Every finding on record at Meridian Care Monte Vista

Based on observation, interviews and record reviews, the facility failed to ensure that a resident who receives necessary respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 1 resident (Resident #2) of 3 residents who received tracheostomy care. The facility failed to secure Resident #2's suctioning tubing to the lid and place the suction catheter tip into the package sleeve after being used. These deficient practices could place residents at risk and could result in the introduction of foreign substances to the airway.The findings include: Record review of Resident #2's electronic face sheet dated 07/16/2026 reflected a [AGE] year-old female admitted on [DATE]/2025. Her diagnoses included: persistent vegetative state (wakefulness without awareness), tracheostomy status, and acute and chronic respiratory failure with hypoxia (low oxygen level in blood). Record review of Resident #2's annual MDS assessment dated [DATE] reflected that she was not a candidate for a BIMS which signified her cognitive status was severely impaired. She was dependent on staff for ADLs. She was noted to have a tracheostomy, mechanical ventilation, oxygen therapy, and suctioning while a resident. Record review of Resident #2's comprehensive care plan dated 06/28/2026 reflected Focus, has a tracheostomy, at risk for complications including respiratory distress, increased secretions, infection and SOB, Interventions, suction as ordered, SUCTION TRACH Q6hours and PRN. Record review of Resident #2's Active Orders as of 07/16/2026 reflected suction trach q6hrs and PRN for trach care, start date 06/16/2023.Record review of Resident #2's TAR for 07/16/2026 reflected RT B performed the suctioning for the resident. Observations on 07/16/2026 at 9:00 am and 07/16/2026 at 10:30 am accompanied by the Treatment Nurse revealed Resident #2 lying in bed, her suction catheter tubing was left hanging over the cannister uncapped or secured to the nipple on the top. The suction catheter tip was lying wedged under the cannister on a stand and not in its protective paper sleeve next to the cannister. During an interview on 07:16/2026 at 9:05 am, the Treatment Nurse revealed Resident #2'Respiratory Therapy provided suctioning, so she was not aware of the equipment not being covered or secured. She stated she was not familiar with their process. During an interview on 07/17/2026 at 07:15 am, the ADM stated she was accountable for everything at the facility and stated the suction equipment needed to be treated like oxygen equipment and secured so nothing could get into the tubing that could cause respiratory distress. During an interview on 07/17/2026 at 09:33 am, the DON stated RT was responsible for the suctioning and care of the equipment. She stated nursing did not do the suctioning unless necessary. She stated the tubing needed to be capped and secured so no air particles could enter it and cause respiratory problems when suctioning. She stated she could not find any manufacturers instructions for the suction catheter or tubing. During an interview on 07/17/2026 at 2:40 pm, RT B stated she was so busy she forgot to secure the suction tip and the tubing. She stated it was important to do that so nothing could enter the tubing or tip prior to suctioning the resident. She stated something entering the airway could cause respiratory distress. Record review of RT B's Skill Checklist titled Trach Suctioning dated 10/2020 reflected she successfully completed the skills assessment. Record review of the facility's policy and procedure titled Tracheostomy Care (undated) reflected maintain clean technique, following the manufacturer's instructions, clean and disinfect reusable parts and/or devices after each use, clean and disinfect reusable equipment before storing with other clean equipment. Review of https://uihc.org/educational-resources/suctioning-tracheostomy, dated November 2024 reflected rinse the suction catheter and connection tubing with clean tap water after each use, store the catheter in the original package until the next use. Do not reuse the catheter if it touches anything else.

Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensiveperson-centered care plan for each resident, consistent with the resident rights, which includes measurable objective andtimes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 Residents (Resident #2) of 9 residents reviewed for comprehensive care plans. The facility failed to accurately reflect Resident #2's skin and preventive interventions in the care plan. This deficient practice placed residents at risk of missed or miscommunicated care.Record review of Resident #2's electronic face sheet dated 07/16/2026 reflected a [AGE] year-old female admitted on [DATE]/2025. Her diagnoses included: contracture of muscle, right and left lower legs (soft tissues of lower legs are stiff or fibrotic) and persistent vegetative state (wakefulness without awareness). Record review of Resident #2's annual MDS assessment dated [DATE] reflected that she was not a candidate for a BIMS which signified her cognitive status was severely impaired. She was dependent on staff for ADLs. She was noted to have impairment on both sides of her lower extremities. She was noted not to have any pressure ulcers/injuries. Record review of Resident #2's comprehensive care plan dated 06/28/2026 reflected Focus, is at risk for developing a pressure ulcer due to limited ability to offload pressure related to trach/respiratory failure status, interventions, air loss mattress to be used to prevent pressure ulcers, focus, has multiple pressure ulcers that require treatments, interventions, air mattress and float heels with pillow or heel protectors while in bed. Record review of Resident #2's weekly skin assessments for June 2026 reflected no skin breakdown or pressure sores. Record review of Resident #2's Active Orders as of 07/16/2026 did not reflect orders for any wound or foot protection devices. Observations on 07/16/2026 at 9:00 am and 07/16/2026 at 10:30 am revealed Resident #2 was lying in bed, no air mattress was in place, her feet were not elevated on a pillow, and no foot protectors were seen in her area of the room. During an interview on 07:16/2026 at 10:43 am, the Treatment Nurse revealed Resident #2 had no skin issues. She stated she had a wedge cushion only to keep her contracted lower legs apart. She stated that only Residents with a pressure ulcer received an air mattress as an interventions. She continued to state she could not recall any elevation of feet or foot protector orders for Resident #2. During an interview on 07/17/2026 at 07:15 am, the ADM stated she was accountable for everything at the facility and stated the comprehensive care plan for Resident #2 needed to be accurate to show what the resident needed for care. During an interview on 07/17/2026 at 09:33 am, the DON stated the importance of an accurate care plan was care needs communicated to the staff who provided care, and needed care could be missed or inaccurate. During an interview on 07/17/2026 at 3:08 pm, LVN A stated she completed Resident #1's comprehensive care plan wrong, and she must have made a mistake. She stated care could be misinterpreted if the care plan was inaccurate. Record review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered dated December 2016 reflected A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on interviews and record reviews, the facility failed to ensure assessments accurately reflected thestatus of the residents for 1 of 9 residents (Resident #1) reviewed for resident assessments. The facility failed to ensure Resident #1s shortness of breath, mechanical ventilation and active diagnosis of pneumonia (lung infection) was reflected on the discharge MDS dated [DATE]. This deficient practice could place residents at risk of inadequate care. The findings include: Record review of Resident #1's electronic face sheet dated 07/16/2026 reflected a [AGE] year-old male admitted on [DATE] and discharged on 06/29/2026. His diagnoses included acute and chronic respiratory failure (short- and long-term condition where lungs don't adequately function) and had a tracheostomy (tube to trachea for oxygen administration to facilitate breathing) and required mechanical ventilation (life support technique in which a ventilator machine pushes air into the lungs to support or fully replace breathing when a person cannot breathe adequately on their own). Record review of Resident #1's discharge MDS assessment dated [DATE] reflected he was not a candidate for a BIMS which signified his cognitive status was severely impaired. He was dependent on staff for ADLs. He was on noted to be taking an antibiotic. Further review revealed that shortness of breath, mechanical ventilation and the active diagnosis of pneumonia were not reflected. Record review of Resident #1's comprehensive care plan dated 06/10/2026 reflected Focus, using an invasive mechanical ventilator. Breathing pattern ineffective/spontaneous ventilation inability to sustain/requires use of ventilator, Focus, is receiving doxycycline hyclate tablet 100 MG-give one tablet two times a day for pneumonia 06/23/2026 to 06/30/2026. Record review of Resident #1's Active Orders as of 06/22/2026 reflected MODE: VT: 500 RR: 18 PEEP; 12FI02; (ventilator settings) titrate to keep oxygen saturation greater than 92% every shift, start date 04/27/2026. Record review of Resident #1's SBAR Communication Form dated 06/29/2026 reflected Resident #1 had labored breathing. During an interview on 07/17/2026 at 07:15 am, the ADM stated she was accountable for everything at the facility and stated an inaccurate MDS was needed to ensure the patient's needs were identified and met. During an interview on 07/17/2026 at 09:33 am, the DON stated the importance of an accurate MDS assessment was related to the care provided and development of the comprehensive care plan. She stated care could be missed if the MDS assessment was inaccurate. During an interview on 07/17/2026 at 3:08 pm, LVN A stated she completed Resident #1's discharge MDS and she was only human and made mistakes. She stated if an accurate picture of the residents were not provided on the MDS assessment, care could be missed. She stated the facility did not have a policy or procedure which addressed MDS accuracy and the facility followed the RAI manual. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, dated October 2025 reflected The RAI process has multiple regulatory requirements. Federal regulation required the assessment accurately reflects the resident's status.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals) for 1 of 1 resident (Resident #1) to meet the needs of the resident, in that: The facility failed to ensure Resident #1 received ordered medication Rifaximin 550mg for hepatic encephalopathy between 04/27/2026 - 05/16/2026 due to medication being unavailable. This failure could place residents at risk for not receiving therapeutic effects from their medications. The findings included: A record review of Resident #1's face sheet dated 05/19/2026 revealed an admission date of 07/31/2025 with diagnoses which included hepatic encephalopathy (a condition that occurs when the liver is unable to filter toxins from the blood) and chronic kidney disease stage 4 (kidneys are moderately to severely damaged and are not properly filtering waste from the blood). A record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. A record review of Resident #1's care plan dated 02/20/2026, revealed: Resident #1 at risk for alteration in neurological status r/t hx of hepatic encephalopathy, interventions: Give medications as ordered. Monitor/document for side effects and effectiveness, and Receives Rifaximin oral as per MD orders. A record review of Resident #1's physician order summary dated 05/19/2026 revealed to administer the following medications: rifaximin Oral Tablet 550 MG (Rifaximin) Give 1 tablet by mouth every 12 hours for hepatic encephalopathy, with administration time of 8:00am and 8:00pm, with a start date of 02/18/2026. A record review of Resident #1's MAR in the electronic medical record revealed nursing staff did not document Rifaximin 550mg was administered but instead documented 9=Other/See Nurse Notes, during the period of 04/27/2026 - 05/16/2026 for a total of 31 doses of medication. Corresponding progress notes read Note Text: rifAXIMin Oral Tablet 550 MG. Give 1 tablet by mouth every 12 hours for Hepatic encephalopathy, pending delivery, pending pharmacy, or no supply. Interview with the Pharmacy on 05/20/2026 at 9:30am stated that Rifaximin 550mg tablets were no longer covered by Resident #1's insurance and facility may need to submit for prior authorization. During an interview on 05/20/2026 at 10:39 am with LVN A, she stated she was aware Resident#1 had run out of Rifaximin 550mg tablets and that she had called the pharmacy on multiple occasions and faxed the medication order to the pharmacy in attempts to receive the medication. LVN A stated she informed the ADONs that prior authorization was needed. LVN A stated the proper procedure to follow when a medication was not available was to call the pharmacy, inform the ADONs and inform the physician. LVN A stated she did not notify the responsible party and she did not notify the physician because she thought the ADONs would inform him. LVN A stated the risk to a resident missing ordered medications could cause worsening symptoms and cause the resident to become sick. During an interview on 05/20/2026 at 11:45am, ADON B stated she was not aware that Resident #1's Rifaximin 550mg was unavailable, or the need for prior authorization, and that it was not reported to her by the nursing staff. ADON B stated that when she became aware on 05/19/2026, she notified the RP and the physician and obtained new orders for stat labs, new medication and monitoring. ADON B stated the facility initiated an in-service regarding medication availability and the process to follow. During an interview on 05/20/2026 at 12:15pm, ADON C stated she was not aware that Resident #1's Rifaximin 550mg was unavailable, nor was it reported to her the need for a prior authorization. ADON C stated the process to follow if a medication is unavailable was to call the pharmacy, physician and family and let them know and to document that communication. During an interview on 05/19/2026 at 2:10pm with the DON, she stated her expectation for an unavailable medication was that nursing staff contact the pharmacy, check the emergency medication kit, and if not available, notify the DON, physician and family. The DON stated she was not aware of Resident #1 not having Rifaximin 550mg available. During an interview on 05/20/2026 at 11:20am, the DON stated Resident #1's physician and RP had been notified about the missed doses of Rifaximin 550mg on 05/19/2026, and new orders had been obtained and an in-service initiated. The DON stated the risk to residents if medications were not administered as ordered could include a worsening of symptoms. The DON stated there was currently Rifaximin 550mg available for Resident #1 and the facility would pay for the medication if it was not covered by insurance. A record review of the facility's policy titled, Administering Medications, dated 04/2019, revealed, 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on interview and record review the facility failed to immediately consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there is a significant change in the resident's physical, mental, or psychosocial status for 1 of 1 resident (Resident #1) reviewed for medication administration, in that: The facility failed to ensure the physician and RP were notified of missed doses of Rifaximin 550mg for hepatic encephalopathy between 04/27/2026 and 05/16/2026 due to medication not being available. This failure puts the resident at risk for not receiving therapeutic effects from their medications. The findings include: A record review of resident #1's face sheet dated 05/19/2026 revealed an admission date of 07/31/2025 with diagnoses which included hepatic encephalopathy (a condition that occurs when the liver is unable to filter toxins from the blood) and chronic kidney disease stage 4 (kidneys are moderately to severely damaged and are not properly filtering waste from the blood). A record review of resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. A record review of resident #1's care plan dated 02/20/2026, revealed: Resident #1 at risk for alteration in neurological status r/t hx of hepatic encephalopathy, interventions: Give medications as ordered. Monitor/document for side effects and effectiveness, and Receives Rifaximin oral as per MD orders. A record review of resident #1's physician order summary dated 05/19/2026 revealed to administer the following medications: rifaximin Oral Tablet 550 MG (Rifaximin) Give 1 tablet by mouth every 12 hours for hepatic encephalopathy, with administration time of 8:00am and 8:00pm, with a start date of 02/18/2026. A record review of resident #1's MAR in the electronic medical record revealed nursing staff did not document Rifaximin 550mg was administered but instead documented 9=Other/See Nurse Notes, during the period of 04/27/2026 - 05/16/2026 for a total of 31 doses of medication. Corresponding progress notes read Note Text: rifAXIMin Oral Tablet 550 MG, Give 1 tablet by mouth every 12 hours for Hepatic encephalopathy, pending delivery, pending pharmacy, or no supply. A record review of resident #1's progress notes during the period of 04/27/2026 - 05/16/2026 revealed no documentation that the resident's physician or RP had been informed of the missed doses of Rifaximin 550mg. During an interview on 05/20/2026 at 9:58 am with Resident #1's RP, she stated she was not made aware of Resident #1 not receiving her Rifaximin 550mg until the facility informed her on 05/19/2026, and she did not know how long she had gone without her medication. During an interview on 05/20/2026 at 10:39 am with LVN A, she stated she was aware resident#1 had run out of Rifaximin 550mg tablets. LVN A stated the proper procedure to follow when a medication is not available is to call the pharmacy, inform the ADONs and inform the physician. LVN A stated she did not notify the RP and she did not notify the physician because she thought the ADONs would inform him. LVN stated the risk to a resident missing ordered medications could cause worsening symptoms and cause the resident to become sick. During an interview on 05/20/2026 at 11:45am, ADON B stated she was not aware that resident #1's Rifaximin 550mg was unavailable, but she became aware on 05/19/2026, at which point the RP and physician were notified. ADON B stated the RP and physician should be informed when a medication is unavailable. During an interview on 05/19/2026 at 2:10pm with the DON, she stated her expectation for an unavailable medication was that nursing staff contact the pharmacy, check the emergency medication kit, and if not available, notify the DON, physician and family. The DON confirmed there was no documentation that RP or physician were notified about Resident #1's Rifaximin being unavailable. The DON stated the risk to residents if medications were not administered as ordered could include worsening of symptoms. A record review of the facility's policy titled Resident Rights, dated 03/2021, revealed, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: (j) be notified of his or her medical condition and of any changes in his or her condition.

Based on interviews and record reviews, the facility failed to ensure residents the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 of 10 (Resident #1) reviewed for advance directives. The facility failed to honor Resident #1's Out-of-Hospital Do Not Resuscitate (OOH DNR) when on [DATE] the resident was found unresponsive and was resuscitated after respirations and pulse ceased. The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on [DATE] and ended on [DATE]. The facility corrected the non-compliance before the survey began on [DATE]. This failure could place residents at risk of pain associated with resuscitation and mental anguish.The findings included: Record review of Resident #1's face sheet, dated [DATE], revealed a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses that included: depression, anxiety disorder, ALS ( fatal neurodegenerative disease that causes nerves in the brain and spinal cord to degenerate, resulting in muscle weakness), and tracheostomy (surgical opening made in the neck to create an airway for breathing using a ventilator). Record review of Resident #1's comprehensive MDS assessment, dated [DATE], revealed a BIMS of 15. Record review of Resident #1's CP, dated [DATE], revealed Resident #1was care planned for code status DNR. Record review of Resident #1's OOH DNR revealed the document was signed on [DATE] by the physician and two witnesses. Record review of Resident #1's physician order, dated [DATE], revealed Resident #1's advance directive was DNR. Record review of Resident #1's progress note, dated [DATE], revealed Resident #1 was found unresponsive at 6:38 PM by CNA B. CNA B informed LVN C, and LVN C checked Resident #1 for a pulse and found it weak, but Resident #1 was breathing. LVN A entered the room and did a sternal rub (painful stimuli used to assess consciousness) with no response. LVN C checked for a pulse in Resident #1's wrist, groin, and behind the knee and found no pulse. LVN A called a code, and CPR started at 6:40 PM. Record review of in-services: Timely Emergency Services & Professional Standards for CPR; How to Identify the Resident Code Status; and Abuse & Neglect dated [DATE] revealed all staff received in-service trainings. All new hires with start date [DATE] and beyond were required to have the in-service trainings as well. Record review of the CPR certifications for LVN F, LVN A, and RT D, who participated in the code blue of Resident #1, revealed all were valid. During an interview with LVN A on [DATE] at 12:59 PM, LVN A said LVN C was informed by agency CNA B that Resident #1 was unresponsive. LVN A said LVN C went into the room to do an assessment and found Resident #1 to have a weak pulse and breathing. LVN A said she entered the room to do an assessment because the nurse assigned to Resident #1 was busy. LVN A said she attempted to get a response from Resident #1 by doing a sternal rub, and she shook Resident #1, but Resident #1 did not respond. LVN A said while she assessed Resident #1, LVN C checked Resident #1's pulse and found nothing in her wrist, behind her knee, and her groin. LVN A said Resident #1 had stopped breathing. LVN A said she called CODE BLUE, and RT D removed the breathing circuit (components that deliver oxygen to the tracheostomy) from Resident #1's tracheostomy, began suctioning Resident #1 and then RT D started to use the ambu bag (hand-held manual resuscitator) for breaths. LVN A said LVN C retrieved the backboard and LVN A retrieved the crash cart. LVN A said she told CNA B to call 911 while she looked for verification of the code status in the crash cart binder. LVN F arrived and started chest compressions. LVN A said the DNRs that were in the binder had residents' names that were no longer at the facility and the binder had not been updated. LVN A said she went to the computer to look for the DNR in Resident #1's electronic medical record. LVN A said while she was looking for the DNR, EMS arrived. LVN A said when she found the DNR, LVN A told EMS that Resident #1 was a DNR, but a pulse had been recovered. LVN A said she had the in-services for A & N, and how to handle a resident who stopped breathing and had no pulse. LVNA said they learned that the crash cart binders were updated daily, the night shift nurses printed the census sheet and highlighted the names of the residents that were DNRs and every morning, the ADONs for each floor would check the binders to make sure they were correct to prevent someone from being resuscitated who was a DNR. LVN A said doing that did not respect the resident's right. During a telephone interview on [DATE] at 1:44 PM LVN C said an aide from the agency came to the nurses station and told him that Resident #1 was unresponsive. LVN C said he told the agency CNA B to get the nurse for Resident #1 and LVN C went into the room to assess Resident #1. LVN C assessed Resident #1 and found Resident #1's color to be a little pale. LVN C said Resident #1 was breathing and he did a sternal rub, but Resident #1 did not respond. LVN C said LVN A entered and she did an assessment with a sternal rub, shaking and calling her name. LVN C said while LVN A did her assessments, he checked further, he checked Resident #1's her radial pulse that was weak. LVN A tried to move her more aggressively to get a response, and LVN C said he checked for a pulse and found no pulse. LVN C said he checked for a pulse in her groin and the popliteal (behind the knee) and still found no pulse for Resident #1. LVN C said everyone asked if Resident #1 was a DNR or full code. LVN C said there was a hesitation because LVN A was not sure. LVN C said LVN A left the room perhaps to look at the name on the wall outside the door to see if Resident #1 was a DNR because there would be a red dot there and when LVN A returned she said Resident #1 was a full code. LVN C said he did not know who brought the backboard, but RT E brought the ambu bag. He said RT E did the ambu bag once LVN A called Code Blue, but LVN F came in the room, but because he had not renewed his CPR certificate, he started writing everything down during the code. LVN C said after EMS arrived, he gave the notation to LVN A. LVN C said the agency aide CNA B was told by LVN A to call EMS. When EMS arrived, they continued compressions and one of the personnel from EMS asked for a hard copy of the full code status and while LVN A went to get the documentation, EMS got a pulse. LVN C said when LVN A came back, LVN A told EMS that Resident #1 was a DNR. LVN C said he had given statements about what happened, and the administration said they were going to start implementing updated binders and checking electronic medical record. LVN C said he was in-serviced on Code Blue and he learned the process of the protocol of not being unsure, check the crash cart binder, and check the electronic medical record. LVN C said the binders were updated every night and checked by the ADONs. The names of the residents that were DNRs should be highlighted. During an interview on [DATE] at 2:27 PM, CNA G said she received an in-service for abuse and neglect before she could return to work. CNA G said she also received the in-service for DNRs and Code Blue. CNA G said she learned after the in-services that she would check the binder on the crash cart to see who the residents that were DNRs and CNA G said she would get to know a resident if they were new and look in the computer to find out how to take care of them and to see if they were a DNR. During an interview on [DATE] at 2:27 PM CNA J said she received the in-service training for DNR and where she could find them. CNA J said she could find the name of the residents that were DNRs on the crash cart and in the electronic medical record. During an interview on [DATE] at 2:45 PM, CNA P said she received the in-services for abuse and neglect and for what to do in case of a code blue. CNA P said she learned she could look in the binder on the crash cart to check to see if a resident was a full code or DNR. CNA P said the names of the residents that were DNRs were highlighted. CNA P said if she found a resident unresponsive, she would immediately get the nurse and look in the binder or in the electronic medical record. CNA P said the binders were updated daily by the night shift, the ADONs checked the binders to make sure they were correct and there was a copy of the DNR in the binder for each resident. During an interview on [DATE] 3:34 PM, CNA O said she received in-service for abuse and neglect and they would have it frequently. CNA O said she had the in-service for DNRs as well on the same day. She said she learned the DNRs were kept in the binder on the crash cart and was updated every day with the names highlighted that were DNRs. CNA O said there was a copy of the DNR in the binder, and she could also look in the computer to see if a resident was a DNR or not because they used the computer to find out how to care for a resident. CNA O said if she saw a resident that was not responding, she would get the nurse immediately and follow instructions given to her. During an interview on [DATE] at 9:41 AM, LVN K (worked 10PM-6AM) said she worked the night shift and was responsible for printing out the DNR list to be placed in a binder on the crash cart. LVN K said it was done daily using the midnight census. LVN K said the previous way was if a code was called for a resident, CPR was started until it was verified and once it was verified, either it would be stopped or continue with CPR. LVN K said even if the person was new, and knew nothing about the code status, it should be on the census sheet because when it was printed on the midnight census, the name should be highlighted and placed in the binder on the crash cart with a copy of the DNR. During an interview with EMS on [DATE] at 10:08 AM, EMS said the call came in on [DATE] at 6:43 PM and three units were dispatched to the facility in response to the Cod Blue for Resident #1. The first unit arrived at 6:45 PM; the second arrived at 6:46 PM; and the third unit arrived at 6:48 PM. During a telephone interview with CNA B (agency) on [DATE] at 10:13 AM, CNA B said she went to Resident #1's room to do rounds and found the resident unresponsive. CNA B said she told LVN C that Resident #1 was unresponsive and LVN C went to the room to assess Resident #1. CNA B said RT D went into the room and suctioned Resident #1. CNA B said when LVN A entered the room and tried to wake Resident #1, LVN C told LVN A there was no pulse and Resident #1 stopped breathing. CNA B said LVN A called a code and told her to call 911. CNA B said another RT (RT E) entered the room and another LVN F came into the room to help with CPR. CNA B said while she called 911, LVN A looked for the crash cart binder for Resident #1's DNR. CNA B said there seemed to be a discrepancy about whether she was a DNR or not because it said she was in one place and another place Resident #1 was not, so LVN A was not sure. CNA B said LVN A found out Resident #1 was a DNR after EMS arrived, and LVN A informed them that Resident #1 was a DNR. CNA B said she did not have the in-service because she had not been back to the facility since that incident During an interview with the SW on [DATE] at 11:58 PM, the SW said if a resident was already at the facility and decided to become a DNR, she had a form and she would find out if the resident was their own responsible party or if they had one. The SW said she would verify with the RP and once the document was signed, she would give it to the DON to update the electronic medical record. During an interview with Resident #1's RP on [DATE] at 12:17 PM, Resident #1's RP said she signed a DNR on [DATE] she believed. The RP said the doctors at the hospital told her that Resident #1 would not live much longer because the CPR rushed blood to her head. The RP said hospice went to the facility to get a copy of the DNR to transport her to a facility for hospice care where she expired early the next day. The RP said the DNR was in place because Resident #1 said she did not want her ribs cracked. The RP said another DNR was done after Resident #1 admitted to the facility with the one from the hospital because they told her she needed one from the facility. The RP said she was called Monday evening, [DATE], and told Resident #1 was found unresponsive and transported to the hospital. The RP stated the family went to the hospital and spent some time with Resident #1. The RP said at that point, they knew if Resident #1 recovered, the resident would not be in the same frame of mind. The RP said the facility did not abide by Resident #1's wishes. During an interview with RT D on [DATE] at 3:11 PM, RT D said he was called to assist with Resident #1 and when he walked into the room, a nurse (LVN A) and a CNA (CNA B) were working with Resident #1. RT D said he checked Resident #1's airway and suctioned Resident #1. RT D said RT E came in the room as well and took Resident #1 off the ventilator and used the ambu bag until EMS arrived. RT D said he checked the airway and suctioned the Resident #1. RT D said RT E entered the room as well. RT D said RT E took her off he ventilator and used the ambu bag until EMS arrived and RT D said he grabbed the backboard and moved to allow EMS to work. RT D said he had the in-services, and he learned that the census was printed by the night nurses and they highlighted all the names of the residents that were DNRs and then put them in the binder on the crash cart on each floor. During an interview with the ADM on [DATE] at 3:48 PM, the ADM said she was not aware Resident #1 was a DNR, but once they were told that she coded, all managers immediately went to the facility to investigate why the resident was resuscitated when she was a DNR. The ADM said she, the DON, and ADONs for each floor in-serviced the staff about resident rights with: Timely Emergency Services & Professional Standards for CPR, How to Identify the Resident Code Status, and Abuse & Neglect. The ADM said going forward, they implemented that every day, the night shift nurses would print out the resident census sheets and highlight the names of the residents that were DNRs and place the sheets in the crash cart binder along with the copy of the DNR. The ADM said the census would have the date it was printed and that was a way to validate it was done. The ADM said on the morning shift, the ADONs for each floor would check the crash cart binder for accuracy and for any updates of DNR code status that were needed and the DON also checked code status. The ADM said the residents' rights should be respected to maintain a healthy quality of life for them. The ADM said all new hires with start date [DATE] and beyond were required to have the in-service trainings as well. During interview and observation on [DATE] at 4:50 PM, the DON said they implemented the plan for the night shift nurses to print the daily census and placed them in the crash cart binder with the residents' names highlighted that were DNRs. The DON said the date would be printed and that was a way to have accountability. The DON said there was also a weekly SOC (standard of care) on a spreadsheet that was mandatory to complete. The DON said on the spreadsheet, there was a column for DNR and if there was a change, the date for the change by the name of the resident would be there. The DON said the spreadsheet was an internal document that the facility's corporate nurse tracked. The DON said audits were done on a printed report for new admits checking for code status and updating the crash cart binders. The DON said also, when there was a DNR done with the SW, the SW would deliver the DNR to the DON and she would update it in the resident's electronic medical record, and add it to the crash cart binder, and updated in the SOC that was done weekly. The facility implemented a plan for the DON to audit resident charts for DNRs weekly for four weeks, also SOCs done weekly would be audited by the corporate nurse for the facility. Record review of in-services: Timely Emergency Services & Professional Standards for CPR; How to Identify the Resident Code Status; and Abuse & Neglect dated [DATE] revealed all staff received in-service trainings. All new hires with start date [DATE] and beyond were required to have the in-service trainings as well. Record review of LVN F, LVN A, and RT D who participated in the code blue of Resident #1 revealed all CPR certifications were valid. During an interview on [DATE] at 12:30 PM, LVN N said the crash cart binder was updated daily by the nurses on nigh shift. LVN N said the new printed copy would be placed in the crash cart binder with the names highlighted. The LVN said if a resident was unresponsive with no breath or pulse, staff should check the crash cart binder that was checked daily by the ADONs for accuracy as a way for accountability to not have an error as before with Resident #1. During an interview on [DATE] at 9:30 AM, ADON Q2 said she was responsible for ensuring the crash cart binder's census sheet was printed with the residents who were DNRs names highlighted. ADON Q2 said when a resident codes, the binder on the crash cart should be accurate to verify a resident's code status to prevent a resident's rights not being honored. Interview on [DATE] at 12:28 PM, LVN H said the way to identify who was a DNR was by the binder on the crash cart. LVN H said the ADONs checked the binders daily after the night shift nurses printed a new census sheet daily and the names of the residents that were DNRs were highlighted. LVN H said she had several in-services that day after a resident (Resident #1) was resuscitated who was a DNR. LVN H said there should be no mistakes because the binder was checked daily, even with new admissions and the other way to check was in the medical record. Interview on [DATE] at 9:20 AM, LVN I said she knew who was a DNR on her shift 10:00 PM-6:00 AM. LVN I said there was a DNR book on the crash cart. LVN I said she printed the lists of residents who were DNRs for her floor and for the 1st floor as well because she felt it was important to know in case a code was called on another floor. LVN I said she would highlight the residents on her floor- 2nd floor. LVN I said if there was a new resident, and they may not know them, she would have someone to check the crash cart binder, and check the electronic medical records. LVN I said the binders were to be checked daily in the morning by the ADONs for each floor. Interview on [DATE] at 9:41 AM LVN K (worked 10PM-6AM) said she worked the night shift and was responsible for printing out the DNR list to be placed in a binder on the crash cart. LVN K said it was done daily using the midnight census. LVN K said the previous way was if a code was called for a resident, until it was verified and once it was verified, either it would be stopped if it was verified as a DNR or continue if they were a full code. LVN K said even if the person was new, and knew nothing about the code status, it should be on the census sheet because when it was printed on the midnight census, the name should be highlighted and placed in the binder on the crash cart with a copy of the DNR. Interview on [DATE] at 9:50 AM, RN L said she worked the night shift(10PM-6AM), and would update the binders daily on the crash cart with the residents that were DNRs highlighted. RN L said it could also be found in the electronic medical records. RN L said a hard copy of the DNR would be in the binder and it could be found in the electronic medical record under miscellaneous. RN L said she had the in-services after the incident of a resident (Resident #1) being coded that was a DNR and printing the midnight census was a part of correction and if a resident was new, a copy of the DNR would be given by the DON and the new name would be on the census when printed and the name highlighted. During an interview on [DATE] at 10:08 AM, CNA R said if she found someone who had no pulse or breath, she would inform the nurse and the nurse would initiate CODE BLUE and start CPR and would continue until the status was verified. She said there was a binder on the crash cart and there was a list of the residents that were DNRs. CNA R said since the received the in-service, they would first check the crash cart binder to make sure the resident was a DNR before starting CPR. CNA R said the names in the crash cart binder should be highlighted because the night shift nurses do it and the ADONs check them every day in the morning. Interview on [DATE] at 11:58AM the SW said she received the in-services immediately after the incident with Resident #1. The SW said the binders on the crash carts were updated and verified daily by the ADONs on each floor. The SW said the census should be printed during the night shift and the names were highlighted for the residents that were DNRs. During an interview on [DATE] at 3:55 PM, LVN M said he received an in-service for DNR along with others the same day. LVN M said he learned the crash cart binders were updated during the overnight shift when they printed the midnight census and highlighted the residents that were DNRs. LVN M said that it was supposed to ensure that a resident that was a DNR wishes would be respected. LVN M said if it was not found in the binder, he would look in the computer in the medical record of the resident and if it was a new resident, the DON would bring a copy of the DNR to the floor and give it to a nurse to place in the binder and update the name on the list. LVN M said if it was given to him, he would place it in the binder, write the name on the census sheet and put it on the 24-hour report so the night shift would be aware that way as well as the binder. During an interview on [DATE] at 4:55 PM, ADON Q1 said she received the in-services and the one for Code Blue was for her as an ADON to check the crash cart binder for the 1st floor to ensure the resident census was printed out over night by the nurses and highlighted names of the residents who were DNRs. ADON Q1 said the census date should be the following day from the previous date, which would be accountability that they're being printed. ADON Q1 said she would go through the electronic medical record of all the names on the list for the 1st floor were correct as being highlighted as DNRs. Investigator requested policy for Out-of-Hospital DNR and was informed there was no policy for Out-of-Hospital DNR, only for Resident Rights. During an interview on [DATE] at 6:30 PM, CNA S said she received the in-services for abuse and neglect and DNR. CNA S said she learned if she found a resident unresponsive, she would get the nurse and look in the binder on the crash cart and then tell the nurse the code status. CNA S said she would be able to find the code status in the binder on the crash cart and on the computer where she would look to know what a resident needs when she took care of them. CNA S said the binder is updated every day and it should be safe to use the binder to find out if a resident was a full code or DNR. CNA S said there was also a copy of the DNR in the binder on the crash cart. Record review of the 1st floor crash cart binder on [DATE] at 2:54 PM revealed the date on the census sheet was dated [DATE] with the names of the residents highlighted as DNRs. The 2nd floor crash cart binder with the census was dated [DATE] with the names of the residents as DNRs highlighted. Record review of the facility's policy titled, Statement of Resident Rights, undated, revealed: You, the resident do not give up any rights when you enter a nursing facility. The facility must encourage and fully assist you to fully exercise your rights. You have a right to participate in developing a plan of care, to refuse treatment. The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on [DATE] and ended on [DATE]. The facility corrected the non-compliance before the survey began on [DATE].

Based on interviews and record review, the facility failed to ensure a resident's responsible party was informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose alternative options is he or she preferred for 2 of 5 (Residents #52 and #4) residents reviewed for resident rights. The facility failed to notify and obtain consent from Resident #52 or her RP to administer buspirone (used to treat anxiety) and failed to adequately disclose potential side effects or complete all portions of the consents including physician diagnostic criteria and signature for diazepam (a benzodiazepine used to treat anxiety) and Lexapro (antidepressant). 2. The facility failed to notify and obtain consent from Resident #4 to administer Atarax (medication that caused sedation) and failed to adequately disclose potential side effectors or complete all portions of the consent including physician diagnostic criteria and signature for duloxetine (antidepressant). This failure could affect residents and/or responsible parties by placing them at risk for not being fully informed of the treatment and/or protentional risks of treatment. The findings included:1. Record review of Resident #52's face sheet dated 2/12/2026 revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: amyotrophic lateral sclerosis (progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord, leading to muscle weakness and atrophy), depression and anxiety disorder. Record review of Resident #52's significant change in status MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated she was cognitively intact. Her functional status was listed as completely dependent on staff for all movement and all care. The assessment indicated Resident #52 was taking multiple medications listed a high-risk class drugs including antianxiety and antidepressant medications. Record review of Resident #52's Care Plan last revised 12/22/2025 revealed she had a plan of care for medication related to depression and anxiety which included side effect monitoring and behavior monitoring. Record review of Resident #52's Order Summary for February 2026 revealed the following medications:1. buspirone tablet 7.5 mg, give one tablet two times a day related to anxiety disorder with a start date of 12/12/2025. 2. diazepam tablet 5 mg, give 0.5 tablet one time a day for anxiety related to anxiety disorder with a start date of 2/5/20263. Lexapro 20 mg tablet, give one abet one time a day replated to anxiety and depression with a start date of 1/29/2026 Record review of Resident #52's consents for psychotropic medications revealed:There was no consent for buspirone in the resident's medical record. The consent for diazepam dated 1/22/2026 on form 3713 was incomplete. Information by the provider for length of time treating the patient was blank. The psychiatric condition or maladaptive behavior was left blank. The diagnoses based on diagnosis criteria and assessment indicated antianxiety without any additional information. Medication dose and frequency was left blank. The side effects and risk of proposed treatment had a statement that stated benefits outweigh the risks without listing the possible side effects of the medication. The document had not been signed by the physician or the Medical Director. The form indicated verbal consent was obtained by the RP. The consent for Lexapro dated 12/03/2020 on form 3713 which was incomplete. Information by the provider for length of time treating the patient was blank. The psychiatric condition or maladaptive behavior was left blank. The diagnoses based on diagnosis criteria and assessment indicated depression without any additional information. Medication dose and frequency was left blank. The side effects and risk of proposed treatment had a statement that stated benefits outweigh the risks without listing the possible side effects of the medication. The document had not been signed by the physician or the Medical Director. The form indicated verbal consent was obtained by the RP. During an interview on 2/12/2025 at approximately 3:40 p.m., Resident #52 was unable to answer whether or not she received information about her medication. She indicated her family member may have received the information. During an interview on 2/12/2026 at 4:00 p.m., Resident #52's RP (family member) stated she was called twice for consents for anxiety but did not remember the name of the medications. She stated she was not told of any potential side effects. She stated a nurse (unknown name) just told her the resident needed the medication and she agreed. 2. Record review of Resident #4's face sheet dated 2/12/2026 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: moderate recurrent major depressive disorder, generalized anxiety disorder, and cyclothymic disorder (mood disorder with fluctuating highs/mania and lows/depression). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated she was cognitively intact. Her functional status was maximal dependance on staff for movement and total dependance on staff for bodily hygiene. The MDS assessment indicated Resident #4 was taking antidepressant, medications. Record review of Resident #4's Care Plan last revised 12/08/2025 revealed she was taking antidepressant medications with an intervention which included: Assure consent is gen for administration of antidepressant. The care plan revealed she was taking antianxiety medication including buspirone and staff should assess for behavior manifested and notify MD. The care plan indicated the resident was receiving Atarax per MD orders for itching and refusal to shower (behavior). Record review of Resident #4's Order Summary for February 2026 revealed: Atarax (hydroxyzine) 10 mg, give one tablet by mouth every 8 hours as needed for itching with a start date of 1/15/2026. Duloxetine delayed release capsules 60 mg, give one capsule one time a day for depression with a start date of 1/15/2026. Record review of Resident #4's physician order for Atarax 10 (hydroxyzine) 10 mg in PCC had the following staff alert and drug protocol on this order: Clinical Reviews: Antianxiety Agents Notes: Must have consent for medication .This class of medication requires a consent . Record review of Resident #4's consents for treatment revealed: No consents for the use of Atarax were found in the resident's medical record. The consent for duloxetine dated 11/17/2025 on form 3713 was incomplete. Information by the provider for length of time treating the patient was blank. The psychiatric condition or maladaptive behavior was left blank. The diagnoses based on diagnosis criteria and assessment indicated major depressive disorder without any additional information or assessment. Medication dose and frequency was left blank. The side effects and risk of proposed treatment had a statement that stated benefits outweigh the risks without listing the possible side effects of the medication. The document had not been signed by the physician or the Medical Director. The form had the signature of the resident. During an interview on 2/12/2026 at approximately 3:48 p.m., Resident #4 stated she did not know if she had received information about her medication treatments. During an interview on 2/12/2026 at 4:21 p.m., LVN F stated consents for psychotropic medications were obtained when a new order was received by the physician. She stated it was typically the nurse who received the order's responsibility. LVN F stated they would tell the resident to ensure they were in agreement with the treatment and obtain consent from the RP. She stated if the resident was unable to sign, such as Resident #52, they would get signatures or telephone consent from the RP. LVN F stated two nurses were required to confirm telephone consent. She stated after the consents were obtained, she would make a copy of the consent and give one to the DON and one to medical records. LVN F stated ADON E and management were responsible for obtaining the physicians signature and consent because they were the ones making rounds with the physicians. LVN F stated she was the nurse responsible for Resident #52's diazepam consent. She stated there was only one nurse as a witness for the telephone consent. She stated she could not remember who else verified the RP gave consent. LVN F stated the consents for Resident #52's diazepam and Lexapro and Resident #4's duloxetine were missing most of the information. LVN F stated the DON gave the nurses instructions on how to fill out the forms. She stated the forms were prefilled in and she just obtained the actual consent. She stated she did not write anything else on the forms. LVN F stated the DON's signature was on Resident #52's Lexapro consent form as having completed the form which was incomplete. She stated she did not know who was responsible for completing Resident #4's consents or why they were missing and incomplete. During an interview on 2/12/2026 at 4:32 p.m., ADON E stated acknowledgement that the existing consents for Residents #52 and #4 were missing documentation and physician signatures. ADON E stated a few days ago (date unknown) she reviewed the consents for completeness and agreed they were not complete. She stated she was unaware of missing consents. ADON E stated up until a few days ago it was not part of her job duties and the DON was responsible. ADON E stated consents should be obtained for psychotropic medications including antipsychotics, hypnotics and antianxiety medication. She stated a consent for Atarax was not needed for Resident #4 because the medication was prescribed off label for itching and was not as a psychotropic medication. During an interview on 2/13/2026 at 9:42 a.m., the DON stated ADON E was responsible for monitoring psychotropic consents. She stated the charge nurses were responsible for obtaining the consents. The DON stated everything stops in her office (meaning she has final oversight). The DON stated they did some audits on consents but could not remember the details because she was consumed with the challenge of finding some things. She stated the ADONs should be double checking the consents for accuracy. The DON stated treatments were discussed during morning meetings. She stated the process was the nurses got the consents, the ADONs double check and she validates. The DON stated Atarax, even used off label should still get a consent. The DON stated it was important to obtain consent to treat and administer psychotropic medications so the family and resident were aware of the medication and so they could monitor outcomes. Record review of a Texas Health and Human Services list of psychotropic medications dated January 2025 listed: Atarax (hydroxyzine), diazepam and buspirone in the class of medications of anxiolytics/sedatives/hypnotics. Duloxetine and Lexapro were listed as antidepressants. Record review of the facility policy, titled Resident Rights dated February 2021 revealed: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: p. be informed of, and participate in, his or her care planning and treatment. Record review of the facility policy, titled Antipsychotic Medication Use dated July 2022 revealed: 13. Residents (and/or resident representatives) will be informed of the recommendation, risks, benefits, purpose and potential adverse consequences of antipsychotic medication use. Residents (and/or representatives) may refuse medications of any kind.

Based on observation, interview, and record review, the facility failed to ensure drugs and biological were stored in a manner that permitted only authorized personnel to have access to the keys for 1of 2 Medication Rooms (100 hall medication room) reviewed for pharmacy services. The facility failed to ensure 1 of 2 doors remained locked on the hallway medication room. This failure could place residents receiving medication at risk for access by unauthorized personal, visitors and residents. The findings included: During an observation on 2/11/2026 at 2:11 p.m., the medication room on the first floor 100 hallway was observed to have two doors. The door inside the nurse's station was locked. The door on the hallway was unlocked and was able to be opened. Inside the medication room, visible from the doorway were multiple over the counter medications, a medication refrigerator, a resident snack refrigerator and resident snacks. A cabinet on the bottom shelf with prescription medication that was visible through a crack was locked. There was no staff present in the hallway or at the nurse's station. During an interview on 2/11/2026 at 2:14 p.m., LVN H stated she was not aware the door on the hallway to the medication room was unlocked. She stated the door was supposed to be locked at all times. She stated the medication room had over the counter meds, insulin in the refrigerator and other prescription medications in the refrigerator. She stated the bottom locked shelf contained prescription medications for destruction. LVN H stated the snacks were meant for the residents. She stated residents were not allowed in the room, only staff with keys. She stated she had keys to the medication room. She stated only licensed staff held the keys. LVN H stated it was important for the medication room to remain locked because the room held medications and residents could get to them if left unlocked. During an interview on 02/11/2026 at 3:24 p.m., the DON stated she was not aware there was a second door that was being utilized to the 100-hallway med room. She stated the med room should remain locked at all times. She stated only licensed staff had keys and should have access to the room. The DON stated it was important because there were meds stored in the room that should have be accessed. Record review of the facility policy, titled Medication Labeling and Storage dated February 2023 revealed: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, )

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 6 residents (Residents #3, #5 and#43) reviewed for infection control, in that: 1.On 02/12/2026, the Facility failed to ensure LVN A changed gloved and sanitize her hands after touching Resident #3's environment. 2. On 02/12/2026, the Facility failed to ensure RT C wore a gown while providing care for Resident #5 who was on Enhanced Barrier Precaution. 3.On 02/12/2026, the Facility failed to ensure LVN A used a disposable cloth under Resident #43's wound, during wound care, to prevent cross contamination. These deficient practices could place residents at-risk for infection due to improper care practices.The findings include: 1.Record review of Resident #3s face sheet, dated 02/13/2026 , revealed an admission date of 07/31/2025 and, a readmission date of 01/22/2026, with diagnoses that included: Dementia (decline in cognitive abilities), Bipolar disorder (Mental disorder characterized by periods of depression and periods of abnormally elevated mood), Chronic kidney disease (gradual loss of kidney function), Tracheostomy status (artificial opening into trachea allowing breathing), Gastrostomy status (opening through the abdominal wall into the stomach allowing feeding), Type 2 diabetes mellitus (high level of sugar in the blood) and, Hypertension (High blood pressure). Record review of Resident #3's significant change MDS assessment, dated 01/28/2026, revealed a BIMS score of 7, which indicated the resident's cognition was severely impaired, and was indicated to always be incontinent of bowel and bladder. Record review of Resident #3's care plan dated 02/02/2026, revealed a problem of requires Enhanced Barrier Precautions. and an intervention of Maintain Enhanced Barrier Precautions during high contact resident care activities (i.e., dressing, bathing/showering, transferring, providing hygiene, linen changes, peri care/changing briefs/toileting, chronic wound care, and all in-dwelling device care:tracheostomy, central lines, feeding tubes, urinary catheters Observation on 02/12/2026 at 01:02 p.m. revealed while providing incontinent care for Resident #3, LVN A touched the privacy curtain with her gloved hands and without changing her gloves or sanitizing her hands touched the resident's skin to start assisting CNA B with providing care. During an interview on 02/12/2026 at 1:16 p.m. with LVN A, she stated she did not think about the curtain being considered dirty and she should have changed her gloves and sanitized her hands to prevent cross contamination and infection for the resident. She stated she had received infection control training within the year. During an interview with the DON on 02/12/2026 at 3:15 p.m., she stated that staff should change their gloves and sanitize their hands after touching anything in the resident's proximity and before touching the resident and provide care. She stated training for infection control was provided at least annually by the DON and ADONs. Record review of facility's policy titled Standard precautions, dated September 2022, revealed, Hand hygiene is performed [ .] after contact with items in the resident's room. 2. Record review of Resident #5's face sheet, dated 02/12/2026 , revealed an admission date of 02/19/2025 and, a readmission date of 09/17/2025, with diagnoses that included: Anoxic brain damage(Brain injury caused by lack of oxygen), Tracheostomy status (artificial opening into trachea allowing breathing), Gastrostomy status (opening through the abdominal wall into the stomach allowing feeding), Type 1 diabetes mellitus (high level of sugar in the blood). Record review of Resident #5's Annual MDS, dated [DATE], revealed Resident #5 was nonverbal and her cognition was severely impaired. She had a tracheostomy. Record review of Resident #5's care plan dated 12/19/2025, revealed a problem of requires Enhanced Barrier Precautions. and an intervention of Maintain Enhanced Barrier Precautions during high contact resident care activities (i.e., dressing, bathing/showering, transferring, providing hygiene, linen changes, peri care/changing briefs/toileting, chronic wound care, and all in-dwelling device care:tracheostomy, central lines, feeding tubes, urinary catheters Observation on 02/12/2026 at 10 a.m., RT C did not put on a gown before starting to provide Tracheostomy care for Resident #5 During an interview on 02/12/2026 at, 10:13 a.m., RT C stated he knew the resident was on Enhanced Barrier Precaution, but he forgot to put a gown on. He stated he did not know why he had forgotten. He confirmed it was a risk of contamination for the resident. He stated he received infection control training within a year During an interview with the DON on 02/12/2026 at 10:30 a.m., the DON stated that a resident with a tracheostomy was on Enhanced Barrier Precaution and the staff should wear gown and gloves while providing care. She stated the staff were provided with infection control and Enhanced Barrier Precaution training. The training was provided by the DON and the DONs. Record review of facility's policy titled Standard precautions, dated September 2022, revealed, Gowns are worn for direct resident contact [ .]. 3. Record review of Resident #43's face sheet, dated 02/13/2026 , revealed an admission date of 08/04/2025 and, a readmission date of 12/11/2025, with diagnoses that included: Chronic kidney disease (gradual loss of kidney function), Tracheostomy status (artificial opening into trachea allowing breathing), Type 2 diabetes mellitus (high level of sugar in the blood) and, Open wound of back wall of thorax (wound in the middle of the back penetrating in the chest cavity). Record review of Resident #43's significant change MDS, dated [DATE], revealed a BIMS score of 15, which indicated the resident's cognition was intact. The resident was coded as having surgical wounds. Record review of Resident #43's care plan dated 11/20/2025, revealed a problem of is at risk for skin breakdown and is at risk for new pressureulcers r/t limited mobility, [ .] has multiple skin impairments that require treatments and an intervention of Refer to UT Health Infectious Disease related to long term antibiotic management for infection suppression at site of dehisced post-surgical scar. Observation on 02/12/2026 1:18 p.m revealed while providing wound care for Resident #43, LVN A did not place a disposable cloth next to the resident under the wound. After the wound was cleaned, the wound and its surrounding skin was close to the surface of the air mattress. During an interview on 02/12/2026 at 1:35 p.m. with LVN A, she stated she did not use a disposable cloth, but the wound did not touch the mattress after being cleaned. During an interview with the DON on 02/12/2026 at 3:15 p.m., she stated that staff should place a disposable cloth under the wound to prevent potential contamination with linen or mattress under the resident. She stated infection control training was provided annually and staff skills were checked annually. Record review of facility's policy titled Wound care, dated October 2010, revealed, Position resident. Place a disposable cloth next to the resident (under the wound) to serve as a barrier [ .].

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 2 units (unit 200) reviewed for physical environment, in that: The Facility failed to ensure that hazardous products, such as disinfecting wipes, were kept out of reach of the residents. These deficient practices could place residents and staff at-risk for injury.The findings were: Observation on 02/12/2026 at 1:18 p.m., revealed while providing wound care for a resident, LVN A used sanitizing wipes to clean a side table. After sanitizing the side table, she left the wipes container on top of her cart and went in the room to provide care. She closed the door and lost line of sight with the wipes. The wipes were left on top of the cart for the length of the care, from 1:18 p.m. to 1:25 p.m. Observation on 02/12/2026 at 1:25 p.m., revealed the wipes container had a caution label for causes moderate eye irritation, avoid contact with eyes [ .] physical or chemical hazards, flammable. During an interview with LVN A on 02/12/2026 at 1:25 p.m., the LVN Stated she had left the wipes on top of her cart after entering the room. She stated she did not know the wipes should be kept in her cart and away from the residents. During an interview with the DON on 02/12/2026 at 3:15 p.m., the DON stated hazardous product should be kept under lock when not used to prevent resident accessing them and harming themselves. She stated the staff was provided training annually about keeping dangerous products under lock. She confirmed residents with dementia and impaired cognition were on the second floor and some residents could use their wheelchair independently. Record review of facility's policy titled Cleaning and disinfection of environmental surfaces, dated August 2019, revealed Manufacturers' instructions will be followed for proper use of disinfecting products including [ .] storage.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care with 48 hours of the resident's admission for 1 (Resident #68) of 1 residents reviewed for baseline care plans, in that: Resident #68 did not have a baseline care plan. This deficient practice could result in improper treatment.The findings were: Record review of Resident #68's facesheet, dated 02/12/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses including Essential (Primary) Hypertension, Obstructive Sleep Apnea, and Heart Disease. Record review of Resident #68's discharge MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. Record review of Resident #68's full clinical record revealed he resided at the facility from 11/13/2025 to 11/18/2025 and no baseline care plan was developed for him during his admission. During an interview with ADON J on 02/12/2026 at 5:00 p.m., ADON J confirmed that no baseline care plan had been developed for Resident #68 during his tenure at the facility, stated she did not know why it had not been completed, and stated it should have been. ADON J stated the baseline care plan includes information necessary for staff to care for the resident. Record review of the facility policy, Care Plans - Baseline, revised December 2016, revealed, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission.

Based on observation, interview, and record review, the facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Residents #3) reviewed for for quality of care, in that: The facility failed to ensure, while providing incontinent care for Resident #3, CNA B did not make multiple passes with the same wipe to clean Resident #3, she spread the resident's labia and cleaned Resident #3's anal area. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.The findings were: Record review of Resident #3s face sheet, dated 02/13/2026 , revealed an admission date of 07/31/2025 and, a readmission date of 01/22/2026, with diagnoses that included: Dementia (decline in cognitive abilities), Bipolar disorder (Mental disorder characterized by periods of depression and periods of abnormally elevated mood), Chronic kidney disease (gradual loss of kidney function), Tracheostomy status (artificial opening into trachea allowing breathing), Gastrostomy status (opening through the abdominal wall into the stomach allowing feeding), Type 2 diabetes mellitus (high level of sugar in the blood) and, Hypertension (High blood pressure). Record review of Resident #3's significant change MDS, dated [DATE], revealed a BIMS score of 7, which indicated the resident's cognition was severely impaired, and was indicated to always be incontinent of bowel and bladder. Record review of Resident #3's care plan dated 02/02/2026, revealed a problem of is at risk for skin integrity r/t (related to) loss incontinence of bowel and bladder and an intervention of Provide peri-care after each incontinent episode Observation on 02/12/2026 at 01:02 p.m. revealed while providing incontinent care for Resident #3, CNA B did not change wipe between across the abdomen and the right-side groin. CNA B did not separate Resident #3's labia and did not clean Resident #3's anal area. During an interview on 02/12/2026 at 1:16 p.m. with CNA B, she stated she did not change the wipe between the abdomen and right groin. She also stated she should have cleaned between Resident #3's labia and should have cleaned the resident's anal area. She stated she thought she could use the same wipe if she was folding them. She stated she forgot to separate the labia and did not know she should clean deeper between the buttocks. She stated she received training for infection control and incontinent care at least annually. During an interview with the DON on 02/12/2026 at 3:15 p.m., she stated that staff should not do multiple passes with the same wipe during incontinent care. The staff should separate the female resident's labia when cleaning and should clean the anal area. She stated appropriate incontinent care was important to prevent infection for the residents. She stated training was provided for the staff, at least annually and, their skills were checked every year by the DON and ADON. Record review of facility's policy titled Perineal care, dated February 2018, revealed, Separate labia [ .] wash the rectal area thoroughly.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispending, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 8 residents (Resident #5) reviewed for pharmacy services. The facility failed to ensure Resident #5 received the correct dose of ferrous sulfate (iron supplement) on 3/11/2026 of 5 ml of 300 mg/5 ml (60 Fe) as prescribed by the physician. This failure could place residents at risk of receiving the correct dosage of medication and put them at risk for medication errors. The findings included: Record review of Resident #5's face sheet dated 2/13/2026 revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: anoxic brain damage, type 1 diabetes mellitus and dependence on supplemental oxygen. Record review of Resident #5's annual MDS assessment dated [DATE] revealed a BIMS score that could not be obtained with both short term and long-term memory problems and indicated a severe cognitive impairment. The assessment indicated the resident was dependent on staff for care and had a PEG tube. Record review of Resident #5's Care Plan last revised on 12/19/2025 revealed it did not address anemia or the use of iron supplementation. Record review of Resident #5's physician order dated 9/17/2026 revealed an order for ferrous sulfate give 5 ml of ferrous sulfate solution 300 mg/5 ml (60 Fe) via G-tube (feeding tube) two times a day for anemia. During an observation on 2/11/2026 at 8:13 a.m., LVN G dispensed 5 ml of liquid ferrous sulfate 220 mg/5 ml solution and administered it to the resident via a feeding tube. During an interview on 2/11/1026 at 1:22 p.m., LVN G stated the bottle of ferrous sulfate used for the med pass was 220/ml instead of 300/5ml for Resident #5. He stated it was a medication error. He did not respond when asked for the process of administering medication and comparing labels to what was ordered. He stated it was what they had been giving the patient. During an interview on 2/11/2026 at 2:40 p.m., the DON stated medication should be dispensed and given as ordered by the physician. She stated the order should be verified against the medication label on hand and if there were any discrepancies the physician should be notified for clarification. The DON stated it was important, so the resident received the correct dosage of medication. Record review of the facility policy, titled Administering Medications dated April 2019 revealed: Medications are administered in a safe and timely manner, and as prescribed. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on interview and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #4) reviewed for unnecessary medications, in that: The facility failed to ensure Resident #4 psychotropic medication, Atarax was prescribed no longer than 14 days PRN. Resident #4 was ordered PRN Atarax (an antihistamine medication with sedative and hypnotic effects used to treat anxiety disorders) on 1/15/2026 without a stop date. This failure could place residents at risk of receiving unnecessary psychotropic medications. The findings included: Record review of Resident #4's face sheet dated 2/12/2026 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: moderate recurrent major depressive disorder, generalized anxiety disorder, and cyclothymic disorder (mood disorder with fluctuating highs/mania and lows/depression). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated she was cognitively intact. Her functional status was maximal dependance on staff for movement and total dependance on staff for bodily hygiene. Record review of Resident #4's Care Plan last revised 12/08/2025 revealed the resident was receiving Atarax per MD orders for itching and refusal to shower (behavior). Record review of Resident #4's Order Summary for February 2026 revealed: Atarax (hydroxyzine) 10 mg, give one tablet by mouth every 8 hours as needed for itching with a start date of 1/15/2026. Record review of Resident #4's physician order for Atarax 10 (hydroxyzine) 10 mg in PCC had the following staff alert and drug protocol on this order: Antianxiety Agents Notes: Must have consent for medication .This class of medication requires a consent, side effect and behavior monitoring. the end date was listed as indefinite. Record review of Resident #4's consents for treatment revealed: No consents for the use of Atarax were found in the resident's medical record. During an interview on 2/12/2026 at approximately 3:48 p.m., Resident #4 stated she did not know if she had received information about her medication treatments. During an interview on 2/12/2026 at 4:32 p.m., ADON E stated consents should be obtained for psychotropic medications including antipsychotics, hypnotics and antianxiety medication. She stated a consent for Atarax was not needed for Resident #4 because the medication was prescribed off label for itching and was not as a psychotropic medication and would not need a specific end date because it was used for itching and not as a psychotropic medication. She stated she was aware of the rule of 14-day limits for PRN psychotropics but was unsure how they applied because people had told her different things. During an interview on 2/13/2026 at 9:42 a.m., the DON stated the computer flagged psychotropics at 14 days. She stated the psychology group monitored psychotropic medications and communicated with the ADON on Fridays. She stated Atarax usage for Resident #4 was a conversation with the psychologist, the physician and the pharmacy. She stated it was important to limit its use in order to monitor outcomes and ensure it was serving the purpose (intended). Record review of a Texas Health and Human Services list of psychotropic medications dated January 2025 listed: Atarax (hydroxyzine), diazepam and buspirone in the class of medications of anxiolytics/sedatives/hypnotics. Duloxetine and Lexapro were listed as antidepressants. Record review of the facility policy, titled Antipsychotic Medication Use dated July 2022 revealed: 16. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication and documented the rationale for continued use. The duration of the PRN order will be indicated in the order.

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 includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Residents #5) reviewed for care plans: The facility failed to ensure Resident #5 comprehensive care plan included a plan for anemia with goals and interventions to address her low hemoglobin and hematocrit (which could be symptoms of anemia). This deficient practice could cause incomplete information to be given to staff responsible for care to the residents and place residents at risk of receiving improper care and services. The findings included:Record review of Resident #5's face sheet dated 2/13/2026 revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: anoxic brain damage, type 1 diabetes mellitus and dependence on supplemental oxygen. Record review of Resident #5's annual MDS assessment dated [DATE] revealed a BIMS score that could not be obtained with both short term and long-term memory problems and indicated a severe cognitive impairment. The assessment indicated the resident was dependent on staff for care and had a PEG tube. Record review of Resident #5's Care Plan last revised on 12/19/2025 revealed it did not address her anemia or appropriate interventions. Record review of Resident #5's physician order dated 9/17/2026 revealed an order for ferrous sulfate give 5 ml of ferrous sulfate solution 300 mg/5 ml (60 Fe) via G-tube (feeding tube) two times a day for anemia. Record review of Resident #5's lab work dated 1/12/2026 revealed low hemoglobin at 9.6 (normal 11.5-15.5) and hematocrit 32.7 (normal 34.0-45.0) which could be indicitive of anemia. Record review of Resident #5's lab work dated 2/02/2026 revealed low hemoglobin at 9.8 and hematocrit at 33.1 which could be indicative of anemia. During an interview on 2/13/2026 at 12:10 p.m., the MDS Coordinator stated the care plan for Resident #5 did not contain a plan of care for anemia or the use of iron supplementation. She stated ideally the care plan should address the use of iron supplementation for the treatment of anemia. The MDS Coordinator stated she reviewed medications and lab work, and they talked about residents in morning meetings. She stated if it was not discussed in morning meeting she was unaware of it. She stated she does not review labs on a normal basis unless something was brought to her attention. The MDS Coordinator stated the facility communicated as a team and she would expect something like this to have been brought up. She stated the nurses could not alter care plans. She stated she was responsible for most of the review and update of the resident care plans. The MDS Coordinator stated it was important to include iron supplementation and anemia on the care plan so the nurses would know that the physician orders jived (coordinated) with the care plan. During an interview on 2/13/2026 at 12:22 p.m., the DON stated the care plans were interdisciplinary. She stated an RN was required to open a new care area and then the team decided what was included. The DON stated she was an RN, one of the ADON's was an RN and they also had RNs on the nursing staff. She stated the MDS Coordinator was an LVN and could edit based on team input. The DON stated accurate complete comprehensive care plans were important for the resident and so the staff could evaluate the nursing process. Record review of the facility policy, titled Care Plans, Comprehensive Person-Centered dated March 2022 revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observations, record reviews, and interviews, the facility failed to correct impairments during the inspection for 1 of 1 Fire Alarm System, inspected for regulatory requirements, failed to ensure outside areas, were maintained in good condition and kept free of conditions which constituted a fire or health hazard and failed to ensure the Emergency Preparedness Plan had been evaluated and updated annually. The Emergency Preparedness Plan was not updated at least annually. The Fire Alarm Control Panel was impaired indicating a low battery trouble signal. There were multiple trees on the back side of the facility leaning up against the roof which could constitute a fire hazard. These failures could affect the health and safety of residents dependent on staff to maintain the facility free of fire hazards, have a functioning alarm system and ensure staff were prepared to address emergency situations. Findings included:During an interview in the entrance conference, at 09:20 a.m. on 11/07/2025, the Administrator stated she was employed as the Administrator with the facility for one week. She stated she had not had the chance to review the Emergency Preparedness Plan. The Administrator stated the Emergency Preparedness Plan was not reviewed. When asked if she was aware of the Emergency Preparedness Plan binders being updated she stated she was not aware of the requirement. She understood as the Administrator she was responsible to review and update the Emergency Preparedness Plan at least annually. After further discussion the Administrator understood and agreed this could leave the staff unprepared during an emergency, causing confusion, a delay in evacuation, physical injuries, mental distress, and exposure to environmental conditions to the residents.Record review on 11/07/2025 of the Facility's Report, dated 11/07/2025, provided by the Administrator, revealed 52 residents resided in the facility with 17 resident's dependent on ventilators for maintaining oxygen levels.Record review on 11/07/2025 of the Emergency Preparedness Plan obtained from the Administrator reflected an emergency preparedness plan that had been reviewed, signed, and dated in 2005. There was no other documentation provided before exit to reflect a current review of their Emergency Preparedness Plan. Observation on 11/07/2025 at 10:39 A.M., revealed the fire alarm annunciator located near the Nurse Station had a trouble signal indicating Low Battery.During an interview on 11/07/2025, at the time of observation, the Maintenance Director confirmed and stated there was a trouble signal at the Fire Alarm Control Panel. He stated he was aware the Fire Alarm System had a trouble signal and stated it was due to an issue with the board. He stated he had two contractors come out and service the panel and one contractor stated the battery voltage was working properly. The other contractor stated it could be an issue with the board. He stated he would get a complete diagnosis of the issue and make any necessary repairs. The Maintenance Director stated that the low battery trouble signal will come and go periodically and that he developed a method to charge batteries onsite and swap them out if needed. He further stated he would contact the contractor and have them send the estimate for repairs as soon as possible so repairs can be started. The Maintenance Director stated if the Fire Alarm System did not function properly in the event of a fire it could allow the fire to spread to the rest of the building, harming residents. Record review on 11/07/2025 of the Inspection, Testing, and Maintenance sticker affixed to the Fire Alarm control panel, dated 09/10/2025, revealed a red service tag with a list of conditions/area: Fault in panel DC battery charge failure.Record review on 11/07/2025 of the Inspection, Testing, and Maintenance sticker affixed to the Fire Alarm control panel, dated 09/23/2025, revealed a white service tag with a list of services: replaced SD 2nd Floor, Lobby - Checked on battery charger voltage - 27V.During an observation outside inspection of the back side of the facility, it was noted there was vegetation growing over the roof of the building along with multiple dead fallen tree branches, dead brush, and dead leaves along the entirety of the rear adjacent to the smoking area.In an interview on 11/07/2025, at the time of observation, the Maintenance Director stated there were trees leaning against the building. The Maintenance Director stated the area adjacent to the smoking area was also surrounded by dead leaves and fallen tree branches. The Maintenance Director stated he was responsible for ensuring the grounds and maintaining compliance. He stated he was aware of the overgrown vegetation and tree branches; however, he was extremely busy with his workload. He stated he would get a vendor to ensure compliance was met with the outside grounds. He further stated if the facility grounds are not kept free of fire hazards it could place individuals at risk of a diminished quality of life and potential injuries

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 7 of 10 residents (Residents #2, #3, #5, #6, #7, #8 and # 9) reviewed for infection control, in that: 1. RT A was observed providing tracheotomy care to Resident #2 on 08/18/2025 at 10:05 a.m. without wearing a gown while Resident #2 was on enhanced barrier precautions. 2. RT D was observed providing a nebulizer treatment for Resident #3's tracheotomy on 08/18/2025 at 10:45 a.m. Resident #3 was on enhanced barrier precautions and RT D wore a face mask below her mouth and did not wear a gown. 3. Residents # 5,6,7,8, and 9 were observed with a tracheotomy and did not have enhanced barrier precaution signs on the entry to their doors to identify the residents required specific PPE for care. These failures placed residents at risk of transmission of communicable diseases and infections, a decline in health status, and hospitalization. Findings included: 1. Record review of Resident #2's undated face sheet revealed Resident #2 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure (occurs when the lungs cannot adequately exchange oxygen and carbon dioxide leading to low levels of oxygen).Record review of Resident #2's August 2025 medication administration orders revealed an order, Trach care BID every day for trach care, start date 08/03/2025. Resident #2 had an order that stated, Maintain enhanced barrier precautions during high-contact resident care activities (i.e. dressing, bathing/showering, transferring, providing hygiene, linen changes, pericare/changing briefs/toileting, chronic wound care, an all indwelling device care: trachs, central lines, feeding tubes, urinary catheters) every shift for EBP. Start date 08/02/2025. Record review of Resident #2's undated care plan revealed, I require enhanced barrier precautions. The interventions listed in the care plan revealed, Maintain enhanced barrier precautions during high contact resident care activities (i.e. dressing, bathing/showering, transferring, providing hygiene, linen changes, pericare/changing briefs/toileting, chronic wound care, an all indwelling device care: trachs, central lines, feeding tubes, urinary catheters) and staff will doff/don PPE as needed per my EBP status.During an observation, 08/18/2025 at 10:05 a.m., Resident #2 had a sign posted outside of his room door that stated Resident #2 was on enhanced barrier precautions and stated staff must wear a gown and gloves for high contact care activities and listed device care or use of tracheostomies. RT A was observed performing tracheostomy care to Resident #2 without wearing a gown.During an interview with RT A, 08/18/2025 at 10:20 a.m., RT A stated she was not sure if Resident #2 was on EBP precautions and stated the precautions for EBP were gloves and a mask. RT A stated she had received training on EBP and stated residents with wounds, vents or tracheostomies had EBP precautions. RT A observed the sign for EBP on the outside of Resident #2's door and RT A stated she should have worn a gown to perform the trach care. RT A stated it was important to follow EBP because the precautions were for the safety of the residents and staff. 2. Record review of Resident #3's undated face sheet revealed Resident #3 was a [AGE] year old female who admitted to the facility on [DATE] and had diagnoses that included acute respiratory failure (occurs when the lungs cannot adequately exchange oxygen and carbon dioxide leading to low levels of oxygen).Record review of Resident #3's quarterly MDS assessment, dated 07/23/2025, revealed Resident #3 was receiving tracheostomy care and had an invasive mechanical ventilator. Record review of Resident #3's August 2025 medication administration orders revealed Resident #3 had an order, TRACH Shiley 6CN75H every shift, start date 07/01/2025 and Maintain enhanced barrier precautions during high-contact resident care activities (i.e. dressing, bathing/showering, transferring, providing hygiene, linen changes, pericare/changing briefs/toileting, chronic wound care, an all indwelling device care: trachs, central lines, feeding tubes, urinary catheters) every shift for EBP. Start date 01/15/2025.Record review of Resident #3's undated care plan revealed, I require enhanced barrier precautions. The interventions listed in the care plan revealed, Maintain enhanced barrier precautions during high contact resident care activities (i.e. dressing, bathing/showering, transferring, providing hygiene, linen changes, pericare/changing briefs/toileting, chronic wound care, an all indwelling device care: trachs, central lines, feeding tubes, urinary catheters) and staff will doff/don PPE as needed per my EBP status.During an observation, 08/18/2025 at 10:45 a.m., Resident #3 had a sign posted outside of her room door that stated Resident #3 was on enhanced barrier precautions and stated staff must wear a gown and gloves for high contact care activities and listed device care or use of tracheostomies. RT D entered Resident #3 room wearing a face mask that was pulled down below her mouth and a pair of gloves. RT D performed a nebulizer treatment by attaching a nebulizer canula to Resident #3's tracheostomy tubing. During an interview with RT D, 08/18/2025 at 10:49 a.m., RT D stated she was not sure if Resident #3 was on enhanced barrier precautions and stated PPE required for EBP was gown, gloves, and a mask. RT D observed the EBP sign on the resident door and stated she had received training on EBP and should have worn a gown. RT D stated a face mask should be worn over the mouth and nose when in use. RT D stated it was important to use the appropriate PPE for a resident on EBP because the precautions were to protect residents and staff from infection. 3. During an observation of Resident #9, 08/18/2025 at 10:22 a.m. Resident #9 was observed with a tracheostomy and Resident #9 did not have an EBP sign on the outside of his room.During an observation of Resident #8, 08/18/2025 at 10:26 a.m., Resident #8 was observed with a tracheostomy and Resident #8 did not have an EBP sign on the outside of his room.During an observation of Resident #7, 08/18/2025 at 10:26 a.m., Resident #7 was observed with a tracheostomy and Resident #7 did not have an EBP sign on the outside of his room.During an observation of Resident #6, 08/18/2025 at 10:32 a.m., Resident #6 was observed with a tracheostomy and Resident #6 did not have an EBP sign on the outside of her room.During an observation of Resident # 5, 08/18/2025 at 10:32 a.m., Resident #5 was observed with a tracheostomy and Resident #5 did not have an EBP sign on the outside of her room.During an interview with RT A, 08/18/2025 at 10:23 a.m., RT A stated Resident #9 did not have an EBP sign outside of Resident #9's door. RT A stated residents on EBP were identified by the EBP sign on the outside of their room door and staff would not know to use enhanced barrier precautions when providing care to Resident #9. During an interview with LVN B, 08/18/2025 at 10:28 a.m., LVN B stated residents on EBP should have had a sign outside of their room door that stated the resident was on enhanced barrier precautions. LVN B stated Residents #7 and #8 should have had an EBP sign on the outside of their door because both residents were on EBP for tracheotomies. LVN B stated the nurses were responsible for ensuring the EBP signs were placed on the outside of resident doors and stated she had received training on EBP. LVN B stated EBP was important to prevent cross contamination and to protect the residents. During an interview with CNA E, 08/18/2025 at 10:59 a.m., CNA E stated a resident on EBP had a sign outside of their door that reflected the resident was on EBP and which PPE supplies were required when providing care to the resident. Record review of a facility policy titled, Enhanced Barrier Precautions (copyright 2001 [company] August 2022), provided by the Administrator on 08/19/2025, revealed the policy statement, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. The Policy Interpretation and Implementation revealed, 2. EBP's employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. A. Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room) C. Face protection may be used if there is also a risk of splash or spray. 3. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include: .g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.). 10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required.

Based on interview and record review the facility personnel failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 6 residents (Resident #1) whose records were reviewed for code status. Facility staff failed to follow emergency protocol, did not obtain an AED, did not obtain the crash cart, or continue CPR until EMS arrived after Resident #1, and who had a Full Code in place, was found unresponsive with no pulse or respirations. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 9:11 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of their plan of removal. This failure could place residents at risk of not receiving life-saving measures, decline in health resulting in serious injury and or death. The findings included: Record review of Resident #1's face sheet, dated [DATE], reflected she was an [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with dependence on respirator [ventilator] status (patient requires mechanical ventilation to breathe independently due to respiratory failure), dependence on supplemental oxygen, paroxysmal atrial fibrillation (an episode of atrial fibrillation that results in uncoordinated movement of the atria), acute systolic (congestive) heart failure (heart's inability to pump blood effectively, leading to fluid buildup in the body), chronic obstructive pulmonary disease with acute exacerbation (sudden worsening of respiratory symptoms characterized by obstructed airflow that makes it difficult to breathe) and cerebral infarction (occurs when a blood vessel in the brain is blocked, preventing oxygen and nutrients from reaching the brain tissue). Record review of Resident #1's care plan, close date [DATE], revealed the resident was full code status (a patient wishes to recieve all resuscitation efforts and life-saving measures during a medical emergency) and to being CPR after absence of vitals signs, call 911, call physician to notify, ensure staff are aware of code status through designated system, and full code order in chart. Record review of Resident #1's physician orders, dated [DATE], revealed an order for full code with start date of [DATE], and no end date. Record review of Resident #1's progress notes, dated [DATE], revealed:-A note Written by LVN C on [DATE] at 2:45 a.m. Patient was breathing while sleeping when this nurse got to her room to check on her. her vitals were WNL this was about an hour ago before she had an attack. the aids were doing their rounds when they found out she was not breathing, and the nurse was notified which they immediately started CPR on the patient and Ems was called. when they arrived, they tried to revive the patient to no avail she had passed on. Dr.notified.-A note written by RT E on [DATE] at 3:12 a.m. pt expired around 2300. CNA called me to check on patient because she looked pale. PT was unconscious. I checked her o2 sat and her exhaled tidal volumes. Her volumes were of 404 and she didnt have a pulse. We checked her code status and began CPR. During an observation on 8/225 at 1:08 p.m. the facility had an AED by the nurses' station which contained pads with an expiration date of [DATE]. The AED green light indicator, indicated it was in working order. There was a crash cart with various supplies including an Ambu bag (manual resuscitator is a handheld medical device used to provide positive pressure ventilation to patients who are not breathing). During an interview on [DATE] at 12:44 p.m. EMS F stated they were dispatched to a call for Resident #1 at 11:24 p.m. Upon arrival to the facility at 11:26 p.m. the patient was the only person in the room at 11:30 p.m., no care was being provided, and it did not appear that any care had been provided prior to their arrival. Resident #1 was found pulseless and apneic (not breathing). EMS F stated staff told them the resident was full code and did not have a DNR. EMS F stated there were no signs of lividity (bluish-purple discoloration of the skin that occurs after death) or rigor mortis. (stiffening of the body after death) EMS F stated they moved the resident from the bed to the floor and began CPR. EMS F stated the resident was found to be in asystole (absence of electrical activity in the heart). EMS F stated a medical director was contacted and advised to cease efforts and the time of death was 11:52 p.m. During an interview on [DATE] at 3:58 p.m. LVN D stated she was called to the 2nd floor of the building by CNA A and CNA B to check on Resident #1 because she was not breathing and could not find LVN C to help. LVN D stated she went to Resident #1's room, she found her not breathing, pulseless, and began CPR in the resident's bed while holding the phone with her cheek calling 911 and performing compressions. LVN D stated she instructed CNA B to go find the LVN C and CNA A to go find RT E. LVN D stated CNA A returned with RT E. LVN D stated she asked the aide and RT if the resident was full code, and both told her they did not know. LVN D stated RT E started to bag Resident #1 and CNA A took over compression while she left to go look up the resident's code status on the computer. LVN D stated she never returned to the room because EMS showed up while she was at the computer. LVN D stated she never instructed staff to obtain the AED but did ask for the crash cart however it was never obtained. LVN D stated she was CPR certified, and her certification was current. During an interview on [DATE] at 3:25 p.m. CNA A stated she and CNA B went to Resident #1's room to provide incontinent care during her rounds. CNA A stated she was unsure of the exact time this occured. CNA A stated she found the resident with her eyes closed and not responding. She stated they checked Resident #1's pulse and they could not find one. CNA A stated her and CNA B left the resident's room and started looking for LVN C, were not able to find her, and went down to the first floor and got LVN D to help instead. CNA A stated they returned to the Resident #1's room and LVN D started CPR. CNA A stated at some point the maintenance director came into the resident room and stated the resident was a DNR, and showed everyone a text from the ADON stating she was a DNR. CNA A stated the nurse then left the room to check the patient chart for code status and she took over compressions. CNA A stated she called 911 at 11:23 p.m. but was advised by the dispatcher that the nurse had already called, and EMS was in route to the nursing home, and she could hang up. CNA A stated she took over compressions then. CNA A stated RT E came into the room to take over and CNA A left to check the patient's chart for code status. CNA A stated she was CPR certified, and her certification was current. During an interview on [DATE] at 6:07 p.m. RT E stated she was called from the hallway to help with CPR for Resident #1. RT E stated she started bagging Resident #1 when the maintenance director came to the room and stated Resident #1 was DNR. RT E stated she put the resident back on her vent to respect her wishes in case she was DNR and returned to her computer to check the residents code status. RT E stated EMS arrived while she was at her computer, and she went into the room with EMS to assist with CPR. RT E stated she was CPR certified, and her certification was current. During an interview on [DATE] at 7:06 p.m. the DON stated she was informed on a group text that staff called 911 for Resident #1 on the night of [DATE]. The DON stated the primary way staff check a residents' code status is on the EHR. If the resident is full code they should initiate CPR. The DON stated anyone who is CPR certified can initiate CPR and call for help, have other staff obtain the AED and crash cart. The DON stated LVN D did leave the room to obtain the code status but other staff continued CPR to her knowledge. The DON stated she did not know if staff attempted to obtain the AED or crash cart. The DON stated you can do CPR in the resident bed but it is not ideal. The DON stated delayed or stopped CPR could cause prolonged oxygen deprivation to the brain leading to loss of brain activity. The DON stated she would expect staff to continue CPR until EMS arrived. During an interview on [DATE] at 7:27 p.m. the Administrator stated he was notified the resident had passed [DATE]. The administrator stated as far as he knew staff responded appropriately to the resident and there was nothing to report to the state. The Administrator stated when they looked at everything it looked like it was done correctly. Record review of the facility's policy titled Emergency Procedure Cardiopulmonary Resuscitation, dated 2018, stated 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless:a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; orb. there are obvious signs of irreversible death (e.g., rigor mortis).7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 9:11 p.m. The Administrator was notified and provided with the IJ template. The following Plan of Removal (POR) was accepted on [DATE] at 1:44 p.m. and indicated the following: The facility respectfully submits this plan of removal to abate the allegations of immediate jeopardy identified on [DATE]. Plan submitted on [DATE] at 1:20pm. Facility failed to provide timely emergency services and professional standards for CPR. - The facility failed to initiate CPR on Resident #1 who was found unresponsive on [DATE] around 11pm, not breathing, and with no pulse. On [DATE], around 11pm, Resident #1 was found unresponsive, not breathing, and with no pulse by CNA A and CNA B. CNAs A and B left Resident #1's room to locate the Charge Nurse for help. CNA A is CPR certified and did not initiate CPR on Resident #1 who was a full code. When LVN D arrived moments later, CPR was initiated. Staff did not obtain either the AED or crash cart. CPR remained in effect for several minutes until the time that staff reports they were notified by the ADON (who has remote access for PointClickCare log-in) that Resident #1 was a DNR. At this time, they stopped CPR and exited room. EMS arrived moments later and re-initiated CPR. Residents with the potential to be affected by the alleged deficient practice:On [DATE], The Facility completed an audit of Resident code status. Eighteen (18) Residents were confirmed as DNR and thirty-seven (37) Residents were confirmed as full code. Red dot visual aide for all DNR Residents was audited and confirmed accurate. DNR Binder with OOH DNRs was audited and found accurate. Staff in-servicing of all Charge Nurses and Respiratory Therapists was immediately initiated regarding how to confirm/verify code status prior to initiating CPR; location of code status is confirmed by using PointClickCare; where to find the DNR binder at nurses' station with copies of OOH DNRs, and to utilize the red dot visual reminder on Resident's door for DNR Residents. Resident identified to have been affected by the alleged deficient practice:- Resident #1, who was a full code, was identified as having been affected by the alleged deficient practice. Systemic Measures: Training Topics for timely emergency services and professional standards for CPR will be added to new-hire orientation: The Facility immediately added the training for providing timely emergency services and professional standards for CPR to all new hire education. (See training topics below.) Mock Codes: The Facility immediately implemented a mock code program in which random monthly mock codes will be called on all 3 shifts to ensure appropriate and timely response occurs from all staff. The first mock code was conducted by the DON on [DATE] on the 10p-6a shift. Code Status Audits: The Facility's DON and/or Designee will perform daily code status audits to ensure the OOH DNR is in the DNR binder and the red dot visual reminder is on the Resident's nameplate. The audit will be completed by pulling the Order Listing Report daily from PCC for review of any new/changed code status orders. If any new/changed orders exist, the DON and/or Designee will then ensure that any needed OOH DNRs are confirmed in the binder, and that any needed Red Dot visual aides are in place on the Resident's nameplate. Training: Will be completed by [DATE] as follows:a. Re-initiate staff in-servicing on CPR/code status to include the additional topics of any CPR certified staff member initiating CPR (if you are CPR certified and the Resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR); non-CPR certified staff member action (if you are not CPR certified, you must call 911 and follow the 911 operator's instruction until a CPR certified staff member arrives); Charge Nurse and/or Designee will be responsible for confirming any unclear code status; ensuring AED is placed on Resident during all codes; ensuring crash cart is brought to Resident's room during all codes; and to continue all CPR efforts until you have been relieved of this duty by EMS. All Facility staff will be included the aforementioned in-servicing. Inservice sign in sheet will be cross referenced with employee roster. Quality Assurance Performance Improvement: On [DATE], the Quality Assessment and Assurance Committee members to include the Medical Director, Administrator, and Director of Nursing, and the Regional Director of Clinical Services met to review and approve this plan. The Administrator and/or Designee will review any new-hire packets weekly for 3 months to ensure training on timely emergency services and professional standards for CPR has been completed. The Administrator and/or Designee will review the random monthly mock code sign-in sheets to ensure it is being completed at least monthly on all 3 shifts on a weekly basis for 3 months. The Administrator and/or Designee will review the code status audits weekly for 3 months. The results of the Administrator and/or Designee reviews will be presented to the Quality Assessment and Assurance Committee for review of trends and/or negative findings and further recommendations during the scheduled meetings for 3 months. The committee will make recommendations for further education as warranted and develop further performance improvement plans as necessary. Plan of Removal Verification[DATE] On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ after verifying their POR had been initiated and/or completed by: On [DATE] at 1:49 p.m. residents #1-#18 rooms were verified to have red dots next to their names. Record review on [DATE] of the 100 hall and 200 hall DNR binders contained DNRs for 18 residents and were available in the nurses station. Record review of order audit report, dated [DATE], revealed a list of all current residents' code status orders. Record review of order audit report, dated [DATE], revealed a list of 18 residents who's order for code status was DNR. Record review of a facility document titled DNR Audits-monitoring frequency-weekly x3 months, no date, revealed a log with a start date on the log of [DATE]-[DATE] for tracking completion of weekly DNR audits. Record review of facility document titled Timely Emergency Services and Professional Standards for CPR, no dated, stated scare providers for our Residents, we need to ensure that we always provide timely emergency services and professional standards for CPR. Key points to ensure this is achieved are: If you are CPR certified and the Resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. Non-CPR certified staff members must call 911 and follow the 911 operator's instruction until a CPR certified staff member arrives. The Charge Nurse and/or Designee will be responsible for confirming any unclear code status. To determine a Resident's code status, you can look in the Resident's chart/orders in PCC or you can refer to the visual red dot aide. If you see a red dot on the resident's nameplate by the door it indicates the Resident is a DNR. Any Resident with a red dot on his/her nameplate is a DN R. If you are a CNA, you can also find the Resident's CPR status on the Resident's tab in the POC. To be able to perform effective compressions, you must either place the backboard from the crash cart under the Resident OR move the Resident to the floor. In any code situation, the crash cart and AED must be brought to the room and utilized. The AED should be placed on the Resident as soon as possible as it will guide the CPR process from that point forward. Once the CPR process is initiated, it cannot be stopped for any reason until EMS arrives and completely takes over. Record review of a log titled New Hire Training Emergency Services and Professional Standards for CPR, no date, monitor frequency- weekly x3 months, with a start date of [DATE] through [DATE]. During an interview on [DATE] at 6:34 p.m. the DON stated new hire orientation is given by HR, that would be included in the nursing portion of new hire orientation. The DON stated nursing management participated in new hire orientation. The DON stated orientation was usually on a set date of the week and management all had a time slot to present training material. The DON stated nurses have extra training they had to completed and the emergency training would be implemented for new hires. During an interview on [DATE] at 4:38 p.m. the ADON G stated they had a mock code the night of [DATE] and that morning. ADON G stated that morning she went into the room and put my call light to see how long staff would take. She was unresponsive by holding a sign that said she was unresponsive, full code, and laid in a patient bed. The ADON stated staff eventually figured out it was a mock code, grabbed the crash cart and AED, simulated compressions and calling 911. Record review of a document with Mock Code written at the top, and no date, showed on [DATE] 5 staff signatures that participated in the mock code. Another date of [DATE] showed 7 staff signatures participated in the mock code. Record review of a document titled Mock Code, no date, revealed a check list of questions asking if mock codes were conducted on all 3 shifts at least monthly? If not was this immediately corrected? And admin/designee signature and date. The start date was [DATE]. During an interview on [DATE] at 6:34 p.m. the DON stated herself and ADON G had done the mock codes on [DATE] during the night shift and on [DATE] during the morning shift. The DON stated they had a person pretending to be unconscious in an empty room, they pulled the call light, waited for someone to respond, and had a sign on that said I am not breathing. The DON stated then staff realized what was going on, they had them go through the steps and pretend to call 911, get the AED, get the crash cart, and get other staff. They had done the mock codes on both floor the 1st and the 2nd floor. The staff upstairs had done better probably due to most of the emergency codes they actually had were upstairs because it was where the vent unit was and they are used to emergency code situations. The DON stated the downstairs staff had parts of the code were easier for some and parts needed to be refreshed on. The DON stated they went through the scenario more than once and introduced new scenarios each time. During an interview on [DATE] at 4:40 p.m. ADON G stated she had assisted with chart audits. The ADON stated they have an order listing report which pulled all the resident orders from whatever time range they set. The ADON stated they would check the report daily. The ADON stated chart audits were a team effort between the ADONs and DON. The DON would check the current DNR binders to ensure they were up to date and located at the nurse's station. Record review of in-service, dated 8/1, reviewed topics of: advance directives-you must always verify code status on your residents prior to initiating/ not initiating CPR, look in PCC profile DNR/ full code this is priority, visual reminder with the red dot on the door of DNR patients, code book of nurses station with copies of OOH DNR. The in-service was signed by 54 direct care staff between [DATE]-[DATE] Record review of in-service, dated 8/2 and 8/3, reviewed topics of: CPR code status-who is there I code states in PCC, these are your active current physician orders. Residents who are DNR will have (red dot) on the name plate on their door and copy of OOH DNR in binder at nurses station. Once decision is made to initiate CPR and code status these verified, CPR certified staff will initiate CPR (chest compressions) and call for help. Either place patient on the floor or utilize backboard for effective CPR. Crash cart and AED brought to room and placed AED on patient following directions of ADD. Once CPR is initiated it is never stopped until EMS arrives and assumes care of patient fully taking over CPR/ ALS. If you are CPR certified and the resident DNR status is unclear CPR will be initiated until it is determined that there is a DNR on a physicians order not to administer CPR. If you are not CPR certified, you must call 911 and follow the 911 operator instructions until the CPR certified staff member arrives. The in-service was signed by 54 staff in person. Record review of a current employee list 2025 by department revealed there were 89 staff at the facility. 82 were in service in person or by phone. One staff was active duty and not available, 2 staff phones were disconnected, 3 did not answer, and 1 was on FLMA. Record review of in-service titled AED and Crash Cart, dated [DATE], revealed anytime you are performing CPR on a resident, you must ensure the AED and crash cart are obtained. The AED should be placed on the resident as soon as possible and the crash cart must be available. LVN D was in-service via phone by RN H. LVN D verbalized understanding of the above. 18 staff (CNA A, ADON G, LVN I, LVN J, RT K, LVN L, RT M, DOR N, DA O, FDS P, HR, MS, AD, HK Q, HKS, CNA R, COOK S, DA T, CAN U, and CNA V) were interviewed to include direct care staff, non-direct care staff, day shift, and night shift staff were on [DATE] between 3:26 p.m. and 5:24 p.m. All staff verbalized understanding the in-service training over CPR, code status, and emergency response. CPR certified staff were able to verbalize appropriate emergency response actions and non CPR certified staff were able to verbalize appropriate emergency response actions. All staff verbalized understanding of the code status systems. During an interview on [DATE] at 6:34 p.m. the DON stated she gave the in-service on [DATE], [DATE], and [DATE]. The DON stated she went over how to find resident code status that it is in the patient's profile in PCC. The DON stated she trained staff to ensure they gave effective CPR compressions on a hard surface with the back board or on the floor, utilized the AED and crash cart, the importance of initiating 911 for advanced life support, initiating CPR immediately, and not stopping till EMS comes in and takes over. The DON stated she trained on the red dot system; the red dot was a visual reminder of resident with DNR code status, and orders for DNR. The DON stated she was the one who places the dot by residents' names on the door, after she verified there is a valid DNR, and signed order. Record review of a log titled Quality Assessment and Assurance Committee, dated [DATE], revealed the DON, Medical Director, Administrator, and Regional nurse attended a meeting reviewing the POR for this IJ. During an interview on [DATE] at 7:03 p.m. Administrator stated they had a QA meeting on [DATE] where they went over the dos and Don'ts of a DNR or full code, if residents had the red dot you would not resuscitate, they would get help if you are not DNR code status, if there was not red dot net to the resident's name they can assume they were full code, and if non clinical staff of course they would not start CPR, they would call for help. The Administrator stated once staff arrived with a crash cart if you are not clinical you could step out or be on stand by for assistance. During an interview on [DATE] at 6:34 p.m. the DON stated they went over CPR if the code status was unknown, they would initiate CPR until they were confirmed DNR or until EMS arrived. Record review of a log titled New Hire Training Emergency Services and Professional Standards for CPR, no date, revealed a log to monitor frequency- weekly x3 months, with a start date of [DATE] through [DATE]. Record review of a document titled Mock Code, no date, revealed a check list asking if mock codes were conducted on all 3 shifts at least monthly? If not was this immediately corrected? And admin/designee signature and date. The start date was [DATE]. During an interview on [DATE] at 6:34 p.m. the DON stated they would complete the mock code and fill out the forms. Herself and the ADONs will perform the mock code or nursing management. Record review of a facility document titled DNR Audits-monitoring frequency-weekly x3 months revealed a log with a start date on the log of [DATE]-[DATE] to monitor if DNR audits were completed weekly for 3 months. During an interview on [DATE] at 7:03 p.m. Administrator stated he was going to oversee the binder with the logs, the DON and ADON were going to be doing the code status, and logs were for him to fill out based on the information they gave him. The Administrator stated he would say yes or no to them filling out the log and completing the task. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 7:19 p.m. While the IJ was removed on [DATE] at 7:19 p.m., the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of their plan of removal.

Based on record reviews and interviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 4 of 10 residents (Residents #1, #2, #3, #4) reviewed for the allegation of abuse, neglect, exploitation and or mistreatment. 1. On 12/3/2024 the facility failed to report to the state agency an allegation of abuse and or mistreatment when Resident #1's Representative alleged a nurse treated Resident #1 poorly and made Resident #1 cry. 2. On 12/23/2024 the facility failed to report to the state agency an allegation of neglect and or mistreatment when Resident #2 alleged a nurse neglected to change a gastric tube stoma dressing. Resident #2 alleged the nurse handed her the gauze dressing and told her to do it herself. 3. On 3/12/2025 the facility failed to report to the state agency an allegation of abuse with rough incontinent care, when Resident #3 alleged her diaper grabbed and pulled up to give her wedgy. 4. On 3/13/2025 the facility failed to report to the state agency an allegation of verbal abuse when Resident #4 alleged staff insulted him by stating he smelled like an animal. These failures could have harmed residents by not having their allegations of ANE reported. The findings included: 1. A record review of Resident #1's admission record dated 6/19/2025, revealed an admission date of 3/23/2025 with diagnoses which included cerebral vascular accident (a stroke) and seizures (a surge of electrical activity in the brain). A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old-female admitted for long term care and assessed with a BIMS score of 9 out of a possible 15 which indicated moderate cognitive impairment. A record review of Resident #1's care plan dated 6/19/2025 revealed, I have impaired cognitive function AEB SEVERE IMPAIRMENT ON MY BIMS r/t neurological symptoms . Engage the resident in simple activities that avoid overly demanding tasks. I have a communication impairment due to no speech pattern but able to communicate with gestures & mouthing words. o Utilize nonverbal cues and gestures to communicate with resident A record review of Resident #1's grievance report dated 12/03/2024 revealed the previous administrator documented a grievance report on behalf of Resident #1 when Resident #1's representative made an allegation of abuse. The previous Administrator documented, [Resident #1's representative] reported that her [Resident #1] called her yesterday afternoon. She stated that [Resident #1] had complained that a female nurse had treated her poorly. [Resident #1's representative] stated that her [Resident #1] began to cry and this is rare for her to do. 2. A record review of Resident #2's admission record, dated 6/19/2025, revealed an admission date of 8/9/2024 and a discharge date of 1/31/2025 with diagnoses which included encounter for attention to gastrostomy (aka a feeding tube, a device that's inserted into the stomach through the abdomen. It's used to supply nutrition and medications, aka percutaneous endoscopic gastrostomy (PEG), G tube.) A record review of Resident #2's quarterly MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old-female admitted for rehabilitation care. Resident #2 was assessed with a BIMS score of 14 out of a possible 15, which indicated intact cognition. A record review of Resident #2's care plan dated 1/31/2025 revealed, require assistance ADL's due to generalized weakness, . Bed Mobility: I require extensive assistance in self-performance with 2-person physical assistance staff support. Dressing: I require extensive assistance in self-performance with 1-person physical assistance staff support. Eating G-tube: I am NPO. I require total assistance in self-performance with 1-person physical assistance staff support. I require total nutrition and hydration through my gastrostomy tube A record review of Resident #2's grievance report dated 12/23/2024 revealed the DON documented Resident #2 alleged a night nurse came in her room handed her a gauze and told her to change her PEG dressing herself. RN did not clean site or assist her, only left room. During an interview on 6/20/2025 at 10:50 AM the DON stated she did not recall the grievance report dated 12/3/2024 for Resident #1 nor the grievance report for Resident #2 dated 12/23/2024 but did state all grievance reports were reviewed by the IDT which included the previous Administrator who would have been the ANE prevention coordinator at the time. The DON stated she had not reported the allegations made in the grievance reports to the state agency and the reporting could have been made by the previous Administrator. 3. A record review of Resident #3's admission record dated 6/19/2025 revealed an admission date of 3/25/2025 and a discharge date of 4/24/2025 with diagnoses which included end stage renal disease (kidneys no longer work as they should to meet the body's needs and dialysis is required), severe obesity, and acquired absence of left leg above the knee. A record review of Resident #3's discharge MDS assessment dated [DATE] revealed Resident #3 was a [AGE] year-old female admitted for rehabilitation and assessed with a BIMS score of 15 out of a possible 15 which indicated intact cognition. A record review of Resident #3's care plan dated 4/24/2025 revealed, I have had Amputation of AKA to left leg . Monitor/document emotional status of resident. Observe residents' acceptance of body image changes, ability to cope with physical changes. Be supportive. Encourage resident to vent fears, concerns, and any other relevant feelings. Monitor/document pain management. Document frequency, duration, intensity of pain, phantom pain. Report to physician if medications are not effective. I require limited to extensive assistance ADL's . toileting: I require supervision, limited to extensive assistance in self-performance with 1-person physical assistance staff support A record review of Resident #3's grievance report dated 3/12/2025 revealed the SW documented Resident #3 alleged a lady provided rough incontinent care causing soreness to her amputated leg, Afro-American lady 10:00 PM came in to ask change was needed and was rough. Diaper grabbed and pulled up to give her a wedgie. Diaper had to be loosened to breathe. [Resident #3] felt she was inconvenienced 2x's. She was wiped roughly by the aide. A turned her rough. Amputated leg is sore. During an interview on 6/19/2025 at 3:50 PM the ADON stated she recalled discussing the allegation from Resident #3 with the DON and the Administrator and the resident could not recall the incident the next day and there were no staff that worked that day that fit the description. The ADON stated she had not reported the allegation to the state agency and the reporting could have been made by the Administrator. 4. A record review of Resident #4's admission record dated 6/19/2025 revealed an admission date of 8/12/2024 with diagnoses which included adjustment disorder with depressed mood (a mood disorder that causes a persistent feeling of sadness and loss of interest. it affects how you feel, think and behave and can lead to a variety of emotional and physical problems) and Parkinson's disease (a movement disorder of the nervous system that worsens over time). A record review of Resident #4's quarterly MDS assessment dated [DATE] revealed Resident #4 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 8 out of a possible 15 which indicated moderate cognitive impairment. A record review of Resident #4's care plan dated 6/19/2025 revealed, sic[Resident #4] requires staff assistance with ADL Self Care Performance due to dementia . BATHING: [NAME] requires X 1 staff participation with bathing . has hx of depression . Monitor/document report to Nurse/MD s/sx of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness A record review of Resident #4's grievance report dated 3/13/2025 revealed the SW documented Resident #4's alleged verbal abuse, [Resident #4] said very early in the morning a CNA Afro-American doesn't remember name came into room with another CNA and told him that he smelled like an animal. A record review of the Texas Unified Licensure Information Portal (a database for incidents and allegations of ANE) website https://txhhs.my.salesforce.com/?ec=302&startURL=%2Fvisualforce%2Fsession%3Furl%3Dhttps%253A%252F%252Ftxhhs.lightning.force.com%252Flightning%252F accessed 6/19/2025, revealed no evidence of a report for the alleged instances of ANE from the period of 12/3/2024 to 6/19/2025 During an interview on 6/19/2025 at 3:50 PM the ADON stated she recalled discussing the allegation from Resident #4 with the DON and the Administrator and the resident could not recall the incident the next day and there were no staff that worked that day fit the description. The ADON stated she had not reported the allegation to the state agency and the reporting could have been made by the Administrator. During an interview on 6/18/2025 at 4:40 PM the Administrator reviewed the grievance reports for residents as follows: 1. On 12/3/2024 Resident #1's Representative alleged a nurse treated Resident #1 poorly and made Resident #1 cry. 2. On 12/23/2024 Resident #2 alleged a nurse neglected to change a gastric tube stoma dressing. Resident #2 alleged the nurse handed her the gauze dressing and told her to do it herself. 3. On 3/12/2025 Resident #3 alleged diaper grabbed and pulled up to give her wedgy. 4. On 3/13/2025 Resident #4 alleged staff insulted him by stating he smelled like an animal. The Administrator stated all the grievances reviewed would have warranted a report of alleged ANE to the state agency. The Administrator stated he was not the administrator in December 2024 but was the administrator during March 2025. The Administrator stated he had not recognized the grievances as reportable allegations of ANE at the time. The Administrator stated the risks to residents could be their allegations of ANE would not be reported. A record review of the facility's Reporting Allegations or Suspicions of Abuse undated policy revealed, Report alleged or suspicions of abuse to HHSC by email reporting or via TULIP reporting within the designated time frames in accordance with HHSC . - are reported immediately, - but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, - or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury,

Based on record reviews and interviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, had evidence that all alleged violations were thoroughly investigated, prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress. for 4 of 10 residents (Resident #1, #2, #3, #4) reviewed for the allegations of abuse, neglect, exploitation and or mistreatment. 1. On 12/3/2024 the facility failed to investigate an allegation of abuse and or mistreatment when Resident #1's Representative alleged a nurse treated Resident #1 poorly and made Resident #1 cry. 2. On 12/23/2024 the facility failed to investigate an allegation of neglect and or mistreatment when Resident #2 alleged a nurse neglected to change a gastric tube stoma dressing. Resident #2 alleged the nurse handed her the gauze dressing and told her to do it herself. 3. On 3/12/2025 the facility failed to investigate an allegation of abuse with rough incontinent care, when Resident #3 alleged diaper grabbed and pulled up to give her wedgy. 4. On 3/13/2025 the facility failed to investigate an allegation of verbal abuse when Resident #4 alleged staff insulted him by stating he smelled like an animal. These failures could have harmed residents by not having their allegations of ANE investigated. The findings included : 1. A record review of Resident #1's admission record dated 6/19/2025, revealed an admission date of 3/23/2025 with diagnoses which included cerebral vascular accident (a stroke) and seizures (a surge of electrical activity in the brain). A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old-female admitted for long term care and assessed with a BIMS score of 9 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #1's care plan dated 6/19/2025 revealed, I have impaired cognitive function AEB SEVERE IMPAIRMENT ON MY BIMS r/t sic [related to] neurological symptoms . Engage the resident in simple activities that avoid overly demanding tasks. I have a communication impairment due to no speech pattern but able to communicate with gestures & mouthing words. Utilize nonverbal cues and gestures to communicate with resident A record review of Resident #1's grievance report dated 12/03/2024 revealed the previous administrator documented a grievance report on behalf of Resident #1 when Resident #1's representative made an allegation of abuse. The previous administrator documented, [Resident #1's representative] reported that her [Resident #1] called her yesterday afternoon. She stated that [Resident #1] had complained that a female nurse had treated her poorly. [Resident #1's representative] stated that her [Resident #1] began to cry and this is rare for her to do. 2. A record review of Resident #2's admission record, dated 6/19/2025, revealed an admission date of 8/9/2024 and a discharge date of 1/31/2025 with diagnoses which included encounter for attention to gastrostomy (aka a feeding tube, a device that's inserted into the stomach through the abdomen. It's used to supply nutrition and medications, aka percutaneous endoscopic gastrostomy (PEG), G tube.) A record review of Resident #2's quarterly MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old-female admitted for rehabilitation care. Resident #2 was assessed with a BIMS score of 14 out of a possible 15, which indicated intact cognition. A record review of Resident #2's care plan dated 1/31/2025 revealed, require assistance ADL's due to generalized weakness, . Bed Mobility: I require extensive assistance in self-performance with 2-person physical assistance staff support. Dressing: I require extensive assistance in self-performance with 1-person physical assistance staff support. Eating G-tube: I am NPO. I require total assistance in self-performance with 1-person physical assistance staff support. I require total nutrition and hydration through my gastrostomy tube A record review of Resident #2's grievance report dated 12/23/2024 revealed the DON documented Resident #2 alleged a night nurse came in her room handed her a gauze and told her to change her PEG dressing herself. RN did not clean site or assist her, only left room. During an interview on 6/20/2025 at 10:50 AM the DON stated she did not recall the grievance report dated 12/3/2024 for Resident #1 nor the grievance report for Resident #2 dated 12/23/2024 but did state all grievance reports were reviewed by the IDT which included the previous administrator who would have been the ANE prevention coordinator at the time. The DON stated she had investigated but not reported the results of the investigation to the state agency. 3. A record review of Resident #3's admission record dated 6/19/2025 revealed an admission date of 3/25/2025 and a discharge date of 4/24/2025 with diagnoses which included end stage renal disease (kidneys no longer work as they should to meet the body's needs and dialysis is required), severe obesity, and acquired absence of left leg above the knee. A record review of Resident #3's discharge MDS assessment dated [DATE] revealed Resident #3 was a [AGE] year-old female admitted for rehabilitation and assessed with a BIMS score of 15 out of a possible 15 which indicated intact cognition. A record review of Resident #3's care plan dated 4/24/2025 revealed, I have had Amputation of AKA to left leg . Monitor/document emotional status of resident. Observe residents' acceptance of body image changes, ability to cope with physical changes. Be supportive. Encourage resident to vent fears, concerns, and any other relevant feelings. Monitor/document pain management. Document frequency, duration, intensity of pain, phantom pain. Report to physician if medications are not effective. I require limited to extensive assistance ADL's . toileting: I require supervision, limited to extensive assistance in self-performance with 1-person physical assistance staff support A record review of Resident #3's grievance report dated 3/12/2025 revealed the SW documented Resident #3 alleged a lady provided rough incontinent care causing soreness to her amputated leg, Afro-American lady 10:00 PM came in to ask change was needed and was rough. Diaper grabbed and pulled up to give her a wedgie. Diaper had to be loosened to breathe. [Resident #3] felt she was inconvenienced 2x's. She was wiped roughly by the aide. A turned her rough. Amputated leg is sore. During an interview on 6/19/2025 at 3:50 PM the ADON stated she recalled discussing the allegation from Resident #3 with the DON and the administrator and Resident #3 could not recall the incident the next day and there were no staff that worked that day who fit the description. The ADON stated she had not reported the results of the investigation to the state agency and the reporting could have been made by the Administrator. 4. A record review of Resident #4's admission record dated 6/19/2025 revealed an admission date of 8/12/2024 with diagnoses which included adjustment disorder with depressed mood (a mood disorder that causes a persistent feeling of sadness and loss of interest. it affects how you feel, think and behave and can lead to a variety of emotional and physical problems) and Parkinson's disease (a movement disorder of the nervous system that worsens over time). A record review of Resident #4's quarterly MDS assessment dated [DATE] revealed Resident #4 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 8 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #4's care plan dated 6/19/2025 revealed, sic[Resident #4] requires staff assistance with ADL Self Care Performance due to dementia . BATHING: [NAME] requires X 1 staff participation with bathing . has hx of depression . Monitor/document report to Nurse/MD s/sx of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness A record review of Resident #4's grievance report dated 3/13/2025 revealed the SW documented Resident #4's alleged verbal abuse, sic[Resident #4] said very early in the morning a CNA Afro-American doesn't remember name came into room with another CNA and told him that he smelled like an animal. During an interview on 6/19/2025 at 3:50 PM the ADON stated she recalled discussing the allegation from Resident #4 with the DON and the administrator and the Resident could not recall the incident the next day and there were no staff that worked that day fit the description. During an interview on 6/18/2025 at 4:40 PM the Administrator reviewed the grievance reports for residents as follows: 1. On 12/3/2024 Resident #1's Representative alleged a nurse treated Resident #1 poorly and made Resident #1 cry. 2. On 12/23/2024 Resident #2 alleged a nurse neglected to change a gastric tube stoma dressing. Resident #2 alleged the nurse handed her the gauze dressing and told her to do it herself. 3. On 3/12/2025 Resident #3 alleged diaper grabbed and pulled up to give her wedgy. 4. On 3/13/2025 Resident #4 alleged staff insulted him by stating he smelled like an animal. A record review of the Texas Unified Licensure Information Portal (a database for incidents and allegations of ANE) website https://txhhs.my.salesforce.com/?ec=302&startURL=%2Fvisualforce%2Fsession%3Furl%3Dhttps%253A%252F%252Ftxhhs.lightning.force.com%252Flightning%252F accessed 6/19/2025, revealed no evidence of a report for the alleged instances of ANE from the period of 12/3/2024 to 6/19/2025 The administrator stated all the grievances reviewed would have warranted a report of alleged ANE to the state agency. The administrator stated he was not the administrator in December 2024 but was the administrator during March 2025. The administrator stated he had not recognized the grievances as reportable allegations of ANE at the time. The Administrator stated the risks to residents could be their allegations of ANE would not be reported. A record review of the facility's Reporting Allegations or Suspicions of Abuse undated policy revealed, Report alleged or suspicions of abuse to HHSC by email reporting or via TULIP reporting within the designated time frames in accordance with HHSC . - are reported immediately, - but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, - or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury,