. The entry was initialed on 06/17/2014, 06/19/2014, 06/24/2014, and 06/26/2014 indicating the medication was administered. On the back of the MAR indicated [REDACTED]. Observation on 07/01/2014 at 9:55 AM revealed Treatment Nurse A in Resident #6's room to provided wound care. Resident #6 was up in wheelchair. Resident #6 had emesis on the front of his shirt. In an interview on 07/01/2014 at 10:00 AM Treatment Nurse A stated she would notify Resident #6's Nurse LVN D regarding the emesis. In an interview on 07/01/2014 at 10:15 AM Treatment Nurse A stated Resident #6 was "ok" and she was going to do his wound care. Observation on 07/01/2014 at 10:16 AM revealed Treatment Nurse A and CNA J in Resident #6's room to provide wound care. Treatment Nurse A asked Resident #6 if he was in pain and Resident #6 stated "yes". Treatment Nurse A then asked Resident #6 to rate his pain. Resident #6 stated his pain was a 10. Treatment Nurse A then proceeded to remove his wound dressings from the top of his feet. Resident #6 was yelling "oh, oh" and moaning during the removal of his dressings. Resident #6 was pulling his legs toward his body and grabbing the sheets with his hands. CNA J was holding Resident # 6's legs still so Treatment Nurse A could perform the treatment. Treatment Nurse A stated that the dressing adhere to the wounds. Treatment Nurse A applied saline to the gauze to assist the removal of the dressings. Resident #6 had an arterial ulcer on the top of his left foot approximately 4 cm long by 2 cm wide and an ulcer on the top of right foot approximately 4 cm long by 3 cm wide. Resident #6's tendons and muscles were exposed. Treatment Nurse A cleansed the ulcer to Resident #6's left foot with [MEDICATION NAME] soaked gauze. Resident #6 stated "I don't think I will make it if you keep hurting me". Treatment Nurse A continued with Resident #6's wound treatment stating "I will be done in just a minute, almost done." Resident #6 continued to moan and yell out "oh, oh" throughout the cleansing and dressing of his arterial ulcer to his left and right foot. Treatment Nurse A exited room without addressing Resident #6's pain. Review of Resident #6's MAR for July 2014 reflected he had received a [MEDICATION NAME] 7.5 mg/ 325mg at 9:45 AM on 07/01/2014 for pain. 15 minutes prior to Resident #6 vomiting. In an interview on 07/01/2014 at 10:50 AM CNA I stated she worked with Resident #6 frequently. CNA I stated Resident #6 had a lot of pain when you turned him and provided care. CNA I further stated "even after they give him medication he has pain, not as bad but he still complains of pain." In an interview on 07/01/2014 at 11:27 AM Treatment Nurse A stated Resident #6 probably vomited his pain medication. Treatment Nurse A further stated "It would not have made a difference he is always in pain." Treatment Nurse A stated she assessed pain by monitoring vocalizations of pain, clinching of fist and calling out and if the Resident had pain she would stop treatment. When asked if Resident #6 was exhibiting all those signs of pain Treatment Nurse A stated "Yes, I should have stopped the wound treatment." Treatment Nurse A further stated hospice was called to check on Resident #6's pain medication order. In an interview on 07/01/2014 at 12:10 PM Hospice RN stated Resident #6 had a lot of pain in his wounds and needed something stronger for pain. The Hospice RN stated she was contacting Resident #6's Physician to get a new order. The Surveyor attempted to contact Resident # 6's Physician to obtain his/her expectations of pain management for the Resident. The Surveyor did not receive a phone contact back from the Physician. In an interview on 07/01/2014 at 12:15 PM LVN D stated she medicated Resident #6 at 9:45 AM "I felt like he was in pain because of facial expressions." LVN D further stated Resident #6 did not have an order to pre-medicate for pain prior to wound care but should have and the Hospice RN was contacting the Physician for an order. Review of Resident #6's Physician Telephone order dated 07/01/2014 at 12:35 PM reflected "[MEDICATION NAME] (A highly concentrated solution of [MEDICATION NAME]) 20 mg/ml 0.25 ml's by mouth one hour prior to wound care." Review of the Hospice Progress Notes for Resident # 6 dated 07/01/2014 the Resident was medicated with [MEDICATION NAME] at 12:35 PM on 07/01/2014. Observation of Resident # 6 on 07/01/2014 at 1:00 PM, Resident # 6 was sleeping, could not be awaken but did not show any signs or symptoms of pain. In an interview on 07/02/2014 at 11:15 AM the DON stated she expected the nursing staff to medicate residents prior to treatments and ensure the medication is effective. The DON stated if a resident exhibits signs of pain during treatment the nurse should stop the procedure. The DON stated Resident #6's pain should have been addressed "He hurts all the time." The DON further stated an in-service was conducted after she became of aware of situation with Resident #6. Review of the In-service training dated 07/01/2014 (no time indicated) reflected "Assessment of Pain and Administration of Pain medications: [REDACTED]. Pay close attention to both verbal and non-verbal indications of pain and refer to the appropriate pain scale to determine the level. Offer residents pain medication/ non-pharmacological interventions prior, during and after treatments as needed. If a resident refuses pain medications make sure you indicate it in your documentation. If at any time during care or treatments a resident complains of pain, stop treatment, and ask resident if they would like something for pain. Be sure you document interventions offered and accepted as well as any refusals. If medicated and ineffective, notify M.D. for alternate interventions." Review of the facility's policy Pain assessment dated ,[DATE] reflected "The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team ...4. Pain should be assessed and documented at regular intervals, as necessary and in accordance with pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is acceptable to the resident should occur ..." The facility provided a list of 21 residents that required wound care treatments.

Based on observation, interview, and record review the facility failed to provide services that meet professional standards of quality for one (1) of two (2) treatment LVNs reviewed for wound care, when: Treatment Nurse A did not address Resident #6's pain during wound care resulting in Resident #6 enduring painful wound treatments. This deficient practice placed 21 resident with wounds at risk for enduring painful wound treatments Finding Include: Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11 Standards of Nursing Practice (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; (G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices; (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; (O) Implement measures to prevent exposure to infectious pathogens and communicable conditions; (P) Collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care; (Q) Consult with, utilize, and make referrals to appropriate community agencies and health care resources to provide continuity of care; (U) Supervise nursing care provided by others for whom the nurse is professionally responsible; (2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and: (A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by: (i) collecting data and performing focused nursing assessments; (ii) participating in the planning of nursing care needs for clients; (iii) participating in the development and modification of the comprehensive nursing care plan for assigned clients; (iv) implementing appropriate aspects of care within the LVN's scope of practice; and (v) assisting in the evaluation of the client's responses to nursing interventions and the identification of client needs; (B) Shall assign specific tasks, activities and functions to unlicensed personnel commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made and shall maintain appropriate supervision of unlicensed personnel. (C) May perform other acts that require education and training as prescribed by board rules and policies, commensurate with the licensed vocational nurse's experience, continuing education, and demonstrated licensed vocational nurse competencies. Review of Resident #6's Face Sheet reflected an [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly MDS assessment dated [DATE] reflected Resident #6 had a BIMS score of four (4) indicating he had severe cognitive impairment. Resident #6 was assessed to be totally dependent on staff for all ADL's and to have contractures of his bilateral lower extremities. Resident #6 was assessed to have pain occasionally that made it hard to sleep and limited daily activities. Resident #6 pain intensity rating was assessed to be a seven (7) out of 10. Resident #6 was assessed to have three (3) arterial ulcers. Review of Resident #6's Comprehensive Care Plan reflected a care plan dated 04/15/2014 which reflected "Arterial Ulcers: top of right foot, top of left foot and second toe right foot." Further review of Resident #6's Care Plan reflected a plan of care dated 05/30/2014 which reflected "is at risk for pain related to arterial wounds." Approaches included "evaluate pain daily using 1-10 scale; pain goal is three (3); assist to change positions slowly; Monitor for worsening of pain symptoms and report to physician; Monitor for effectiveness of pain medications." Review of Resident #6's Readmission Physician orders [REDACTED].#6's arterial ulcers on the top of his right, top of left foot and second toe right foot with wound cleanser, swab with [MEDICATION NAME], pat dry and cover with foam dressing. Further review of Resident #6's readmission Physician orders [REDACTED]. Review of Resident #6's Wound Care Physician's Progress note dated 05/16/2014 reflected that Resident #6 had chronic full thickness (A full-thickness wound extends into deeper tissues which may involve subcutaneous tissue, muscle, bone, or other supporting structures.) arterial ulcers to the top of his left foot, top of right foot and second toe right foot. The progress note further reflected that Resident #6 reported pain in wounds of level four (4). Review of Resident #6's Treatment Administration Record (TAR) for June 2014 reflected an entry "Treatment: any/ pain reported before treatment, 0= no 1= yes, if pain needs to be addressed." The TAR was initialed from 06/17/2014 through 06/30/2014 and a zero was documented indicating Resident #6 had no pain. Review of Resident #6's Medication Administration Record [REDACTED]. The entry was initialed on 06/17/2014, 06/19/2014, 06/24/2014, and 06/26/2014 indicating the medication was administered. On the back of the MAR indicated [REDACTED]. Observation on 07/01/2014 at 9:55 AM revealed Treatment Nurse A in Resident #6's room to provided wound care. Resident #6 was up in wheelchair. Resident #6 had emesis on the front of his shirt. In an interview on 07/01/2014 at 10:00 AM Treatment Nurse A stated she would notify Resident #6's Nurse LVN D regarding the emesis. In an interview on 07/01/2014 at 10:15 AM Treatment Nurse A stated Resident #6 was "ok" and she was going to do his wound care. Observation on 07/01/2014 at 10:16 AM revealed Treatment Nurse A and CNA J in Resident #6's room to provide wound care. Treatment Nurse A asked Resident #6 if he was in pain and Resident #6 stated "yes" . Treatment Nurse A then asked Resident #6 to rate his pain. Resident #6 stated his pain was a 10. Treatment Nurse A then proceeded to remove his wound dressings from the top of his feet. Resident #6 was yelling "oh, oh" and moaning during the removal of his dressings. Resident #6 was pulling his legs toward his body and grabbing the sheets with his hands. CNA J was holding Resident # 6's legs still so Treatment Nurse A could perform the treatment. Treatment Nurse A stated that the dressing adhere to the wounds. Treatment Nurse A applied saline to the gauze to assist the removal of the dressings. Resident #6 had an arterial ulcer on the top of his left foot approximately 4 cm long by 2 cm wide and an ulcer on the top of right foot approximately 4 cm long by 3 cm wide. Resident #6's tendons and muscles were exposed. Treatment Nurse A cleansed the ulcer to Resident #6's left foot with [MEDICATION NAME] soaked gauze. Resident #6 stated "I don't think I will make it if you keep hurting me". Treatment Nurse A continued with Resident #6's wound treatment stating "I will be done in just a minute, almost done." Resident #6 continued to moan and yell out "oh, oh" throughout the cleansing and dressing of his arterial ulcer to his left and right foot. Treatment Nurse A exited room without addressing Resident #6's pain. Review of Resident #6's MAR for July 2014 reflected he had received a [MEDICATION NAME] 7.5 mg/ 325mg at 9:45 AM on 07/01/2014 for pain. 15 minutes prior to Resident #6 vomiting. In an interview on 07/01/2014 at 10:50 AM CNA I stated she worked with Resident #6 frequently. CNA I stated Resident #6 had a lot of pain when you turned him and provided care. CNA I further stated "even after they give him medication he has pain, not as bad but he still complains of pain." In an interview on 07/01/2014 at 11:27 AM Treatment Nurse A stated Resident #6 probably vomited his pain medication. Treatment Nurse A further stated "It would not have made a difference he is always in pain." Treatment Nurse A stated she assessed pain by monitoring vocalizations of pain, clinching of fist and calling out and if the Resident had pain she would stop treatment. When asked if Resident #6 was exhibiting all those signs of pain Treatment Nurse A stated "Yes, I should have stopped the wound treatment." Treatment Nurse A further stated hospice was called to check on Resident #6's pain medication order. In an interview on 07/01/2014 at 12:10 PM Hospice RN stated Resident #6 had a lot of pain in his wounds and needed something stronger for pain. The Hospice RN stated she was contacting Resident #6's Physician to get a new order. The Surveyor attempted to contact Resident # 6's Physician to obtain his/her expectations of pain management for the Resident. The Surveyor did nto receive a phone contact back from the Physician. In an interview on 07/01/2014 at 12:15 PM LVN D stated she medicated Resident #6 at 9:45 AM "I felt like he was in pain because of facial expressions." LVN D further stated Resident #6 did not have an order to pre-medicate for pain prior to wound care but should have and the Hospice RN was contacting the Physician for an order. Review of Resident #6's Physician Telephone order dated 07/01/2014 at 12:35 PM reflected "[MEDICATION NAME] (A highly concentrated solution of [MEDICATION NAME]) 20 mg/ml 0.25 ml's by mouth one hour prior to wound care." Review of the Hospice Progress Notes for Resident # 6 dated 07/01/2014 the Resident was medicated with [MEDICATION NAME] at 12:35 PM on 07/01/2014. Observation of Resident # 6 on 07/01/2014 at 1:00 PM, Resident # 6 was sleeping, could not be awaken but did not show any signs or symptoms of pain. In an interview on 07/02/2014 at 11:15 AM the DON stated she expected the nursing staff to medicate residents prior to treatments and ensure the medication is effective. The DON stated if a resident exhibits signs of pain during treatment the nurse should stop the procedure. The DON stated Resident #6's pain should have been addressed "He hurts all the time." The DON further stated an in-service was conducted after she became of aware of situation with Resident #6. Review of the In-service training dated 07/01/2014 (no time indicated) reflected "Assessment of Pain and Administration of Pain medications: [REDACTED]. Pay close attention to both verbal and non-verbal indications of pain and refer to the appropriate pain scale to determine the level. Offer residents pain medication/ non-pharmacological interventions prior, during and after treatments as needed. If a resident refuses pain medications make sure you indicate it in your documentation. If at any time during care or treatments a resident complains of pain, stop treatment, and ask resident if they would like something for pain. Be sure you document interventions offered and accepted as well as any refusals. If medicated and ineffective, notify M.D for alternate interventions." Review of the facility's policy Pain assessment dated ,[DATE] reflected "The purpose of this procedure is to assess the resident ' s pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team ...4. Pain should be assessed and documented at regular intervals, as necessary and in accordance with pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is acceptable to the resident should occur ..." The facility provided a list of 21 residents that required wound care treatments.

Based on observation, interview and record review the facility failed to implement policies and procedures to prevent neglect for one (1) of 12 residents (Resident # 4) reviewed for abuse/neglect when they failed to thoroughly investigate an injury of unknown origin, provide medical treatment and report the incident to the State survey and certification agency for further investigation. Resident # 4 had continuous and extensive bruising to multiple parts of her body including her back, breasts, underneath her arms extending to the elbow area and the side of her left foot. Resident # 4 had swelling to her left elbow and left ankle. The facility failed to conduct a thorough investigation, report the incident to the State survey and certification agency and report their findings accurately to the administrator and the State survey and certification agency. This deficient practice resulted in an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 04/24/2013. While the IJ was removed on 04/26/2013 the facility remained out of compliance at a level of Actual Harm of Isolated. This deficient practice affected Resident # 4 and placed an additional 45 cognitively impaired residents who require assistance with bed mobility, transfers or incontinent care at risk for injury. Findings Include: Review of Resident #4 Face Sheet reflected a [AGE] year old female who was admitted to the facility on [DATE] . Resident # 4's [DIAGNOSES REDACTED]. Review of Resident # 4's Significant Change Minimum Data Set (MDS) assessment dated [DATE] reflected the resident was severely cognitively impaired, totally dependent on staff for all activities of daily living and required extensive assistance for bed mobility. The assessment reflected transfer activity did not occur. Resident # 4 was incontinent of bowel and bladder. Review of Resident # 4's Comprehensive Care Plan dated 01/10/2013 reflected the Resident required extensive assistance of one person with bed mobility and refused to get out of bed. The Care Plan reflected Resident #4 needed total care of one staff member to assist with incontinent care, dressing and hygiene. The Care Plan reflected Resident #4 is " at risk for fx ' s " (fractures) related to a [DIAGNOSES REDACTED]. Observation on 04/22/2013 at 3:17 PM revealed Resident #4 had significant bruising (Increased distress to tissue causing capillaries to break under the skin, allowing blood to escape and build up. As time progresses, blood seeps into the surrounding tissues, causing the bruise to darken and spread) to her back (upper [MEDICATION NAME] area) . The bruising was dark purple/black in color with a faint yellowish greenish tint around the edges. The bruising was continuous and extended from Resident # 4's breasts and bilateral armpits to below her bilateral rib cages and wrapped around her posterior [MEDICATION NAME] area extending to approximately four inches from her spine. Resident # 4's left elbow was swollen with extensive bruising. The side of Resident # 4's left foot had an approximate 6 inch long by 2 inch wide bruise that extended from her ankle down to her toes. Resident # 4's ankle was swollen with two plus [MEDICAL CONDITION]. (measurement estimated by Registered Nurse (RN) Surveyor) Review of Resident # 4's Physician Orders reflected the resident received Vitamin C 500 milligrams (mg) twice per day for 30 days beginning 03/25/2013, Multivitamins with minerals one tablet per day and Med Pass 2.0 60 cubic centimeter (cc) four times per day for 30 days beginning 03/25/2013. There was no physician order for [REDACTED]. In an interview on 04/23/2013 at 8:00 AM Resident # 4 could only answer simple questions. When asked if she could recall sustaining an injury, Resident # 4 replied "no". When asked if she had fallen, Resident # 4 replied "no". When asked if she was in pain, Resident # 4 replied "no". In an interview on 04/22/2013 at 6:08 PM the Director of Nursing (DON) stated he was made aware of the bruising by the charge nurse on duty 04/12/2013. The DON stated an incident/accident report was completed. The DON stated he remembered seeing the bruising on Resident # 4 on 04/12/2013 but was not sure how the bruising occurred. The DON stated he suspected blood thinners or some hematological disorder (a disorder that primarily affects the blood) and he had requested the Nurse Practitioner (NP) to order a CBC (complete blood count) laboratory test. Review of the CBC laboratory report for Resident # 4 dated 04/16/2013 (delivered on 04/16/2013 date at 3:27 PM) reflected the resident's hemoglobin count was low at 10.6. The range for a normal hemoglobin count was referenced at 12.0 - 15.6. grams per deciliter (g/dl). There was no medical intervention after receipt of this lab report until 04/22/2013, after the survey team observed the bruising). In an interview on 04/22/2013 at 4:27 PM the Nurse Practitioner (NP) stated she did not know why x-rays were not ordered when the bruising and swelling was identified however she now felt it was a good idea and ordered x-rays to bilateral ribs, left arm to include the elbow and left foot and ankle on 04/22/2013. Review of Resident # 4's x-ray results dated 04/22/2013 reflected there was no fracture to the Resident's arms, ribs or left foot/ankle. Review of the Incident/Accident Report dated 04/12/2013 reflected at 3:30 PM Licensed Vocational Nurse (LVN) B was called to Resident # 4's room after Certified Nurse Aides (CNA) Q & R had showered the Resident. LVN B reported there was "sporadic bruising up and down her lateral sides which was not visible yesterday." The report listed one aide (CNA Q) as witness. The investigation report reflected Resident # 4's [DIAGNOSES REDACTED]. The investigation report further reflected Resident # 4 was placed on the "turtle" program (a program designed by the facility to ensure staff used caution when caring for the resident). The outcome of the investigation reflected there as diffuse (to become widely disbursed; spread out) discoloration to LUE (left upper extremity), bilateral postural [MEDICATION NAME] region. Physician was notified. Resident's room evaluated for possible cause. Labs (CBC) ordered to rule out possible cause. The final outcome of the investigation reflected "areas were showing positive signs of healing. The physician's representative is aware and evaluated briefly on rounds. Will continue to monitor for signs and symptoms of healing." There was one witness statement attached to the report from CNA Q who stated "When getting Resident # 4 up for a shower I noticed multiple bruises under her arms and down the sides of her back and breasts. I notified the nurse." There was lab results for Resident # 4 attached to the investigation report that reflected the resident was slightly anemic. There was no additional witness statements obtained, no interviews with other staff members that had cared for Resident # 4 prior to the findings and no resident interviews to indicate residents had been questioned to ensure safety from potential abuse and/or neglect. The report indicated abuse and/or neglect was not suspected. In an interview on 04/23/2013 at 2:15 PM Resident # 4's NP stated she was notified of the Resident's bruising while in the building making rounds on 04/15/2013. The NP stated she examined Resident # 4 and there was distinct generalized bruising to the left side and left elbow. The NP stated she did not have staff roll Resident # 4 onto her other side to examine the bruising on the right side of the Resident's body. The NP stated she thought the bruising was from [MEDICATION NAME] trauma and could have been caused by a Hoyer lift and was "really disturbed about how the DON blew me off." The NP stated she had requested the DON to look at the bruising with her and "he didn't do it." The NP stated the bruising lends itself from the Resident pulling back from staff, or it could have been self-induced, however she had advised the DON to investigate the incident and to talk to aides that had cared for Resident # 4 in the 48 hours prior to the bruising being identified. In an interview on 04/22/2013 at 7:00 PM the DON stated, after he received the lab work back that indicated the bruising was not caused by a hematological condition, the only thing he could think of that caused bruising of that sort on a Resident could have been a Hoyer lift. When asked why he did not document a Hoyer lift as the potential cause of Resident # 4's bruising the DON stated "my bad." The DON stated he had not in-serviced staff relating to proper Hoyer lift transfers, or transfers of any type, after the incident with Resident # 4. The DON stated he had not reported this injury of unknown source to the State survey and certification agency for further investigation. Review of the facility staff in-service records for April, 2013 reflected no transfer technique in-service was provided to staff after Resident # 4's incident. In an interview on 04/23/13 at 300 PM LVN B stated she had completed the incident report for Resident # 4's bruising on 04/12/2013 . LVN B stated she was called to Resident # 4's room by two aides to assess bruising found on the Resident. Resident # 4 was still in her shower chair and her hair was wet. LVN B stated there was no Hoyer lift in Resident # 4's room and there was no sling underneath the resident that indicated a Hoyer lift was not used during the transfer of Resident # 4 to or from the shower chair. LVN B stated she was stunned when she observed the bruising on Resident # 4 and notified the DON immediately. In an interview on 04/24/2013 at 2:30 PM CNA Q stated she was one of the nurse aides that gave Resident # 4 a shower on 04/12/2013 and noticed the bruising. CNA Q stated she and CNA R transferred Resident # 4 from the bed to the shower chair using a "cradle" lifting method. CNA Q stated she had cradled Resident # 4 with one arm under the Resident's arm and around her back and the other arm under her leg. CNA Q stated CNA R did the same thing on the other side of Resident # 4. CNA Q stated Resident # 4 was still clothed with a hospital gown when transferring her out of the bed but while in the shower room and disrobed, the bruises were evident on Resident # 4's back, underarms, breasts and elbows. CNA Q stated Resident # 4's shower was completed and she was brought back to her room using the shower chair and LVN B was notified immediately when the Resident was back in her room. CNA Q stated she was upset because before she came to visit with the survey team, DON # 1 had talked with her and requested she advise the survey team she and CNA R had used a Hoyer lift to transfer Resident # 4 when they had not. CNA Q stated DON #1 had asked her to tell the survey team they used the Hoyer lift and needed to be in-serviced in transferring Residents using a Hoyer lift. In a telephone interview on 04/24/2013 at 2:50 PM CNA R stated DON # 1 had been trying to reach her by phone but she had not returned his phone calls. CNA R stated she is no longer employed by the facility. CNA R stated a Hoyer lift was not used to transfer Resident # 4 from her bed to the shower chair or back to her bed on the date of the incident, 04/12/2013. CNA R stated while showering Resident # 4 bruises were noticed on the Resident's back, underarms and breasts. CNA R stated the bruising was already black and appeared to be at least one day old. In an interview on 04/24/2013 at 9:55 AM Resident # 4's Primary Care Physician (PCP) stated he had learned of the Resident's bruising the day before on 04/23/2013. The PCP reviewed pictures of the Resident's bruising and stated "that poor lady." The PCP stated looking at the pictures, logically you would look into abuse and/or neglect, potentially picking the Resident up and dropping her. The PCP stated people get bruised all the time without a fracture. The PCP stated Resident # 4 had lost a lot of blood and he had never seen this before. The PCP stated it could have been caused by some sort of improper lifting but it would have had to have been vigorous. The PCP stated he would expect the facility to investigate this bruising thoroughly and report it to the State survey and certification agency for further investigation. In an interview on 04/24/2013 at 10:20 AM the Medical Director stated he was made aware of Resident # 4's bruising on 04/22/2013 when the NP had discussed the issue with him. The Medical Director looked at Resident # 4's photos and stated the bruising was older because you could see orangish, greenish and yellowish colors on the sides of the bruising. The Medical Director stated the [MEDICAL CONDITION] was from trauma and that bruising could cause swelling, it's "asymptomatic of trauma." The Medical Director stated he would have expected the facility to thoroughly investigate this situation not only for Resident # 4 but for future potential bruising and trauma. The Medical Director stated this incident should have definitely been reported to the State survey and recertification agency and he felt it was a bad situation that the facility did not report it for further investigation. In an interview on 04/24/2013 at 11:00 AM the Administrator # 1 stated he had been advised by DON # 1 that Resident # 4 had sustained extensive bruising. The Administrator # 1 stated DON # 1 had first advised him the bruising was probably caused by some hematological disorder then later stated it could have been caused by a Hoyer lift. The Administrator #1 could not remember the date DON # 1 had advised him it was not from a hematological cause but potentially from a Hoyer lift. The Administrator stated an in-serviced should have been performed regarding improper lifting methods and felt it was a communication breakdown and it "got by us." Administrator # 1 stated it was his expectation when staff discover an injury of unknown origin, that the incident be thoroughly investigated to rule out abuse or neglect, to interview staff and residents and determine the cause, if possible. Administrator # 1 stated if a cause could not be determined the incident should be reported to the State certification and survey agency for investigation. Review of the facility policy regarding Accident and Incidents - Investigating and Reporting, undated, reflected: All accidents or incidents involving residents, employees, visitors, vendors, etc. occurring on our premises should be investigated and reported to the Administrator. 1. Reporting of Accidents/Incidents d. An Accident or Incident Report Form should be completed for all reported accidents or incidents, including visitors and vendors. Obtain handwritten statements from witnesses to the incident. Interview all those with knowledge to the incident. e. We will follow the Guidelines of Reporting Incidents as outlined in Provider Letter #06-43 (Texas Department of Aging and Disability Services) if there is a suspicion of: Serious Accidental Injuries Serious or Suspicious Injuries of Unknown So0urce Conditions That Pose a Threat to Resident Health and Safety Review of the facility policy regarding Abuse/Neglect dated 01/13 reflected : Procedure: The facility abuse prohibition policy includes but is not limited to the following components:....identifying events which may indicate abuse, investigation protocols.... Component V: Investigation Although Component V did not address injuries of unknown origin the following apply: The facility Nurse Manager will, to the extent warranted and necessary, obtain written statements from all parties involved in the incident, any witnesses to the incident and any family members who may add pertinent information to the investigation. The facility Social Services and/or Activity Departments will conduct resident interviews regarding Staff treatment of [REDACTED]. All written statements, incident reports and investigative information will be turned into the Administrator or Designee for summation and final disposition. Component VII: Reporting/Response Did not address injuries of unknown origin. On 04/24/2013 at 7:04 PM, the Administrator # 1 and DON # 1 was notified that an IJ was identified due to the above deficient practices. The following final Plan of Removal was submitted by the Administrator # 1 on 04/25/2013 at 11:20 AM. The final Plan of Removal was accepted by the Survey Team on 04/25/2013 at 11:26 AM and reflected the following: Please accept this as a plan of removal and remedy of Immediate Jeopardy in relation to failure to thoroughly investigate and report and incident to TDADS as per regulations. Issues #1 Failure failed to conduct a thorough investigation and report the incident to TDADS. Interventions to Issue # 1: Investigation and Report 1. Facility re-opened investigation. 2. Incident reported to TDADS. Issue # 2 Facility failed to conduct interviews with all staff to determine the cause of the resident's injury. Interventions to Issue # 2 - Investigation/Statements 1. Initiated interviews with all direct care staff to determine knowledge or witness of injury to resident to cause bruising to Resident # 4. 2. Audit of clinical record to determine information regarding injury. 3. Reviewed all resident's transfer status. 4. Inspection of Hoyer lift for defects and pattern match of injuries sustained. 5. All transfer equipment inspected for proper functioning. Issue # 3 Facility failed to implement policy and procedure regarding incident and accident investigation and reporting. Interventions to Issue # 3 - Implement Policy and Procedures 1. In-service Administrator and DON on thoroughly investigating and reporting all abuse, neglect and other reportable incidents, including injuries of unknown origin according to facility policy and procedure and federal and state regulation. This will be completed by the Vice President of Operations (VPO) on 04/24/2013. 2. Interdisciplinary team (Assessment Nurse, Social Services, Dietary Services, Activities Director, Administrator, DON and therapy) will review all incident and accident reports in the morning meeting to verify that investigative and reporting guidelines have been met to include witness statements. Staff will be trained on state regulatory self-report guidelines for abuse, neglect and injuries of unknown origin. This will be completed by QA Nurse Consultant with current staff by 04/25/2013. 3. Facility Abuse Coordinator is the Administrator, (Administrator #1) (effective 04/25/2013, Administrator #2 is Administrator of record). All facility staff will be in-serviced on who the abuse coordinator is and their responsibility to report any and all allegations of potential abuse. In-service all facility staff on the proper procedure for reporting, any observed incidents/accidents and on the facility's abuse prohibition policy and procedure. In-service will be conducted by Administrator. In-service will include reassurance that all staff can report any allegation without fear of retaliation and will be completed with the current staff by 04/25/2013 with the exception of those unavailable and they will be in-serviced prior to being allowed to work. Issue # 4 Facility failed to adequately train nurse aide staff on proper procedures to follow when performing resident care to ensure resident safety including all acceptable transfer techniques. Interventions for Issue # 4 - Staff Training 1. In-service nurse aides on proper procedure to follow when performing resident positioning and transfers to ensure resident safety. This will be completed with current staff by 04/25/2013. Anyone not in-serviced by the completion date will be in-serviced prior to returning to work. 2. Transfer skills will be performed by nurse managers with staff before they are allowed to work, to verify that direct care staff are proficient with resident safety. this will begin 04/24/2013 with completion on or before 04/30/2013. Skills will be performed during new hire orientation before employee assumes job duties. Issue # 5 Facility failed to provide services that meet professional standards and administration. Interventions for Issue # 5 - Professional Standards 1. Management staff will be in-serviced on Provider Letter # 06-43 and Company Policy and Procedure regarding conducting proper investigations. 2. Management staff will review all incident and accident reports in the daily in start-up and 3:00 PM stand-down meetings and any incident and accident investigations not completed by the end of the day one will be carried to the following mornings start up for continued review. Incidents and accidents will be reviewed to determine if they meet the criteria for reporting. 3. Management staff will review all incidents and accidents for the past 60 days to verify there are no further incidents that meet the criteria for reporting, and that a complete investigation was conducted. Findings will be reported to the facility QA Committee. Appropriate action will be taken as indicated. To be completed by 04/26/2013. 4. Medical Director has been notified of the Immediate Jeopardy. 5. Social Worker to interview cognitive residents concerning care provided by the facility. Initial interviews completed by 04/26/2013 and ongoing. 6. All monitoring steps included in the plan of removal will be kept in a binder for TDADS review in the Administrator's office. Monitoring of the Plan of Removal was conducted by the Survey Team between 04/25/2013 and 04/26/2013. Resident # 4's Incident Investigation was re-opened by the Corporate Staff and was called to the State certification and survey agency. In-services had begun with approximately 75 percent of the staff trained. Transfer assistance was observed to be appropriate according to the facility Plan of Removal. The Administrator # 2 was notified on 04/26/2013 at 5:40 PM that the IJ was removed, however, the facility remains out of compliance at a Severity level of Harm at a Scope of Isolated that is not IJ due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility provided a list of 46 residents who were cognitively impaired and required assistance with bed mobility, transfers or incontinent care.

Based on observation, interview and record review the facility failed to ensure all alleged violations involving mistreatment, neglect, abuse or injuries of an unknown source was reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency and that all alleged violations were thoroughly investigated to prevent further potential for abuse for one of 12 residents (Resident # 4) reviewed for abuse/neglect. Resident # 4 had continuous and extensive bruising to multiple parts of her body including her back, breasts, underneath her arms extending to the elbow area and the side of her left foot. Resident # 4 had swelling to her left elbow and left ankle. The facility failed to conduct a thorough investigation, report the incident to the State survey and certification agency and report their findings accurately to the administrator and the State survey and certification agency. This deficient practice resulted in an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 04/24/2013. While the IJ was removed on 04/26/2013 the facility remained out of compliance at a level of Actual Harm of Isolated. These deficient practice affected Resident # 4 and placed an additional 45 cognitively impaired residents who require assistance with bed mobility, transfers or incontinent care at risk for injury. Findings Include: Review of Resident #4 Face Sheet reflected a [AGE] year old female who was admitted to the facility on [DATE] . Resident # 4's [DIAGNOSES REDACTED]. Review of Resident # 4's Significant Change Minimum Data Set (MDS) assessment dated [DATE] reflected the resident was severely cognitively impaired, totally dependent on staff for all activities of daily living and required extensive assistance for bed mobility. The assessment reflected transfer activity did not occur. Resident # 4 was incontinent of bowel and bladder. Review of Resident # 4's Comprehensive Care Plan dated 01/10/2013 reflected the Resident required extensive assistance of one person with bed mobility and refused to get out of bed. The Care Plan reflected Resident #4 needed total care of one staff member to assist with incontinent care, dressing and hygiene. The Care Plan reflected Resident #4 is " at risk for fx ' s " (fractures) related to a [DIAGNOSES REDACTED]. Observation on 04/22/2013 at 3:17 PM revealed Resident #4 had significant bruising (Increased distress to tissue causing capillaries to break under the skin, allowing blood to escape and build up. As time progresses, blood seeps into the surrounding tissues, causing the bruise to darken and spread) to her back (upper [MEDICATION NAME] area) . The bruising was dark purple/black in color with a faint yellowish greenish tint around the edges. The bruising was continuous and extended from Resident # 4's breasts and bilateral armpits to below her bilateral rib cages and wrapped around her posterior [MEDICATION NAME] area extending to approximately four inches from her spine. Resident # 4's left elbow was swollen with extensive bruising. The side of Resident # 4's left foot had an approximate 6 inch long by 2 inch wide bruise that extended from her ankle down to her toes. Resident # 4's ankle was swollen with two plus [MEDICAL CONDITION]. (measurement estimated by Registered Nurse (RN) Surveyor) Review of Resident # 4's Physician Orders reflected the resident received Vitamin C 500 milligrams (mg) twice per day for 30 days beginning 03/25/2013, Multivitamins with minerals one tablet per day and Med Pass 2.0 60 cubic centimeter (cc) four times per day for 30 days beginning 03/25/2013. There was no physician order for [REDACTED]. In an interview on 04/23/2013 at 8:00 AM Resident # 4 could only answer simple questions. When asked if she could recall sustaining an injury, Resident # 4 replied "no". When asked if she had fallen, Resident # 4 replied "no". When asked if she was in pain, Resident # 4 replied "no". In an interview on 04/22/2013 at 6:08 PM the Director of Nursing (DON) stated he was made aware of the bruising by the charge nurse on duty 04/12/2013. The DON stated an incident/accident report was completed. The DON stated he remembered seeing the bruising on Resident # 4 on 04/12/2013 but was not sure how the bruising occurred. The DON stated he suspected blood thinners or some hematological disorder (a disorder that primarily affects the blood) and he had requested the Nurse Practitioner (NP) to order a CBC (complete blood count) laboratory test. Review of the CBC laboratory report for Resident # 4 dated 04/16/2013 (delivered on 04/16/2013 date at 3:27 PM) reflected the resident's hemoglobin count was low at 10.6. The range for a normal hemoglobin count was referenced at 12.0 - 15.6. grams per deciliter (g/dl). There was no medical intervention after receipt of this lab report until 04/22/2013, after the survey team observed the bruising). In an interview on 04/22/2013 at 4:27 PM the Nurse Practitioner (NP) stated she did not know why x-rays were not ordered when the bruising and swelling was identified however she now felt it was a good idea and ordered x-rays to bilateral ribs, left arm to include the elbow and left foot and ankle on 04/22/2013. Review of Resident # 4's x-ray results dated 04/22/2013 reflected there was no fracture to the Resident's arms, ribs or left foot/ankle. Review of the Incident/Accident Report dated 04/12/2013 reflected at 3:30 PM Licensed Vocational Nurse (LVN) B was called to Resident # 4's room after Certified Nurse Aides (CNA) Q & R had showered the Resident. LVN B reported there was "sporadic bruising up and down her lateral sides which was not visible yesterday." The report listed one aide (CNA Q) as witness. The investigation report reflected Resident # 4's [DIAGNOSES REDACTED]. The investigation report further reflected Resident # 4 was placed on the "turtle" program (a program designed by the facility to ensure staff used caution when caring for the resident). The outcome of the investigation reflected there as diffuse (to become widely disbursed; spread out) discoloration to LUE (left upper extremity), bilateral postural [MEDICATION NAME] region. Physician was notified. Resident's room evaluated for possible cause. Labs (CBC) ordered to rule out possible cause. The final outcome of the investigation reflected "areas were showing positive signs of healing. The physician's representative is aware and evaluated briefly on rounds. Will continue to monitor for signs and symptoms of healing." There was one witness statement attached to the report from CNA Q who stated "When getting Resident # 4 up for a shower I noticed multiple bruises under her arms and down the sides of her back and breasts. I notified the nurse." There was lab results for Resident # 4 attached to the investigation report that reflected the resident was slightly anemic. There was no additional witness statements obtained, no interviews with other staff members that had cared for Resident # 4 prior to the findings and no resident interviews to indicate residents had been questioned to ensure safety from potential abuse and/or neglect. The report indicated abuse and/or neglect was not suspected. In an interview on 04/23/2013 at 2:15 PM Resident # 4's NP stated she was notified of the Resident's bruising while in the building making rounds on 04/15/2013. The NP stated she examined Resident # 4 and there was distinct generalized bruising to the left side and left elbow. The NP stated she did not have staff roll Resident # 4 onto her other side to examine the bruising on the right side of the Resident's body. The NP stated she thought the bruising was from [MEDICATION NAME] trauma and could have been caused by a Hoyer lift and was "really disturbed about how the DON blew me off." The NP stated she had requested the DON to look at the bruising with her and "he didn't do it." The NP stated the bruising lends itself from the Resident pulling back from staff, or it could have been self-induced, however she had advised the DON to investigate the incident and to talk to aides that had cared for Resident # 4 in the 48 hours prior to the bruising being identified. In an interview on 04/22/2013 at 7:00 PM the DON stated, after he received the lab work back that indicated the bruising was not caused by a hematological condition, the only thing he could think of that caused bruising of that sort on a Resident could have been a Hoyer lift. When asked why he did not document a Hoyer lift as the potential cause of Resident # 4's bruising the DON stated "my bad." The DON stated he had not in-serviced staff relating to proper Hoyer lift transfers, or transfers of any type, after the incident with Resident # 4. The DON stated he had not reported this injury of unknown source to the State survey and certification agency for further investigation. Review of the facility staff in-service records for April, 2013 reflected no transfer technique in-service was provided to staff after Resident # 4's incident. In an interview on 04/23/13 at 300 PM LVN B stated she had completed the incident report for Resident # 4's bruising on 04/12/2013 . LVN B stated she was called to Resident # 4's room by two aides to assess bruising found on the Resident. Resident # 4 was still in her shower chair and her hair was wet. LVN B stated there was no Hoyer lift in Resident # 4's room and there was no sling underneath the resident that indicated a Hoyer lift was not used during the transfer of Resident # 4 to or from the shower chair. LVN B stated she was stunned when she observed the bruising on Resident # 4 and notified the DON immediately. In an interview on 04/24/2013 at 2:30 PM CNA Q stated she was one of the nurse aides that gave Resident # 4 a shower on 04/12/2013 and noticed the bruising. CNA Q stated she and CNA R transferred Resident # 4 from the bed to the shower chair using a "cradle" lifting method. CNA Q stated she had cradled Resident # 4 with one arm under the Resident's arm and around her back and the other arm under her leg. CNA Q stated CNA R did the same thing on the other side of Resident # 4. CNA Q stated Resident # 4 was still clothed with a hospital gown when transferring her out of the bed but while in the shower room and disrobed, the bruises were evident on Resident # 4's back, underarms, breasts and elbows. CNA Q stated Resident # 4's shower was completed and she was brought back to her room using the shower chair and LVN B was notified immediately when the Resident was back in her room. CNA Q stated she was upset because before she came to visit with the survey team, DON # 1 had talked with her and requested she advise the survey team she and CNA R had used a Hoyer lift to transfer Resident # 4 when they had not. CNA Q stated DON #1 had asked her to tell the survey team they used the Hoyer lift and needed to be in-serviced in transferring Residents using a Hoyer lift. In a telephone interview on 04/24/2013 at 2:50 PM CNA R stated DON # 1 had been trying to reach her by phone but she had not returned his phone calls. CNA R stated she is no longer employed by the facility. CNA R stated a Hoyer lift was not used to transfer Resident # 4 from her bed to the shower chair or back to her bed on the date of the incident, 04/12/2013. CNA R stated while showering Resident # 4 bruises were noticed on the Resident's back, underarms and breasts. CNA R stated the bruising was already black and appeared to be at least one day old. In an interview on 04/24/2013 at 9:55 AM Resident # 4's Primary Care Physician (PCP) stated he had learned of the Resident's bruising the day before on 04/23/2013. The PCP reviewed pictures of the Resident's bruising and stated "that poor lady." The PCP stated looking at the pictures, logically you would look into abuse and/or neglect, potentially picking the Resident up and dropping her. The PCP stated people get bruised all the time without a fracture. The PCP stated Resident # 4 had lost a lot of blood and he had never seen this before. The PCP stated it could have been caused by some sort of improper lifting but it would have had to have been vigorous. The PCP stated he would expect the facility to investigate this bruising thoroughly and report it to the State survey and certification agency for further investigation. In an interview on 04/24/2013 at 10:20 AM the Medical Director stated he was made aware of Resident # 4's bruising on 04/22/2013 when the NP had discussed the issue with him. The Medical Director looked at Resident # 4's photos and stated the bruising was older because you could see orangish, greenish and yellowish colors on the sides of the bruising. The Medical Director stated the [MEDICAL CONDITION] was from trauma and that bruising could cause swelling, it's "asymptomatic of trauma." The Medical Director stated he would have expected the facility to thoroughly investigate this situation not only for Resident # 4 but for future potential bruising and trauma. The Medical Director stated this incident should have definitely been reported to the State survey and recertification agency and he felt it was a bad situation that the facility did not report it for further investigation. In an interview on 04/24/2013 at 11:00 AM the Administrator # 1 stated he had been advised by DON # 1 that Resident # 4 had sustained extensive bruising. The Administrator # 1 stated DON # 1 had first advised him the bruising was probably caused by some hematological disorder then later stated it could have been caused by a Hoyer lift. The Administrator #1 could not remember the date DON # 1 had advised him it was not from a hematological cause but potentially from a Hoyer lift. The Administrator stated an in-serviced should have been performed regarding improper lifting methods and felt it was a communication breakdown and it "got by us." Administrator # 1 stated it was his expectation when staff discover an injury of unknown origin, that the incident be thoroughly investigated to rule out abuse or neglect, to interview staff and residents and determine the cause, if possible. Administrator # 1 stated if a cause could not be determined the incident should be reported to the State certification and survey agency for investigation. Review of the facility policy regarding Accident and Incidents - Investigating and Reporting, undated, reflected: All accidents or incidents involving residents, employees, visitors, vendors, etc. occurring on our premises should be investigated and reported to the Administrator. 1. Reporting of Accidents/Incidents d. An Accident or Incident Report Form should be completed for all reported accidents or incidents, including visitors and vendors. Obtain handwritten statements from witnesses to the incident. Interview all those with knowledge to the incident. e. We will follow the Guidelines of Reporting Incidents as outlined in Provider Letter #06-43 (Texas Department of Aging and Disability Services) if there is a suspicion of: Serious Accidental Injuries Serious or Suspicious Injuries of Unknown So0urce Conditions That Pose a Threat to Resident Health and Safety Review of the facility policy regarding Abuse/Neglect dated 01/13 reflected : Procedure: The facility abuse prohibition policy includes but is not limited to the following components:....identifying events which may indicate abuse, investigation protocols.... Component V: Investigation Although Component V did not address injuries of unknown origin the following apply: The facility Nurse Manager will, to the extent warranted and necessary, obtain written statements from all parties involved in the incident, any witnesses to the incident and any family members who may add pertinent information to the investigation. The facility Social Services and/or Activity Departments will conduct resident interviews regarding Staff treatment of [REDACTED]. All written statements, incident reports and investigative information will be turned into the Administrator or Designee for summation and final disposition. Component VII: Reporting/Response Did not address injuries of unknown origin. On 04/24/2013 at 7:04 PM, the Administrator # 1 and DON # 1 was notified that an IJ was identified due to the above deficient practices. The following final Plan of Removal was submitted by the Administrator # 1 on 04/25/2013 at 11:20 AM. The final Plan of Removal was accepted by the Survey Team on 04/25/2013 at 11:26 AM and reflected the following: Please accept this as a plan of removal and remedy of Immediate Jeopardy in relation to failure to thoroughly investigate and report and incident to TDADS as per regulations. Issues #1 Failure failed to conduct a thorough investigation and report the incident to TDADS. Interventions to Issue # 1: Investigation and Report 1. Facility re-opened investigation. 2. Incident reported to TDADS. Issue # 2 Facility failed to conduct interviews with all staff to determine the cause of the resident's injury. Interventions to Issue # 2 - Investigation/Statements 1. Initiated interviews with all direct care staff to determine knowledge or witness of injury to resident to cause bruising to Resident # 4. 2. Audit of clinical record to determine information regarding injury. 3. Reviewed all resident's transfer status. 4. Inspection of Hoyer lift for defects and pattern match of injuries sustained. 5. All transfer equipment inspected for proper functioning. Issue # 3 Facility failed to implement policy and procedure regarding incident and accident investigation and reporting. Interventions to Issue # 3 - Implement Policy and Procedures 1. In-service Administrator and DON on thoroughly investigating and reporting all abuse, neglect and other reportable incidents, including injuries of unknown origin according to facility policy and procedure and federal and state regulation. This will be completed by the Vice President of Operations (VPO) on 04/24/2013. 2. Interdisciplinary team (Assessment Nurse, Social Services, Dietary Services, Activities Director, Administrator, DON and therapy) will review all incident and accident reports in the morning meeting to verify that investigative and reporting guidelines have been met to include witness statements. Staff will be trained on state regulatory self-report guidelines for abuse, neglect and injuries of unknown origin. This will be completed by QA Nurse Consultant with current staff by 04/25/2013. 3. Facility Abuse Coordinator is the Administrator, (Administrator #1) (effective 04/25/2013, Administrator #2 is Administrator of record). All facility staff will be in-serviced on who the abuse coordinator is and their responsibility to report any and all allegations of potential abuse. In-service all facility staff on the proper procedure for reporting, any observed incidents/accidents and on the facility's abuse prohibition policy and procedure. In-service will be conducted by Administrator. In-service will include reassurance that all staff can report any allegation without fear of retaliation and will be completed with the current staff by 04/25/2013 with the exception of those unavailable and they will be in-serviced prior to being allowed to work. Issue # 4 Facility failed to adequately train nurse aide staff on proper procedures to follow when performing resident care to ensure resident safety including all acceptable transfer techniques. Interventions for Issue # 4 - Staff Training 1. In-service nurse aides on proper procedure to follow when performing resident positioning and transfers to ensure resident safety. This will be completed with current staff by 04/25/2013. Anyone not in-serviced by the completion date will be in-serviced prior to returning to work. 2. Transfer skills will be performed by nurse managers with staff before they are allowed to work, to verify that direct care staff are proficient with resident safety. this will begin 04/24/2013 with completion on or before 04/30/2013. Skills will be performed during new hire orientation before employee assumes job duties. Issue # 5 Facility failed to provide services that meet professional standards and administration. Interventions for Issue # 5 - Professional Standards 1. Management staff will be in-serviced on Provider Letter # 06-43 and Company Policy and Procedure regarding conducting proper investigations. 2. Management staff will review all incident and accident reports in the daily in start-up and 3:00 PM stand-down meetings and any incident and accident investigations not completed by the end of the day one will be carried to the following mornings start up for continued review. Incidents and accidents will be reviewed to determine if they meet the criteria for reporting. 3. Management staff will review all incidents and accidents for the past 60 days to verify there are no further incidents that meet the criteria for reporting, and that a complete investigation was conducted. Findings will be reported to the facility QA Committee. Appropriate action will be taken as indicated. To be completed by 04/26/2013. 4. Medical Director has been notified of the Immediate Jeopardy. 5. Social Worker to interview cognitive residents concerning care provided by the facility. Initial interviews completed by 04/26/2013 and ongoing. 6. All monitoring steps included in the plan of removal will be kept in a binder for TDADS review in the Administrator's office. Monitoring of the Plan of Removal was conducted by the Survey Team between 04/25/2013 and 04/26/2013. Resident # 4's Incident Investigation was re-opened by the Corporate Staff and was called to the State certification and survey agency. In-services had begun with approximately 75 percent of the staff trained. Transfer assistance was observed to be appropriate according to the facility Plan of Removal. The Administrator # 2 was notified on 04/26/2013 at 5:40 PM that the IJ was removed, however, the facility remains out of compliance at a Severity level of Harm at a Scope of Isolated that is not IJ due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility provided a list of 46 residents who were cognitively impaired and required assistance with bed mobility, transfers or incontinent care.

Based on observation, interview and record review the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect and abuse (including injuries of unknown origin) for one of 12 residents (Resident # 4) reviewed for abuse/neglect. Resident # 4 had continuous and extensive bruising to multiple parts of her body including her back, breasts, underneath her arms extending to the elbow area and the side of her left foot. Resident # 4 had swelling to her left elbow and left ankle. The facility failed to conduct a thorough investigation, report the incident to the State survey and certification agency and report their findings accurately to the administrator and the State survey and certification agency. This deficient practice resulted in an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 04/24/2013. While the IJ was removed on 04/26/2013 the facility remained out of compliance at a level of Actual Harm of Isolated. These deficient practice affected Resident # 4 and placed an additional 45 cognitively impaired residents who require assistance with bed mobility, transfers or incontinent care at risk for injury. Findings Include: Review of the facility policy regarding Abuse/Neglect dated 01/13 reflected: : Procedure: The facility abuse prohibition policy includes but is not limited to the following components:....identifying events which may indicate abuse, investigation protocols.... Component V: Investigation Although Component V did not address injuries of unknown origin the following apply: The facility Nurse Manager will, to the extent warranted and necessary, obtain written statements from all parties involved in the incident, any witnesses to the incident and any family members who may add pertinent information to the investigation. The facility Social Services and/or Activity Departments will conduct resident interviews regarding Staff treatment of [REDACTED]. All written statements, incident reports and investigative information will be turned into the Administrator or Designee for summation and final disposition. Component VII: Reporting/Response Did not address injuries of unknown origin. Review of the facility policy regarding Accident and Incidents - Investigating and Reporting, undated, reflected: All accidents or incidents involving residents, employees, visitors, vendors, etc. occurring on our premises should be investigated and reported to the Administrator. 1. Reporting of Accidents/Incidents d. An Accident or Incident Report Form should be completed for all reported accidents or incidents, including visitors and vendors. Obtain handwritten statements from witnesses to the incident. Interview all those with knowledge to the incident. e. We will follow the Guidelines of Reporting Incidents as outlined in Provider Letter #06-43 (Texas Department of Aging and Disability Services) if there is a suspicion of: Serious Accidental Injuries Serious or Suspicious Injuries of Unknown So0urce Conditions That Pose a Threat to Resident Health and Safety Review of Resident #4 Face Sheet reflected a [AGE] year old female who was admitted to the facility on [DATE] . Resident # 4's [DIAGNOSES REDACTED]. Review of Resident # 4's Significant Change Minimum Data Set (MDS) assessment dated [DATE] reflected the resident was severely cognitively impaired, totally dependent on staff for all activities of daily living and required extensive assistance for bed mobility. The assessment reflected transfer activity did not occur. Resident # 4 was incontinent of bowel and bladder. Review of Resident # 4's Comprehensive Care Plan dated 01/10/2013 reflected the Resident required extensive assistance of one person with bed mobility and refused to get out of bed. The Care Plan reflected Resident #4 needed total care of one staff member to assist with incontinent care, dressing and hygiene. The Care Plan reflected Resident #4 is " at risk for fx ' s " (fractures) related to a [DIAGNOSES REDACTED]. Observation on 04/22/2013 at 3:17 PM revealed Resident #4 had significant bruising (Increased distress to tissue causing capillaries to break under the skin, allowing blood to escape and build up. As time progresses, blood seeps into the surrounding tissues, causing the bruise to darken and spread) to her back (upper [MEDICATION NAME] area) . The bruising was dark purple/black in color with a faint yellowish greenish tint around the edges. The bruising was continuous and extended from Resident # 4's breasts and bilateral armpits to below her bilateral rib cages and wrapped around her posterior [MEDICATION NAME] area extending to approximately four inches from her spine. Resident # 4's left elbow was swollen with extensive bruising. The side of Resident # 4's left foot had an approximate 6 inch long by 2 inch wide bruise that extended from her ankle down to her toes. Resident # 4's ankle was swollen with two plus [MEDICAL CONDITION]. (measurement estimated by Registered Nurse (RN) Surveyor) Review of Resident # 4's Physician Orders reflected the resident received Vitamin C 500 milligrams (mg) twice per day for 30 days beginning 03/25/2013, Multivitamins with minerals one tablet per day and Med Pass 2.0 60 cubic centimeter (cc) four times per day for 30 days beginning 03/25/2013. There was no physician order for [REDACTED]. In an interview on 04/23/2013 at 8:00 AM Resident # 4 could only answer simple questions. When asked if she could recall sustaining an injury, Resident # 4 replied "no". When asked if she had fallen, Resident # 4 replied "no". When asked if she was in pain, Resident # 4 replied "no". In an interview on 04/22/2013 at 6:08 PM the Director of Nursing (DON) stated he was made aware of the bruising by the charge nurse on duty 04/12/2013. The DON stated an incident/accident report was completed. The DON stated he remembered seeing the bruising on Resident # 4 on 04/12/2013 but was not sure how the bruising occurred. The DON stated he suspected blood thinners or some hematological disorder (a disorder that primarily affects the blood) and he had requested the Nurse Practitioner (NP) to order a CBC (complete blood count) laboratory test. Review of the CBC laboratory report for Resident # 4 dated 04/16/2013 (delivered on 04/16/2013 date at 3:27 PM) reflected the resident's hemoglobin count was low at 10.6. The range for a normal hemoglobin count was referenced at 12.0 - 15.6. grams per deciliter (g/dl). There was no medical intervention after receipt of this lab report until 04/22/2013, after the survey team observed the bruising). In an interview on 04/22/2013 at 4:27 PM the Nurse Practitioner (NP) stated she did not know why x-rays were not ordered when the bruising and swelling was identified however she now felt it was a good idea and ordered x-rays to bilateral ribs, left arm to include the elbow and left foot and ankle on 04/22/2013. Review of Resident # 4's x-ray results dated 04/22/2013 reflected there was no fracture to the Resident's arms, ribs or left foot/ankle. Review of the Incident/Accident Report dated 04/12/2013 reflected at 3:30 PM Licensed Vocational Nurse (LVN) B was called to Resident # 4's room after Certified Nurse Aides (CNA) Q & R had showered the Resident. LVN B reported there was "sporadic bruising up and down her lateral sides which was not visible yesterday." The report listed one aide (CNA Q) as witness. The investigation report reflected Resident # 4's [DIAGNOSES REDACTED]. The investigation report further reflected Resident # 4 was placed on the "turtle" program (a program designed by the facility to ensure staff used caution when caring for the resident). The outcome of the investigation reflected there as diffuse (to become widely disbursed; spread out) discoloration to LUE (left upper extremity), bilateral postural [MEDICATION NAME] region. Physician was notified. Resident's room evaluated for possible cause. Labs (CBC) ordered to rule out possible cause. The final outcome of the investigation reflected "areas were showing positive signs of healing. The physician's representative is aware and evaluated briefly on rounds. Will continue to monitor for signs and symptoms of healing." There was one witness statement attached to the report from CNA Q who stated "When getting Resident # 4 up for a shower I noticed multiple bruises under her arms and down the sides of her back and breasts. I notified the nurse." There was lab results for Resident # 4 attached to the investigation report that reflected the resident was slightly anemic. There was no additional witness statements obtained, no interviews with other staff members that had cared for Resident # 4 prior to the findings and no resident interviews to indicate residents had been questioned to ensure safety from potential abuse and/or neglect. The report indicated abuse and/or neglect was not suspected. In an interview on 04/23/2013 at 2:15 PM Resident # 4's NP stated she was notified of the Resident's bruising while in the building making rounds on 04/15/2013. The NP stated she examined Resident # 4 and there was distinct generalized bruising to the left side and left elbow. The NP stated she did not have staff roll Resident # 4 onto her other side to examine the bruising on the right side of the Resident's body. The NP stated she thought the bruising was from [MEDICATION NAME] trauma and could have been caused by a Hoyer lift and was "really disturbed about how the DON blew me off." The NP stated she had requested the DON to look at the bruising with her and "he didn't do it." The NP stated the bruising lends itself from the Resident pulling back from staff, or it could have been self-induced, however she had advised the DON to investigate the incident and to talk to aides that had cared for Resident # 4 in the 48 hours prior to the bruising being identified. In an interview on 04/22/2013 at 7:00 PM the DON stated, after he received the lab work back that indicated the bruising was not caused by a hematological condition, the only thing he could think of that caused bruising of that sort on a Resident could have been a Hoyer lift. When asked why he did not document a Hoyer lift as the potential cause of Resident # 4's bruising the DON stated "my bad." The DON stated he had not in-serviced staff relating to proper Hoyer lift transfers, or transfers of any type, after the incident with Resident # 4. The DON stated he had not reported this injury of unknown source to the State survey and certification agency for further investigation. Review of the facility staff in-service records for April, 2013 reflected no transfer technique in-service was provided to staff after Resident # 4's incident. In an interview on 04/23/13 at 300 PM LVN B stated she had completed the incident report for Resident # 4's bruising on 04/12/2013 . LVN B stated she was called to Resident # 4's room by two aides to assess bruising found on the Resident. Resident # 4 was still in her shower chair and her hair was wet. LVN B stated there was no Hoyer lift in Resident # 4's room and there was no sling underneath the resident that indicated a Hoyer lift was not used during the transfer of Resident # 4 to or from the shower chair. LVN B stated she was stunned when she observed the bruising on Resident # 4 and notified the DON immediately. In an interview on 04/24/2013 at 2:30 PM CNA Q stated she was one of the nurse aides that gave Resident # 4 a shower on 04/12/2013 and noticed the bruising. CNA Q stated she and CNA R transferred Resident # 4 from the bed to the shower chair using a "cradle" lifting method. CNA Q stated she had cradled Resident # 4 with one arm under the Resident's arm and around her back and the other arm under her leg. CNA Q stated CNA R did the same thing on the other side of Resident # 4. CNA Q stated Resident # 4 was still clothed with a hospital gown when transferring her out of the bed but while in the shower room and disrobed, the bruises were evident on Resident # 4's back, underarms, breasts and elbows. CNA Q stated Resident # 4's shower was completed and she was brought back to her room using the shower chair and LVN B was notified immediately when the Resident was back in her room. CNA Q stated she was upset because before she came to visit with the survey team, DON # 1 had talked with her and requested she advise the survey team she and CNA R had used a Hoyer lift to transfer Resident # 4 when they had not. CNA Q stated DON #1 had asked her to tell the survey team they used the Hoyer lift and needed to be in-serviced in transferring Residents using a Hoyer lift. In a telephone interview on 04/24/2013 at 2:50 PM CNA R stated DON # 1 had been trying to reach her by phone but she had not returned his phone calls. CNA R stated she is no longer employed by the facility. CNA R stated a Hoyer lift was not used to transfer Resident # 4 from her bed to the shower chair or back to her bed on the date of the incident, 04/12/2013. CNA R stated while showering Resident # 4 bruises were noticed on the Resident's back, underarms and breasts. CNA R stated the bruising was already black and appeared to be at least one day old. In an interview on 04/24/2013 at 9:55 AM Resident # 4's Primary Care Physician (PCP) stated he had learned of the Resident's bruising the day before on 04/23/2013. The PCP reviewed pictures of the Resident's bruising and stated "that poor lady." The PCP stated looking at the pictures, logically you would look into abuse and/or neglect, potentially picking the Resident up and dropping her. The PCP stated people get bruised all the time without a fracture. The PCP stated Resident # 4 had lost a lot of blood and he had never seen this before. The PCP stated it could have been caused by some sort of improper lifting but it would have had to have been vigorous. The PCP stated he would expect the facility to investigate this bruising thoroughly and report it to the State survey and certification agency for further investigation. In an interview on 04/24/2013 at 10:20 AM the Medical Director stated he was made aware of Resident # 4's bruising on 04/22/2013 when the NP had discussed the issue with him. The Medical Director looked at Resident # 4's photos and stated the bruising was older because you could see orangish, greenish and yellowish colors on the sides of the bruising. The Medical Director stated the [MEDICAL CONDITION] was from trauma and that bruising could cause swelling, it's "asymptomatic of trauma." The Medical Director stated he would have expected the facility to thoroughly investigate this situation not only for Resident # 4 but for future potential bruising and trauma. The Medical Director stated this incident should have definitely been reported to the State survey and recertification agency and he felt it was a bad situation that the facility did not report it for further investigation. In an interview on 04/24/2013 at 11:00 AM the Administrator # 1 stated he had been advised by DON # 1 that Resident # 4 had sustained extensive bruising. The Administrator # 1 stated DON # 1 had first advised him the bruising was probably caused by some hematological disorder then later stated it could have been caused by a Hoyer lift. The Administrator #1 could not remember the date DON # 1 had advised him it was not from a hematological cause but potentially from a Hoyer lift. The Administrator stated an in-serviced should have been performed regarding improper lifting methods and felt it was a communication breakdown and it "got by us." Administrator # 1 stated it was his expectation when staff discover an injury of unknown origin, that the incident be thoroughly investigated to rule out abuse or neglect, to interview staff and residents and determine the cause, if possible. Administrator # 1 stated if a cause could not be determined the incident should be reported to the State certification and survey agency for investigation. On 04/24/2013 at 7:04 PM, the Administrator # 1 and DON # 1 was notified that an IJ was identified due to the above deficient practices. The following final Plan of Removal was submitted by the Administrator # 1 on 04/25/2013 at 11:20 AM. The final Plan of Removal was accepted by the Survey Team on 04/25/2013 at 11:26 AM and reflected the following: Please accept this as a plan of removal and remedy of Immediate Jeopardy in relation to failure to thoroughly investigate and report and incident to TDADS as per regulations. Issues #1 Failure failed to conduct a thorough investigation and report the incident to TDADS. Interventions to Issue # 1: Investigation and Report 1. Facility re-opened investigation. 2. Incident reported to TDADS. Issue # 2 Facility failed to conduct interviews with all staff to determine the cause of the resident's injury. Interventions to Issue # 2 - Investigation/Statements 1. Initiated interviews with all direct care staff to determine knowledge or witness of injury to resident to cause bruising to Resident # 4. 2. Audit of clinical record to determine information regarding injury. 3. Reviewed all resident's transfer status. 4. Inspection of Hoyer lift for defects and pattern match of injuries sustained. 5. All transfer equipment inspected for proper functioning. Issue # 3 Facility failed to implement policy and procedure regarding incident and accident investigation and reporting. Interventions to Issue # 3 - Implement Policy and Procedures 1. In-service Administrator and DON on thoroughly investigating and reporting all abuse, neglect and other reportable incidents, including injuries of unknown origin according to facility policy and procedure and federal and state regulation. This will be completed by the Vice President of Operations (VPO) on 04/24/2013. 2. Interdisciplinary team (Assessment Nurse, Social Services, Dietary Services, Activities Director, Administrator, DON and therapy) will review all incident and accident reports in the morning meeting to verify that investigative and reporting guidelines have been met to include witness statements. Staff will be trained on state regulatory self-report guidelines for abuse, neglect and injuries of unknown origin. This will be completed by QA Nurse Consultant with current staff by 04/25/2013. 3. Facility Abuse Coordinator is the Administrator, (Administrator #1) (effective 04/25/2013, Administrator #2 is Administrator of record). All facility staff will be in-serviced on who the abuse coordinator is and their responsibility to report any and all allegations of potential abuse. In-service all facility staff on the proper procedure for reporting, any observed incidents/accidents and on the facility's abuse prohibition policy and procedure. In-service will be conducted by Administrator. In-service will include reassurance that all staff can report any allegation without fear of retaliation and will be completed with the current staff by 04/25/2013 with the exception of those unavailable and they will be in-serviced prior to being allowed to work. Issue # 4 Facility failed to adequately train nurse aide staff on proper procedures to follow when performing resident care to ensure resident safety including all acceptable transfer techniques. Interventions for Issue # 4 - Staff Training 1. In-service nurse aides on proper procedure to follow when performing resident positioning and transfers to ensure resident safety. This will be completed with current staff by 04/25/2013. Anyone not in-serviced by the completion date will be in-serviced prior to returning to work. 2. Transfer skills will be performed by nurse managers with staff before they are allowed to work, to verify that direct care staff are proficient with resident safety. this will begin 04/24/2013 with completion on or before 04/30/2013. Skills will be performed during new hire orientation before employee assumes job duties. Issue # 5 Facility failed to provide services that meet professional standards and administration. Interventions for Issue # 5 - Professional Standards 1. Management staff will be in-serviced on Provider Letter # 06-43 and Company Policy and Procedure regarding conducting proper investigations. 2. Management staff will review all incident and accident reports in the daily in start-up and 3:00 PM stand-down meetings and any incident and accident investigations not completed by the end of the day one will be carried to the following mornings start up for continued review. Incidents and accidents will be reviewed to determine if they meet the criteria for reporting. 3. Management staff will review all incidents and accidents for the past 60 days to verify there are no further incidents that meet the criteria for reporting, and that a complete investigation was conducted. Findings will be reported to the facility QA Committee. Appropriate action will be taken as indicated. To be completed by 04/26/2013. 4. Medical Director has been notified of the Immediate Jeopardy. 5. Social Worker to interview cognitive residents concerning care provided by the facility. Initial interviews completed by 04/26/2013 and ongoing. 6. All monitoring steps included in the plan of removal will be kept in a binder for TDADS review in the Administrator's office. Monitoring of the Plan of Removal was conducted by the Survey Team between 04/25/2013 and 04/26/2013. Resident # 4's Incident Investigation was re-opened by the Corporate Staff and was called to the State certification and survey agency. In-services had begun with approximately 75 percent of the staff trained. Transfer assistance was observed to be appropriate according to the facility Plan of Removal. The Administrator # 2 was notified on 04/26/2013 at 5:40 PM that the IJ was removed, however, the facility remains out of compliance at a Severity level of Harm at a Scope of Isolated that is not IJ due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility provided a list of 46 residents who were cognitively impaired and required assistance with bed mobility, transfers or incontinent care.

Based on observation, interview and record review the Administrator and Director of Nurses (DON) failed to administer the facility in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident when: The Administrator failed to supervise, follow up, consult with the DON and report an incident to the State survey and certification agency to prevent further neglect for one (1) of 12 residents reviewed for abuse/neglect with regards to injuries of unknown origin; and The DON failed to conduct a thorough investigation, assess the condition and ensure appropriate timely medical attention was attained for one of 12 residents reviewed for abuse/neglect and report correct findings to the Administrator and to the State certification and survey agency; when Resident # 4 had continuous and extensive bruising to multiple parts of her body including her back, breasts, underneath her arms extending to the elbow area and the side of her left foot. Resident # 4 had swelling to her left elbow and left ankle. The facility failed to conduct a thorough investigation, report the incident to the State survey and certification agency and report their findings to the administrator and the State survey and certification agency. This deficient practice resulted in an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 04/24/2013. While the IJ was removed on 04/26/2013 the facility remained out of compliance at a level of Actual Harm of Isolated Incident. These deficient practice affected Resident # 4 and placed an additional 45 cognitively impaired residents who require assistance with bed mobility, transfers or incontinent care at risk for injury. Findings Include: Review of Resident #4 Face Sheet reflected a [AGE] year old female who was admitted to the facility on [DATE] . Resident # 4's [DIAGNOSES REDACTED]. Review of Resident # 4's Significant Change Minimum Data Set (MDS) assessment dated [DATE] reflected the resident was severely cognitively impaired, totally dependent on staff for all activities of daily living and required extensive assistance for bed mobility. The assessment reflected transfer activity did not occur. Resident # 4 was incontinent of bowel and bladder. Review of Resident # 4's Comprehensive Care Plan dated 01/10/2013 reflected the Resident required extensive assistance of one person with bed mobility and refused to get out of bed. The Care Plan reflected Resident #4 needed total care of one staff member to assist with incontinent care, dressing and hygiene. The Care Plan reflected Resident #4 is " at risk for fx ' s " (fractures) related to a [DIAGNOSES REDACTED]. Observation on 04/22/2013 at 3:17 PM revealed Resident #4 had significant bruising (Increased distress to tissue causing capillaries to break under the skin, allowing blood to escape and build up. As time progresses, blood seeps into the surrounding tissues, causing the bruise to darken and spread) to her back (upper [MEDICATION NAME] area) . The bruising was dark purple/black in color with a faint yellowish greenish tint around the edges. The bruising was continuous and extended from Resident # 4's breasts and bilateral armpits to below her bilateral rib cages and wrapped around her posterior [MEDICATION NAME] area extending to approximately four inches from her spine. Resident # 4's left elbow was swollen with extensive bruising. The side of Resident # 4's left foot had an approximate 6 inch long by 2 inch wide bruise that extended from her ankle down to her toes. Resident # 4's ankle was swollen with two plus [MEDICAL CONDITION]. (measurement estimated by Registered Nurse (RN) Surveyor) Review of Resident # 4's Physician Orders reflected the resident received Vitamin C 500 milligrams (mg) twice per day for 30 days beginning 03/25/2013, Multivitamins with minerals one tablet per day and Med Pass 2.0 60 cubic centimeter (cc) four times per day for 30 days beginning 03/25/2013. There was no physician order for [REDACTED]. In an interview on 04/23/2013 at 8:00 AM Resident # 4 could only answer simple questions. When asked if she could recall sustaining an injury, Resident # 4 replied "no". When asked if she had fallen, Resident # 4 replied "no". When asked if she was in pain, Resident # 4 replied "no". In an interview on 04/22/2013 at 6:08 PM the Director of Nursing (DON) stated he was made aware of the bruising by the charge nurse on duty 04/12/2013. The DON stated an incident/accident report was completed. The DON stated he remembered seeing the bruising on Resident # 4 on 04/12/2013 but was not sure how the bruising occurred. The DON stated he suspected blood thinners or some hematological disorder (a disorder that primarily affects the blood) and he had requested the Nurse Practitioner (NP) to order a CBC (complete blood count) laboratory test. Review of the CBC laboratory report for Resident # 4 dated 04/16/2013 (delivered on 04/16/2013 date at 3:27 PM) reflected the resident's hemoglobin count was low at 10.6. The range for a normal hemoglobin count was referenced at 12.0 - 15.6. grams per deciliter (g/dl). There was no medical intervention after receipt of this lab report until 04/22/2013, after the survey team observed the bruising). In an interview on 04/22/2013 at 4:27 PM the Nurse Practitioner (NP) stated she did not know why x-rays were not ordered when the bruising and swelling was identified however she now felt it was a good idea and ordered x-rays to bilateral ribs, left arm to include the elbow and left foot and ankle on 04/22/2013. Review of Resident # 4's x-ray results dated 04/22/2013 reflected there was no fracture to the Resident's arms, ribs or left foot/ankle. Review of the Incident/Accident Report dated 04/12/2013 reflected at 3:30 PM Licensed Vocational Nurse (LVN) B was called to Resident # 4's room after Certified Nurse Aides (CNA) Q & R had showered the Resident. LVN B reported there was "sporadic bruising up and down her lateral sides which was not visible yesterday." The report listed one aide (CNA Q) as witness. The investigation report reflected Resident # 4's [DIAGNOSES REDACTED]. The investigation report further reflected Resident # 4 was placed on the "turtle" program (a program designed by the facility to ensure staff used caution when caring for the resident). The outcome of the investigation reflected there as diffuse (to become widely disbursed; spread out) discoloration to LUE (left upper extremity), bilateral postural [MEDICATION NAME] region. Physician was notified. Resident's room evaluated for possible cause. Labs (CBC) ordered to rule out possible cause. The final outcome of the investigation reflected "areas were showing positive signs of healing. The physician's representative is aware and evaluated briefly on rounds. Will continue to monitor for signs and symptoms of healing." There was one witness statement attached to the report from CNA Q who stated "When getting Resident # 4 up for a shower I noticed multiple bruises under her arms and down the sides of her back and breasts. I notified the nurse." There was lab results for Resident # 4 attached to the investigation report that reflected the resident was slightly anemic. There was no additional witness statements obtained, no interviews with other staff members that had cared for Resident # 4 prior to the findings and no resident interviews to indicate residents had been questioned to ensure safety from potential abuse and/or neglect. The report indicated abuse and/or neglect was not suspected. In an interview on 04/23/2013 at 2:15 PM Resident # 4's NP stated she was notified of the Resident's bruising while in the building making rounds on 04/15/2013. The NP stated she examined Resident # 4 and there was distinct generalized bruising to the left side and left elbow. The NP stated she did not have staff roll Resident # 4 onto her other side to examine the bruising on the right side of the Resident's body. The NP stated she thought the bruising was from [MEDICATION NAME] trauma and could have been caused by a Hoyer lift and was "really disturbed about how the DON blew me off." The NP stated she had requested the DON to look at the bruising with her and "he didn't do it." The NP stated the bruising lends itself from the Resident pulling back from staff, or it could have been self-induced, however she had advised the DON to investigate the incident and to talk to aides that had cared for Resident # 4 in the 48 hours prior to the bruising being identified. In an interview on 04/22/2013 at 7:00 PM the DON stated, after he received the lab work back that indicated the bruising was not caused by a hematological condition, the only thing he could think of that caused bruising of that sort on a Resident could have been a Hoyer lift. When asked why he did not document a Hoyer lift as the potential cause of Resident # 4's bruising the DON stated "my bad." The DON stated he had not in-serviced staff relating to proper Hoyer lift transfers, or transfers of any type, after the incident with Resident # 4. The DON stated he had not reported this injury of unknown source to the State survey and certification agency for further investigation. Review of the facility staff in-service records for April, 2013 reflected no transfer technique in-service was provided to staff after Resident # 4's incident. In an interview on 04/23/13 at 300 PM LVN B stated she had completed the incident report for Resident # 4's bruising on 04/12/2013 . LVN B stated she was called to Resident # 4's room by two aides to assess bruising found on the Resident. Resident # 4 was still in her shower chair and her hair was wet. LVN B stated there was no Hoyer lift in Resident # 4's room and there was no sling underneath the resident that indicated a Hoyer lift was not used during the transfer of Resident # 4 to or from the shower chair. LVN B stated she was stunned when she observed the bruising on Resident # 4 and notified the DON immediately. In an interview on 04/24/2013 at 2:30 PM CNA Q stated she was one of the nurse aides that gave Resident # 4 a shower on 04/12/2013 and noticed the bruising. CNA Q stated she and CNA R transferred Resident # 4 from the bed to the shower chair using a "cradle" lifting method. CNA Q stated she had cradled Resident # 4 with one arm under the Resident's arm and around her back and the other arm under her leg. CNA Q stated CNA R did the same thing on the other side of Resident # 4. CNA Q stated Resident # 4 was still clothed with a hospital gown when transferring her out of the bed but while in the shower room and disrobed, the bruises were evident on Resident # 4's back, underarms, breasts and elbows. CNA Q stated Resident # 4's shower was completed and she was brought back to her room using the shower chair and LVN B was notified immediately when the Resident was back in her room. CNA Q stated she was upset because before she came to visit with the survey team, DON # 1 had talked with her and requested she advise the survey team she and CNA R had used a Hoyer lift to transfer Resident # 4 when they had not. CNA Q stated DON #1 had asked her to tell the survey team they used the Hoyer lift and needed to be in-serviced in transferring Residents using a Hoyer lift. In a telephone interview on 04/24/2013 at 2:50 PM CNA R stated DON # 1 had been trying to reach her by phone but she had not returned his phone calls. CNA R stated she is no longer employed by the facility. CNA R stated a Hoyer lift was not used to transfer Resident # 4 from her bed to the shower chair or back to her bed on the date of the incident, 04/12/2013. CNA R stated while showering Resident # 4 bruises were noticed on the Resident's back, underarms and breasts. CNA R stated the bruising was already black and appeared to be at least one day old. In an interview on 04/24/2013 at 9:55 AM Resident # 4's Primary Care Physician (PCP) stated he had learned of the Resident's bruising the day before on 04/23/2013. The PCP reviewed pictures of the Resident's bruising and stated "that poor lady." The PCP stated looking at the pictures, logically you would look into abuse and/or neglect, potentially picking the Resident up and dropping her. The PCP stated people get bruised all the time without a fracture. The PCP stated Resident # 4 had lost a lot of blood and he had never seen this before. The PCP stated it could have been caused by some sort of improper lifting but it would have had to have been vigorous. The PCP stated he would expect the facility to investigate this bruising thoroughly and report it to the State survey and certification agency for further investigation. In an interview on 04/24/2013 at 10:20 AM the Medical Director stated he was made aware of Resident # 4's bruising on 04/22/2013 when the NP had discussed the issue with him. The Medical Director looked at Resident # 4's photos and stated the bruising was older because you could see orangish, greenish and yellowish colors on the sides of the bruising. The Medical Director stated the [MEDICAL CONDITION] was from trauma and that bruising could cause swelling, it's "asymptomatic of trauma." The Medical Director stated he would have expected the facility to thoroughly investigate this situation not only for Resident # 4 but for future potential bruising and trauma. The Medical Director stated this incident should have definitely been reported to the State survey and recertification agency and he felt it was a bad situation that the facility did not report it for further investigation. In an interview on 04/24/2013 at 11:00 AM the Administrator # 1 stated he had been advised by DON # 1 that Resident # 4 had sustained extensive bruising. The Administrator # 1 stated DON # 1 had first advised him the bruising was probably caused by some hematological disorder then later stated it could have been caused by a Hoyer lift. The Administrator #1 could not remember the date DON # 1 had advised him it was not from a hematological cause but potentially from a Hoyer lift. The Administrator stated an in-serviced should have been performed regarding improper lifting methods and felt it was a communication breakdown and it "got by us." Administrator # 1 stated it was his expectation when staff discover an injury of unknown origin, that the incident be thoroughly investigated to rule out abuse or neglect, to interview staff and residents and determine the cause, if possible. Administrator # 1 stated if a cause could not be determined the incident should be reported to the State certification and survey agency for investigation. Review of the facility policy regarding Accident and Incidents - Investigating and Reporting, undated, reflected: All accidents or incidents involving residents, employees, visitors, vendors, etc. occurring on our premises should be investigated and reported to the Administrator. 1. Reporting of Accidents/Incidents d. An Accident or Incident Report Form should be completed for all reported accidents or incidents, including visitors and vendors. Obtain handwritten statements from witnesses to the incident. Interview all those with knowledge to the incident. e. We will follow the Guidelines of Reporting Incidents as outlined in Provider Letter #06-43 (Texas Department of Aging and Disability Services) if there is a suspicion of: Serious Accidental Injuries Serious or Suspicious Injuries of Unknown So0urce Conditions That Pose a Threat to Resident Health and Safety Review of the facility policy regarding Abuse/Neglect dated 01/13 reflected : Procedure: The facility abuse prohibition policy includes but is not limited to the following components:....identifying events which may indicate abuse, investigation protocols.... Component V: Investigation Although Component V did not address injuries of unknown origin the following apply: The facility Nurse Manager will, to the extent warranted and necessary, obtain written statements from all parties involved in the incident, any witnesses to the incident and any family members who may add pertinent information to the investigation. The facility Social Services and/or Activity Departments will conduct resident interviews regarding Staff treatment of [REDACTED]. All written statements, incident reports and investigative information will be turned into the Administrator or Designee for summation and final disposition. Component VII: Reporting/Response Did not address injuries of unknown origin. On 06/05/2013 at 3:20 PM, the Administrator and DON were notified that an IJ was identified due to the above deficient practices. First draft of the Plan of removal was submitted by the Administrator on 06/05/2013 at 5:30 PM. It was returned to the Administrator for revision at 5:50 PM. The following final Plan of Removal was submitted by the Administrator on 06/05/2013 at 6:00 PM The final Plan of Removal was accepted by the Survey Team on 06/05/2013 at 6:00 PM and reflected the following: Please accept this as a plan of removal and remedy of Immediate Jeopardy in relation to failure to thoroughly investigate and report and incident to TDADS as per regulations. Issues #1 Failure failed to conduct a thorough investigation and report the incident to TDADS. Interventions to Issue # 1: Investigation and Report 1. Facility re-opened investigation. 2. Incident reported to TDADS. Issue # 2 Facility failed to conduct interviews with all staff to determine the cause of the resident's injury. Interventions to Issue # 2 - Investigation/Statements 1. Initiated interviews with all direct care staff to determine knowledge or witness of injury to resident to cause bruising to Resident # 4. 2. Audit of clinical record to determine information regarding injury. 3. Reviewed all resident's transfer status. 4. Inspection of Hoyer lift for defects and pattern match of injuries sustained. 5. All transfer equipment inspected for proper functioning. Issue # 3 Facility failed to implement policy and procedure regarding incident and accident investigation and reporting. Interventions to Issue # 3 - Implement Policy and Procedures 1. In-service Administrator and DON on thoroughly investigating and reporting all abuse, neglect and other reportable incidents, including injuries of unknown origin according to facility policy and procedure and federal and state regulation. This will be completed by the Vice President of Operations (VPO) on 04/24/2013. 2. Interdisciplinary team (Assessment Nurse, Social Services, Dietary Services, Activities Director, Administrator, DON and therapy) will review all incident and accident reports in the morning meeting to verify that investigative and reporting guidelines have been met to include witness statements. Staff will be trained on state regulatory self-report guidelines for abuse, neglect and injuries of unknown origin. This will be completed by QA Nurse Consultant with current staff by 04/25/2013. 3. Facility Abuse Coordinator is the Administrator, (Administrator #1) (effective 04/25/2013, Administrator #2 is Administrator of record). All facility staff will be in-serviced on who the abuse coordinator is and their responsibility to report any and all allegations of potential abuse. In-service all facility staff on the proper procedure for reporting, any observed incidents/accidents and on the facility's abuse prohibition policy and procedure. In-service will be conducted by Administrator. In-service will include reassurance that all staff can report any allegation without fear of retaliation and will be completed with the current staff by 04/25/2013 with the exception of those unavailable and they will be in-serviced prior to being allowed to work. Issue # 4 Facility failed to adequately train nurse aide staff on proper procedures to follow when performing resident care to ensure resident safety including all acceptable transfer techniques. Interventions for Issue # 4 - Staff Training 1. In-service nurse aides on proper procedure to follow when performing resident positioning and transfers to ensure resident safety. This will be completed with current staff by 04/25/2013. Anyone not in-serviced by the completion date will be in-serviced prior to returning to work. 2. Transfer skills will be performed by nurse managers with staff before they are allowed to work, to verify that direct care staff are proficient with resident safety. this will begin 04/24/2013 with completion on or before 04/30/2013. Skills will be performed during new hire orientation before employee assumes job duties. Issue # 5 Facility failed to provide services that meet professional standards and administration. Interventions for Issue # 5 - Professional Standards 1. Management staff will be in-serviced on Provider Letter # 06-43 and Company Policy and Procedure regarding conducting proper investigations. 2. Management staff will review all incident and accident reports in the daily in start-up and 3:00 PM stand-down meetings and any incident and accident investigations not completed by the end of the day one will be carried to the following mornings start up for continued review. Incidents and accidents will be reviewed to determine if they meet the criteria for reporting. 3. Management staff will review all incidents and accidents for the past 60 days to verify there are no further incidents that meet the criteria for reporting, and that a complete investigation was conducted. Findings will be reported to the facility QA Committee. Appropriate action will be taken as indicated. To be completed by 04/26/2013. 4. Medical Director has been notified of the Immediate Jeopardy. 5. Social Worker to interview cognitive residents concerning care provided by the facility. Initial interviews completed by 04/26/2013 and ongoing. 6. All monitoring steps included in the plan of removal will be kept in a binder for TDADS review in the Administrator's office. Monitoring of the Plan of Removal was conducted by the Survey Team between 04/25/2013 and 04/26/2013. Resident # 4's Incident Investigation was re-opened by the Corporate Staff and was called to the State certification and survey agency. In-services had begun with approximately 75 percent of the staff trained. Transfer assistance was observed to be appropriate according to the facility Plan of Removal. The Administrator # 2 was notified on 04/26/2013 at 5:40 PM that the IJ was removed, however, the facility remains out of compliance at a Severity level of Harm at a Scope of Isolated that is not IJ due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility provided a list of 46 residents who were cognitively impaired and required assistance with bed mobility, transfers or incontinent care.