Every finding on record at Mineola Gardens Wellness & Rehabilitation

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) reviewed for infection control practices and enhanced barrier precautions. 1. The facility failed to ensure CNA A used the proper PPE of gown and gloves while providing care to Resident #1 on 08/11/2026. 2. The facility failed to ensure CNA A changed gloves and performed hand hygiene while providing incontinent care for Resident #1 on 08/11/26. 3. The facility failed to ensure CNA B used the proper PPE of gown while providing care to Resident #1 on 08/11/2026. These failures could place any resident at the facility at risk for cross-contamination and the spread of infection.Findings included: Record review of Resident #1's face sheet dated 8/11/2026 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses which included cerebral palsy (a group of permanent movement disorders that appear in early childhood), spina bifida (a neural tube defect where the spinal cord column fails), dysphasia and autistic disorder (lifelong neurodevelopmental condition that changes how a person thinks, communicates, senses the world, and interacts with others). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated he rarely made himself understood and he rarely understood others. The MDS also indicated he could not complete a BIMS assessment and had short-term and long-term memory problems. The MDS also indicated he required total assistance with ADLs and he was incontinent of bowel and bladder. Record review of Resident #1's comprehensive care plan dated 04/15/2026 indicated he had ADL self-care deficits, and he required enhanced barrier precautions with interventions for the staff to wear gloves and gown while performing high contact resident care to include hygiene, changing briefs, and transferring. Record review of Resident #1's order summary report dated 08/11/2026 indicated he had an order for:Enhanced barrier precautions r/t g-tube: Staff members will wear a clean gown and gloves while performing high contact resident care activities to include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or toileting assistance, and/or caring for indwelling medical devices like central lines, catheters, feeding tube, tracheostomy/ventilator. every shift for standard precautions with a start dated of 03/18/2026 and no end date. During an observation on 08/11/2026 at 2:53 PM CNA A and CNA B entered Resident #1's room that had enhanced barrier precautions sign outside of the door and PPE in drawers. CNA A and CNA B both donned gloves but did not put on gowns. CNA A told Resident #1 what they were going to be doing, and CNA B was there to assist. CNA A opened Resident #1's brief and began to clean urine from Resident #1 using 1 wipe with each swipe and then grabbed the clean brief and placed it on Resident #1 without changing gloves or providing hand hygiene. During an interview on 08/11/2026 at 3:13 PM CNA A said she washed her hands prior to entering Resident #1's room. CNA A said usually used the proper PPE when providing care to Resident #1 but did not realize she forgot to put on a gown at that time. CNA A said she knew she did not change her gloves during the incontinent care, but she thought she only had to change gloves if a resident had a bowel movement. CNA A said it was her mistake because urine was dirty, but her mind was somewhere else. CNA A said the failure placed a risk for cross contamination and spread of infection. During an interview on 08/11/2026 at 3:28 PM The ADON said her expectation was for all of the CNAs to change gloves and hand sanitize in between dirty and clean. The ADON said she also expected CNAs to wear the proper PPE for enhanced barrier precautions which included gloves and a gown. The ADON said the signs were right outside of the rooms as a reminder for staff to use the proper PPE. The ADON said the failure placed a risk for spread of infection. During an interview on 08/11/2026 at 5:26 PM The Senior Director of Nursing said she expected all the facility CNAs to follow the policy for handwashing, providing incontinent care, and enhanced barrier precautions. The Senior Director of Nursing said the facility performed skills check for CNAs upon hire and annually. The Senior Director of Nursing said the failure placed a potential risk for infection but Resident #1 did not have an infection. The Senior Director of Nursing could not provide a skills checkoff for CNA A. During an interview on 08/11/2026 at 5:35 PM The Administrator said his expectation was for the CNAs to change gloves between dirty and clean surfaces and wash hands or sanitize in between glove changes. The Administrator said he expected the staff to wear the proper PPE for enhanced barrier precautions. The Administrator said the failures placed a risk for spread of infection for residents. Record review of the facility policy, dated January 2026, Standard and Enhanced Precautions indicated: The Facility will utilize current guidance from the Centers for Disease Control (CDC) and the Centers for Medicare & Medicaid Services (CMS) to determine the appropriate PPE to be utilized during the care of residents to minimize the risk of infection or spread of infection. Definitions:Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities that are associated with a high risk of MDRO colonization when contact precautions do not otherwise apply and/or transmission such as presence of indwelling devices (e.g., urinary catheter, feeding tube, endotracheal or tracheostomy tube, vascular catheters) and wounds or presence of unhealed pressure ulcers. Record review of the facility policy, dated 6/2020, Hand Hygiene indicated: The Facility considers hand hygiene the primary means to prevent the spread of infections. Facility Staff and volunteers must perform hand hygiene procedures in the following circumstances including but not limited to. A. Wash hands with soap and water: i. Before eating; ii. After using the bathroom. Iii. When soiled with visible dirt or debris; iv. After unprotected (ungloved and damaged gloves) contact with blood, other body fluids, secretions, excretions, mucous membranes, non-intact skin, intact skin soiled with blood and other body fluids, wound drainage and soiled dressings; . B. Alcohol-based hand hygiene products can and should be used to decontaminate hands.

Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 3 residents reviewed for misappropriation. (Resident #1) The facility failed to prevent CNA A from taking Resident #1's debit card and spending $1103.11 from 06/27/26 through 07/13/26. This failure could place residents at risk for decreased quality of life, misappropriation of property, and loss of dignity.Findings included: Record review of Resident #1's face sheet, dated 07/28/26, reflected that he was a [AGE] year-old male, most recently readmitted to the facility on [DATE]. His diagnoses included altered mental status (any sudden or gradual change in a person's thinking, awareness, or level of consciousness), cirrhosis of liver (permanent scarring of the liver caused by long-term damage, leading to symptoms like fatigue, yellow skin, and belly swelling), and spinal stenosis (a narrowing of the spaces within your spine that puts pressure on your spinal cord and nerves, most commonly caused by wear-and-tear arthritis, aging changes, or bone spurs). Record review of Resident #1's quarterly MDS assessment, dated 07/20/26, reflected that he had a BIMS score of 05, which indicated severe cognitive impairment. Further record review indicated Resident #1 was able to understand others and he was able to make himself understood. This MDS indicated Resident #1 did not exhibit behaviors of rejection of care or wandering and was completely dependent on staff for toileting, bathing, dressing, and transfers. He required substantial assistance for eating, oral hygiene, personal hygiene, and rolling left and right. Record review of a police report, dated 07/20/26, reflected that Resident #1 was the victim. Friend A was the reporter. It identified that a debit card was stolen. The report reflected the following: On Monday, July 20, 2026, at approximately [11:23AM], I, [Officer B], of the [facility city] Police Department Patrol Division, was dispatched to [facility address], [facility city], [facility county], Texas [facility zip code] on the report of fraud. [Dispatcher name] of the [facility city] Police Department Communications Division advised the reporting party contacted the [facility city] Police Department and stated someone used [Resident #1's] debit card without him knowing .Upon arrival at approximately [11:23AM], I, [Officer B], made contact with the reporting party, [Friend A]. [Friend A] stated that his neighbor and friend, [Resident #1], is a resident at this location. [Friend A] advised me that he has been helping [Resident #1] pay his bills and sort out his affairs after he became sick. [Friend A] stated that on today's date he arrived at this location to assist [Resident #1] in sending money from his bank account to his landlords. [Friend A] advised that upon opening [Resident #1's] banking account, he found his account was in the negative. [Friend A] stated he knew this was not right, as [Friend A] does not make transactions other than his bills, which he assists him with. [Friend A] advised that he thinks that a staff member at this location assisted [Resident #1] in paying his phone bill with his debit card and afterward kept the debit card, which they began using. I, [Officer B], asked [Friend A] which bank [Resident #1] uses, to which he stated [Bank Name]. [Friend A] also advised that the total amount spent by the suspect was $1003.00. [Friend A] advised [Officer B] that he looked at [Resident #1's] cell phone and found multiple transactions, all local to the [facility area] in various businesses. [Friend A] stated he asked [Resident #1] which staff member helped him, but due to his failing health and mental condition, he could not remember. [Friend A] advised he also checked to see if anyone else had visited [Resident #1] but no one did. [Friend A] advised that about a week and a half ago he had come to assist [Resident #1] with making his cell phone payment, but once he arrived, he could not find [Resident #1's] wallet. [Friend A] stated staff found the wallet at the nurses' station, but [Friend A] advised the debit card was not inside. Thinking that [Resident #1] had misplaced the card, [Friend A] did not file a report at that time. [Friend A] advised that he would like to file charges on behalf of [Resident #1] as his caretaker. Record review of a series of undated screenshots provided by Friend A, reflected there were a total of 50 disputed transactions totaling $1103.11. The screenshots indicated these transactions were disputed on 07/20/26. During an interview on 07/28/26 at 11:04AM, Resident #1 was unable to describe what had happened related to his debit card. He spoke of other unrelated stories. He said he does have a friend that helps him pay his bills. He was unable to describe anyone else that may have helped him pay his bills. He said if someone took over $1000 from him, he would be very upset. During an interview on 07/28/26 at 11:25AM, the HR Director said she was in the facility when CNA A was arrested. She said the police showed up to the facility and arrested CNA A while he was working on 07/22/26 around 6:00PM. She said the police told her that they arrested him on prior warrants and when they searched him Resident #1's debit card and social security card were on his person. She said she was not the HR director when he was hired but he did have criminal mischief charges and jumping bail charges on his background check and she would not have hired him. She said his criminal history and NAR checks were completed prior to hire on 01/16/26. During an interview on 07/28/26 at 11:29AM, Friend A said he was a friend of Resident #1. He said he went to the nursing facility and they found his wallet at the nurse's desk. He said he looked through it and could not find the debit card. He said he looked at Resident #1's bank account and the charges started on the 27th of June, 2026, and continued through 13th of July, 2026. He said after this it stopped because Resident #1 ran out of money. He said the total amount of money that was stolen from Resident #1 was $1103. He said there were charges at dollar general, dollar tree, and a liquor store in [approximately 30 miles from the facility]. He said the debit card was also used at the facility vending machines several times. He said he reported all this to the police and the police said that CNA A had Resident #1's debit card and social security card on him when he was arrested. He said they did put stop payments on Resident #1's account with the bank and they were working with the bank to get the money recovered. During an interview on 07/28/26 at 12:58PM, Seargent C of the [facility city] Police Department said they arrested CNA A because he had outstanding warrants from another county. He said when they searched his person, they found Resident #1's debit card and social security card on CNA A. He said he was unable to share anything else because the investigation was ongoing. During an interview on 07/28/26 at 02:00PM, the DON said the DON and ADON were newly hired as of 07/27/26 and did not have any firsthand knowledge of Resident #1's stolen card, or CNA A. During an interview on 07/28/26 at 02:02PM, the Administrator said she took over as the Administrator about 5 weeks ago. She said Friend A arrived to the facility to help Resident #1 pay bills. She said Friend A was unable to locate Resident #1's debit card. She said Friend A looked at Resident #1's bank statements and saw unauthorized charges. She said the police were notified and they began their investigation. She said they did not have any reason to suspect CNA A had taken this card. She said she had never seen Resident #1 leave out his debit card. The police took a report on July 20th 2026. She said they returned on July 22nd, 2026 and arrested CNA A. She said the police did not speak with her. She said the police would not share anything with them, including bank statements. She said she expected CNA A to not steal Resident #1's debit card. She further said the Abuse Prevention and Prohibition Program policy covers misappropriation of property, and they did not have another policy that covered misappropriation. Record review of the facility's policy, Abuse Prevention and Prohibition Program, last revised 10/24/22, reflected: .PolicyI. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property.Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property.

Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 4 residents (Resident #3) reviewed for resident abuse. The facility failed to ensure CNA D did not handle Resident #3 roughly when he provided incontinent care. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.Findings included: Record review of Resident #3's face sheet dated 04/14/2026, indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included infectious gastroenteritis and colitis (inflammation of the stomach, intestines, and colon caused by an infection), essential primary hypertension (high blood pressure), and benign prostatic hyperplasia with lower urinary tract symptoms (overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine). Record review of Resident #3's Comprehensive MDS assessment dated [DATE] indicated he was understood by others, and he understood others. Resident #3 had a BIMS score of 15, which indicated his cognition was intact. Resident #3 was dependent on staff for toileting, showering/bathing, dressing, and personal hygiene. Record review of Resident #3's care plan initiated 03/31/2026 did not address the level of assistance Resident #3 required for ADLs. During an interview on 04/14/2026 at 1:51 PM, Resident #3 said when he first came to the facility, he needed to be changed because he was dirty, and there was a male CNA that was very rough with him. Resident #3 was unable to provide a specific date. Resident #3 said even when the CNA was wiping him, he was being rough. Resident #3 said he should not have been treated that way because the staff were there to help him, and they were supposed to be gentle when providing care, turning, and wiping him. Resident #3 said he reported the CNA to the nurse when it happened, and to the Administrator the next day. Resident #3 said the Administrator told him she would investigate it, and she never came back to tell him anything. Resident #3 said the CNA had not provided care to him again. During an interview on 04/14/2026 at 4:29 PM, the ADON said on 04/09/2026 COTA C reported to her that Resident #3 said a staff member was rough with him. The ADON said Resident #3 told her a staff member was rough with him when he was changing him. The ADON said Resident #3 told her it was a man with glasses, beard. The ADON said Resident #3 also reported to her his right rib cage was hurting. The ADON said when she looked at the schedule, she identified the staff as CNA D. The ADON said she reported Resident #3's allegations to the Administrator as soon as she was able to on 04/09/2026 because it was an allegation of abuse. The ADON said she told the Administrator Resident #3 had made a complaint of abuse. The ADON said Resident #3's rib cage pain could have been from an assisted fall he had the day before, and they got an x-ray, and it was negative. The ADON said she completed a skin assessment on Resident #3, and he had no redness or bruising. The ADON said it was important for all allegations of abuse to be reported and investigated because allegations could be true and the residents could get hurt and so abuse allegations could be addressed in a timely manner. The ADON said the DON was not available for interview. During an interview on 04/14/2026 at 4:59 PM, COTA C said Resident #3 reported to her that in the middle of the morning/dark hours/early morning on 04/09/2026 a gentleman with glasses came in his room and moved him around roughly and hurt his rib. COTA C said Resident #3 was upset and said he wanted the person fired before he fired him. COTA C said she went to look for the Administrator to report Resident #3's allegation, but the Administrator was not in the building, so she reported it to the ADON. COTA C said it was important for all allegations of abuse to be reported because abuse could happen to other residents. During an interview on 04/14/2026 at 5:04 PM, the Administrator said the ADON notified her of Resident #3's allegation that CNA D was rough with him. The Administrator said she did not report the incident to HHSC because when she talked to Resident #3, she felt like it was more of a customer service issue. The Administrator said when she questioned Resident #3 about what he meant by CNA D being rough with him, Resident #3 said CNA D could have been gentler when moving him. The Administrator said if the staff were rough handling, abusive, or moving roughly it should be reported as abuse to HHSC. The Administrator said if there was an allegation of abuse it should be reported within 2 hours to HHSC. The Administrator said it was important for allegations of abuse to be reported to ensure they had taken all the steps necessary, and all residents were safe, not just the resident making the allegation but all the ones around that may or may not be able to report abuse. During an interview on 04/14/2026 at 5:22 PM, CNA D said he was not allowed to go in Resident #3's room. CNA D said when Resident #3 first arrived at the facility, he provided incontinent care. CNA D said he turned Resident #3 on his side as far as he could because Resident #3 was not able to turn good at all. CNA D said he was not trying to be rough, but he had to push him a little when turning him on his side to get him cleaned up. CNA D said he had to use his body strength to push Resident #3 on his side because it was difficult to turn him over. CNA D said he should have gotten another person to help him change Resident #3 since he was having trouble turning him, but everybody else was busy. CNA D said the DON had talked to him regarding the incident with Resident #3 and he was provided an in-service on abuse and neglect. Record review of the facility's policy titled, Abuse Prevention and Prohibition Program revised 10/24/2022, indicated, To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. III. The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems. IX. Reporting/Response A. Facility Staff are Mandatory Reporters i. Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and any state specific regulations to report known or suspected instances of abuse of elder or dependent adults. B. Administrator, or his/her designee, as Abuse Coordinator i. In order to facilitate reporting, ensure confidentiality, and promote order at the facility, the Administrator, or his/her designee, shall be the individual who reports known or suspected instances of abuse of residents at the facility to the proper authorities. C. All mandated reporters will report reasonable suspicion of a crime against a resident when it is objectively reasonable for a person to entertain a suspicion of conduct that appears to be financial abuse, physical abuse, neglect, abandonment, isolation, abduction or other treatment resulting in physical harm or pain or mental suffering, deprivation of goods or services that are necessary to avoid physical harm or mental suffering. The Facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime i. Immediately, but no later than 2 hours after forming the suspicion - if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation).

Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 4 residents (Resident #3) reviewed for abuse. The facility failed to implement their abuse policy when the Administrator failed to report to HHSC after the ADON reported to the Administrator an allegation of abuse made by Resident #3 on 04/09/2026. This failure could place residents at risk of unreported abuse, neglect, exploitation, and a decreased quality of life.Findings included: Record review of the facility's policy titled, Abuse Prevention and Prohibition Program revised 10/24/2022, indicated, To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. III. The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems. IX. Reporting/Response A. Facility Staff are Mandatory Reporters i. Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and any state specific regulations to report known or suspected instances of abuse of elder or dependent adults. B. Administrator, or his/her designee, as Abuse Coordinator i. In order to facilitate reporting, ensure confidentiality, and promote order at the facility, the Administrator, or his/her designee, shall be the individual who reports known or suspected instances of abuse of residents at the facility to the proper authorities. C. All mandated reporters will report reasonable suspicion of a crime against a resident when it is objectively reasonable for a person to entertain a suspicion of conduct that appears to be financial abuse, physical abuse, neglect, abandonment, isolation, abduction or other treatment resulting in physical harm or pain or mental suffering, deprivation of goods or services that are necessary to avoid physical harm or mental suffering. The Facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime i. Immediately, but no later than 2 hours after forming the suspicion - if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation). Record review of Resident #3's face sheet dated 04/14/2026, indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included infectious gastroenteritis and colitis (inflammation of the stomach, intestines, and colon caused by an infection), essential primary hypertension (high blood pressure), and benign prostatic hyperplasia with lower urinary tract symptoms (overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine). Record review of Resident #3's Comprehensive MDS assessment dated [DATE] indicated he was understood by others, and he understood others. Resident #3 had a BIMS score of 15, which indicated his cognition was intact. Resident #3 was dependent on staff for toileting, showering/bathing, dressing, and personal hygiene. Record review of Resident #3's care plan initiated 03/31/2026 did not address the level of assistance Resident #3 required for ADLs. During an interview on 04/14/2026 at 1:51 PM, Resident #3 said when he first came to the facility, he needed to be changed because he was dirty, and there was a male CNA that was very rough with him. Resident #3 was unable to provide a specific date. Resident #3 said even when the CNA was wiping him, he was being rough. Resident #3 said he should not have been treated that way because the staff were there to help him, and they were supposed to be gentle when providing care, turning, and wiping him. Resident #3 said he reported the CNA to the nurse when it happened, and to the Administrator the next day. Resident #3 said the Administrator told him she would investigate it, and she never came back to tell him anything. Resident #3 said the CNA had not provided care to him again. During an interview on 04/14/2026 at 4:29 PM, the ADON said on 04/09/2026 COTA C reported to her that Resident #3 said a staff member was rough with him. The ADON said Resident #3 told her a staff member was rough with him when he was changing him. The ADON said Resident #3 told her it was a man with glasses, beard. The ADON said Resident #3 also reported his right rib cage was hurting. The ADON said when she looked at the schedule, she identified the staff as CNA D. The ADON said she reported Resident #3's allegations to the Administrator as soon as she was able to on 04/09/2026 because it was an allegation of abuse. The ADON said she told the Administrator Resident #3 had made a complaint of abuse. The ADON said Resident #3's rib cage pain could have been from an assisted fall he had the day before, and they got an x-ray, and it was negative. The ADON said she completed a skin assessment on Resident #3, and he had no redness or bruising. The ADON said it was important for all allegations of abuse to be reported and investigated because allegations could be true and the residents could get hurt and so abuse allegations could be addressed in a timely manner. The ADON said the DON was not available for interview. During an interview on 04/14/2026 at 4:59 PM, COTA C said Resident #3 reported to her that in the middle of the morning/dark hours/early morning on 04/09/2026 a gentleman with glasses came in his room and moved him around roughly and hurt his rib. COTA C said Resident #3 was upset and said he wanted the person fired before he fired him. COTA C said she went to look for the Administrator to report Resident #3's allegation, but the Administrator was not in the building, so she reported it to the ADON. COTA C said it was important for all allegations of abuse to be reported because abuse could happen to other residents. During an interview on 04/14/2026 at 5:04 PM, the Administrator said the ADON notified her of Resident #3's allegation that CNA D was rough with him. The Administrator said she did not report the incident to HHSC because when she talked to Resident #3, she felt like it was more of a customer service issue. The Administrator said when she questioned Resident #3 about what he meant by CNA D being rough with him, Resident #3 said CNA D could have been gentler when moving him. The Administrator said if the staff were rough handling, abusive, or moving roughly it should be reported as abuse to HHSC. The Administrator said according to their policy on abuse if there was an allegation of abuse it should be reported within 2 hours to HHSC. The Administrator said it was important for allegations of abuse to be reported to ensure they had taken all the steps necessary, and all residents were safe, not just the resident making the allegation but all the ones around that may or may not be able to report abuse. During an interview on 04/14/2026 at 5:22 PM, CNA D said he was not allowed to go in Resident #3's room. CNA D said when Resident #3 first arrived at the facility, he provided incontinent care. CNA D said he turned Resident #3 on his side as far as he could because Resident #3 was not able to turn good at all. CNA D said he was not trying to be rough, but he had to push him a little when turning him on his side to get him cleaned up. CNA D said he had to use his body strength to push Resident #3 on his side because it was difficult to turn him over. CNA D said he should have gotten another person to help him change Resident #3 since he was having trouble turning him, but everybody else was busy. CNA D said the DON had talked to him regarding the incident with Resident #3 and he was provided an in-service on abuse and neglect.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, for 1 of 4 residents (Resident #3) reviewed for abuse and neglect reporting. The facility failed to ensure the Administrator reported to HHSC within 2 hours on 04/09/2026 when the ADON reported to her Resident #3 alleged CNA D was rough with him while providing incontinent care. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.Findings included: Record review of Resident #3's face sheet dated 04/14/2026, indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included infectious gastroenteritis and colitis (inflammation of the stomach, intestines, and colon caused by an infection), essential primary hypertension (high blood pressure), and benign prostatic hyperplasia with lower urinary tract symptoms (overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine). Record review of Resident #3's Comprehensive MDS assessment dated [DATE] indicated he was understood by others, and he understood others. Resident #3 had a BIMS score of 15, which indicated his cognition was intact. Resident #3 was dependent on staff for toileting, showering/bathing, dressing, and personal hygiene. Record review of Resident #3's care plan initiated 03/31/2026 did not address the level of assistance Resident #3 required for ADLs. During an interview on 04/14/2026 at 1:51 PM, Resident #3 said when he first came to the facility, he needed to be changed because he was dirty, and there was a male CNA that was very rough with him. Resident #3 was unable to provide a specific date. Resident #3 said even when the CNA was wiping him, he was being rough. Resident #3 said he should not have been treated that way because the staff were there to help him, and they were supposed to be gentle when providing care, turning, and wiping him. Resident #3 said he reported the CNA to the nurse when it happened, and to the Administrator the next day. Resident #3 said the Administrator told him she would investigate it, and she never came back to tell him anything. Resident #3 said the CNA had not provided care to him again. During an interview on 04/14/2026 at 4:29 PM, the ADON said on 04/09/2026 COTA C reported to her that Resident #3 said a staff member was rough with him. The ADON said Resident #3 told her a staff member was rough with him when he was changing him. The ADON said Resident #3 told her it was a man with glasses, beard. The ADON said Resident #3 also reported to her his right rib cage was hurting. The ADON said when she looked at the schedule, she identified the staff as CNA D. The ADON said she reported Resident #3's allegations to the Administrator as soon as she was able to on 04/09/2026 because it was an allegation of abuse. The ADON said she told the Administrator Resident #3 had made a complaint of abuse. The ADON said Resident #3's rib cage pain could have been from an assisted fall he had the day before, and they got an x-ray, and it was negative. The ADON said she completed a skin assessment on Resident #3, and he had no redness or bruising. The ADON said it was important for all allegations of abuse to be reported and investigated because allegations could be true and the residents could get hurt and so abuse allegations could be addressed in a timely manner. The ADON said the DON was not available for interview. During an interview on 04/14/2026 at 4:59 PM, COTA C said Resident #3 reported to her that in the middle of the morning/dark hours/early morning on 04/09/2026 a gentleman with glasses came in his room and moved him around roughly and hurt his rib. COTA C said Resident #3 was upset and said he wanted the person fired before he fired him. COTA C said she went to look for the Administrator to report Resident #3's allegation, but the Administrator was not in the building, so she reported it to the ADON. COTA C said it was important for all allegations of abuse to be reported because abuse could happen to other residents. During an interview on 04/14/2026 at 5:04 PM, the Administrator said the ADON notified her of Resident #3's allegation that CNA D was rough with him. The Administrator said she did not report the incident to HHSC because when she talked to Resident #3, she felt like it was more of a customer service issue. The Administrator said when she questioned Resident #3 about what he meant by CNA D being rough with him, Resident #3 said CNA D could have been gentler when moving him. The Administrator said if the staff were rough handling, abusive, or moving roughly it should be reported as abuse to HHSC. The Administrator said if there was an allegation of abuse it should be reported within 2 hours to HHSC. The Administrator said it was important for allegations of abuse to be reported to ensure they had taken all the steps necessary, and all residents were safe, not just the resident making the allegation but all the ones around that may or may not be able to report abuse. During an interview on 04/14/2026 at 5:22 PM, CNA D said he was not allowed to go in Resident #3's room. CNA D said when Resident #3 first arrived at the facility, he provided incontinent care. CNA D said he turned Resident #3 on his side as far as he could because Resident #3 was not able to turn good at all. CNA D said he was not trying to be rough, but he had to push him a little when turning him on his side to get him cleaned up. CNA D said he had to use his body strength to push Resident #3 on his side because it was difficult to turn him over. CNA D said he should have gotten another person to help him change Resident #3 since he was having trouble turning him, but everybody else was busy. CNA D said the DON had talked to him regarding the incident with Resident #3 and he was provided an in-service on abuse and neglect. Record review of the facility's policy titled, Abuse Prevention and Prohibition Program revised 10/24/2022, indicated, To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. III. The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems. IX. Reporting/Response A. Facility Staff are Mandatory Reporters i. Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and any state specific regulations to report known or suspected instances of abuse of elder or dependent adults. B. Administrator, or his/her designee, as Abuse Coordinator i. In order to facilitate reporting, ensure confidentiality, and promote order at the facility, the Administrator, or his/her designee, shall be the individual who reports known or suspected instances of abuse of residents at the facility to the proper authorities. C. All mandated reporters will report reasonable suspicion of a crime against a resident when it is objectively reasonable for a person to entertain a suspicion of conduct that appears to be financial abuse, physical abuse, neglect, abandonment, isolation, abduction or other treatment resulting in physical harm or pain or mental suffering, deprivation of goods or services that are necessary to avoid physical harm or mental suffering. The Facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime i. Immediately, but no later than 2 hours after forming the suspicion - if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation).

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 3 residents (Resident #2) reviewed for care plans. The facility failed to ensure a care plan was developed to address Resident #2's preference to not have males provide personal/hands on care. This failure could place residents at risk of not having their individual needs met and a decreased quality of life.Findings included: Record review of Resident #2's face sheet dated 04/14/2026, indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves causes unintended or uncontrollable movements), dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities). Record review of Resident #2's Comprehensive MDS assessment dated [DATE] indicated she was able to make herself understood and usually understood others. The MDS assessment indicated Resident #2's BIMS score was 12, which indicated her cognition was moderately impaired. Resident #2 required partial/moderate assistance with showering/bathing self, and supervision or touching assistance with personal hygiene and dressing. Record review of Resident #2's care plan initiated 03/18/2026 did not indicate her preference to not have male staff assist her with hands on care. During an interview on 04/14/2026 at 2:15 PM, Resident #2 said she had told one of the nurses she did not want men cleaning her up or touching her. Resident #2 said she did not like it when the men touched her. Resident #2 said she kept having to tell the nurses she did not want men cleaning her up. During an interview on 04/14/2026 at 3:52 PM, LVN A said he was aware Resident #2 did not want males helping with her personal care. LVN A said one time he went in to try to help her, and she told him she wanted females only no males. LVN A said the preference for females only should be included in the care plan and the ADON and DON were the ones who put that in the care plan. LVN A said it was important to include this in the care plan so the residents felt respected, and because they could have a history of trauma. During an interview on 04/14/2026 at 4:29 PM, the ADON said she did not remember Resident #2 particularly saying she did not want a man to provide her personal care. The ADON said if a female resident did not want males providing care it was placed on the assignment sheets, and it should be a part of the resident's care plan. The ADON said the nurses should report to administration if a female resident does not want a male staff to provide care for the interdisciplinary team to discuss it and care plan it. The ADON said it was important for this to be included in the care plan because the residents could have trauma, and it was the residents' right to say they did not want males in the room. During an interview on 04/14/2026 at 5:04 PM, the Administrator said she was not aware Resident #2 did not want males providing her personal care. The Administrator said she expected this to be included in the residents' care plan, so all the staff were aware, and the residents' rights were respected. Record review of the facility's policy titled, Care Planning, revised 10/24/2022, indicated, To ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs.a culturally competent and trauma-informed comprehensive person-centered care plan will be developed for each resident. The care plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs.changes may be made to the comprehensive care plan on an ongoing basis for the duration of the resident's stay.each resident's comprehensive care plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 3 residents (Resident #1) reviewed for ADLs. The facility failed to ensure Resident #1 received showers as scheduled. This failure could place residents at risk of not receiving needed services and care, decreased self-esteem, and a decreased quality of life.Findings included: Record review of Resident #1's face sheet dated 04/14/2026 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), bipolar disorder (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), and dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #1's Comprehensive MDS assessment dated [DATE] indicated she was understood by others and usually understood others. Resident #1's MDS assessment indicated she had a BIMS score of 15, which indicated her cognition was intact. Resident #1 was independent for upper body dressing, required setup or clean-up assistance with eating and personal hygiene, and required substantial/maximal assistance with showering/bathing self and lower body dressing. Record review of Resident #1's care plan revised on 06/10/2025 indicated she had an ADL self-care performance deficit related to weakness of her dominant side and required extensive assistance by staff with showering and assistance by staff to dress and with personal hygiene. Record review of Resident #1's bathing task record dated 03/16/2026-04/14/2026 did not indicate she received a shower on 3/27/2026, 04/01/2026, and 04/13/2026. During an observation and interview on 04/14/2026 at 11:37 AM, Resident #1 said she was not receiving her showers as scheduled. Resident #1 said the last shower she had was Friday, 04/10/2026. Resident #1 said she was supposed to receive a shower yesterday, 04/13/2026. Resident #1 said the CNAs told her they were too busy and had 18-20 residents to take care of. Resident #1 had light brown stains on her white shirt. Resident #1 said because she had not received a shower she could not fix the back of her hair and it was messy from laying down on the pillow. During an interview on 04/14/2026 at 2:33 PM, CNA B said she provided care to Resident #1 and missed giving her some showers. CNA B said she missed giving baths and showers to the residents due to the construction and the water being too cold. CNA B said yesterday 04/13/2026, the showers were unavailable for use due to the construction. CNA B said Resident #1 was receiving showers Monday, Wednesday, and Friday, but on Friday 04/10/2026 there was a change to the shower schedules. Resident #1 was switched to Tuesday, Thursday, and Saturday for her showers. CNA B said it was important for the residents to get their showers to help them feel better. During an interview on 04/14/2026 at 4:29 PM, the ADON said the CNAs documented on the bathing task record and on shower sheets. The ADON said she was unable to provide shower sheets for Resident #1 because some things were missing due to the construction. The ADON said she was aware showers were missed yesterday (04/13/2026) because they were unaware the painters blocked off the showers. The ADON said some of the residents received bed baths. The ADON said she did not know how they ensured all the residents received their baths on 04/13/2026. The ADON said due to the remodeling, they had been making a lot of room changes, and she had not been able to monitor to ensure the residents were not missing their showers. The ADON said Resident #1's shower days were changed on Friday 04/10/2026 to Tuesday, Thursday, and Saturday. Due to this change, Resident #1 should have received a shower on Saturday 04/11/2026 so she would not go so many days without a shower. The ADON said the CNAs were supposed to be checking the shower schedule daily to ensure they did not miss any showers. The ADON said it was important for the residents to receive their showers for their dignity, quality of life, skin, and infection control. The ADON said the DON was not available for an interview. During an interview on 04/14/2026 at 5:04 PM, the Administrator said she was not aware of the residents not receiving showers as scheduled. The Administrator said it was not true that the construction was interfering with the CNAs giving showers. The Administrator said yesterday (04/13/2026), the painters painted both showers without notifying her, and they were unable to use either shower. The Administrator said this was the only time they were unable to use the showers. The Administrator said the CNAs were supposed to give bed baths to the residents scheduled for showers. The Administrator said it was important for the residents to receive showers because it was a basic need for quality of life and for them to be clean. Record review of the facility's undated policy titled, Showering a Resident, indicated, A shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors. Residents are offered a shower at a minimum of once weekly and given per resident request.

Based on observation, interview, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 3 medication carts (Hall 2 Medication Cart) reviewed for drugs and biologicals. The facility failed to ensure LVN A secured the Hall 2 Medication Cart, when it was not in use and unattended on 04/14/2026. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.Findings included: During an observation and interview starting on 04/14/2026 at 2:09 PM, the Hall 2 Medication Cart was unlocked and unattended stationed by the nurse's station. There were residents, staff, and multiple workers painting by the unlocked medication cart. The Regional Nurse observed the state surveyor standing by the Hall 2 Medication Cart and locked it. The Regional Nurse said the Hall 2 Medication Cart was LVN A's responsibility, and he should have locked it when he stepped away from it. The Regional Nurse said LVN A was outside on a smoke break. The Regional Nurse said the medication carts should not be unlocked when unattended for safety of the medications. During an interview on 04/14/2026 at 3:52 PM, LVN A said he was responsible for ensuring the medication cart was locked. LVN A said he thought he locked the Hall 2 Medication Cart before he went outside to smoke. LVN A said if the medication carts were left unlocked a patient or anybody could have gotten the medications. During an interview on 04/14/2026 at 4:29 PM, the ADON said the charge nurses were responsible for ensuring the medication carts were locked every time they stepped away from the medication cart. The ADON said it was important for the medication carts to be locked when unattended so the residents and no one could get into the medication cart except for the person who accepted responsibility for the cart. The ADON said the DON was not available for an interview. During an interview on 04/14/2026 at 5:16 PM, the Administrator said she expected the medications carts to be locked when the nurses walked away from them or when they were no longer facing the medication cart. The Administrator said all department heads were responsible for ensuring the medication carts were locked. If they saw an unlocked medication cart, they should lock it and notify her so she could take the proper steps and address it with the staff who left it unlocked. The Administrator said the medication carts should be locked because a resident who did not know any better could take the medications and harm themselves or the medications could be stolen, and the residents would not have what they needed. Record review of the facility's policy titled, Medication Storage, revised 01/2026, indicated, To establish standards that safeguard residents by preventing unauthorized access to medications and ensuring compliance with applicable federal and state pharmacy regulations. Medication carts must remain locked and always secured unless under direct and continuous supervision of authorized personnel during medication administration. These standards are required to ensure resident safety and regulatory compliance.This policy applies to all licensed nurses.medication rooms, carts, and cabinets must remain locked at all times. carts must be locked whenever they are not actively attended. The medication cart must be locked: when turning away from the cart, when more than arm's reach from the cart, during breaks, meals, or when leaving the unit.

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 resident (Residents #9) reviewed for infection control.RN A failed to put on a gown prior to administering medications through a jejunostomy tube (also called aJ-Tube, enteral tube, or feeding tube).This failure could place residents at risk of exposure and/or possible transmission of communicable diseases and infections.Findings include: A record review of a face sheet dated 07/08/2025 indicated Resident #9 was a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included feeding difficulties, artificial opening of gastrointestinal tract status (a jejunostomy which is a tube inserted through the abdomen into the small intestine to provide nutrition and medications), oropharyngeal dysphagia (difficulty in swallowing), and cerebral infarction (a stroke). A record review of Resident #9's admission MDS assessment dated [DATE] noted Resident #9 had a BIMS of 3 which indicated her cognition was severely impaired. The MDS assessment indicated Resident #9 had a feeding tube. A record review of the physician's orders dated 07/08/2025 indicated Resident #9 had a J-Tube for administration of medications and nutrition. A record review of Resident #9's care plan dated 05/21/2025 indicated EBP were to be used when providing care involving the J-Tube.During an observation on 07/08/2025 at 09:08 AM, RN A prepared Resident #9's morning medications for administration through her feeding tube. RN A put on gloves and entered Resident #9's room. Resident #9 had a sign on the doorway entrance into her room which indicated Enhanced Barrier Precautions were required. The sign also said that all providers and staff must wear gloves and a gown for high-contact activities which included feeding tube care or use. There was a 3-drawer plastic container outside the doorway which contained PPE that included gloves and gowns. RN A did not put on a gown. RN A told Resident #9 that she had her medications. RN A checked tube placement and administered the medications through the feeding tube. After completion of the task, RN A removed her gloves, disposed of them, and washed her hands. RN A then returned to her cart and said she was finished. During an interview on 07/08/2025 at 09:12 AM, RN A said she should have put on a gown prior to administering Resident #9's medications because Resident #9 had a feeding tube which required EBP. RN A said EBP was important for preventing the spread of infection. RN A said she forgot to put on a gown because she was nervous. During an interview with the DON on 07/08/2025 at 10:45 AM, she said she expected the nurses to adhere to Enhanced Barrier Precautions when providing direct care to residents with feeding tubes. She said EBP required the wearing of gloves and gowns when providing direct care to residents with indwelling medical devices. She said the purpose was to reduce the risk of spreading infections and diseases. During an interview with the MDS Coordinator on 07/08/2025 at 03:12 PM, she said she was a registered nurse and the Infection Preventionist for the facility. She said nurses were required to wear gloves and a gown when administering medications through a feeding tube to reduce the spread of infections and diseases.A record review of the facility's policy titled Enhanced Barrier Precautions and dated 08/2022 indicated the following:1. Enhanced barrier Precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and gloves use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room).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, .).

Based on interview and record review, the facility failed to immediately consult with the resident's physician and notify the resident representative of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 6 residents reviewed for notification of changes. The facility failed to ensure LVN A notified the physician/designee and the resident's representative after Resident #1 had a change of condition with agonal breathing (the medical term for gasping for air), fixed pupils, no urine output and lethargy. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 04/07/2025 and ended on 04/08/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for not receiving appropriate care and interventions and/or death. The findings included: Record review of Resident #1's face sheet dated 04/15/2025 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of chronic atrial fibrillation (a heart condition where the upper two chambers of the heartbeat irregularly and rapidly, lasting longer than 12 months), repeated falls and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 which indicated moderate cognitive impairment. Resident #1 was usually understood by others and usually understands. Resident #1 required setup assistance for eating and moderate assistance for personal hygiene. Resident #1 required maximal assistance with bathing, dressing and dependent with toileting hygiene. Record review of Resident #1's care plan dated 10/17/2023, reflected I have chosen do not resuscitate status. Ensure resident wishes are followed as desired. Follow my advanced directive/code status. Record review of Resident #1's orders undated revealed advanced directives code status DNR (do not resuscitate). Record review of Resident #1's nurse progress note dated 04/07/2025 at 5:00 a.m., wrote by LVN A said she was called by CNA this nurse to resident's room and upon assessment resident shows agonal breathing, skin is cold, eyes are fixed. Resident #1 vital signs were 54/53, 54, 93%, 128. Resident was a DNR and on hospice. Will continue to monitor. Record review of Resident #1's SW progress note date 04/05/2025 revealed, this social intern called the resident's family today. Family Member #1 asked not to be called at 3 A.M. unless it's an emergency, Resident #1 has passed or is in the emergency room . Record review of Resident #1's hospital records dated 04/07/2025 revealed death due to cardiopulmonary arrest. During an interview on 04/15/2025 at 8:50 A.M., the DON said CNA B reported the change of condition of Resident #1 to LVN A. LVN A only monitored Resident #1. LVN C the oncoming nurse assessed Resident #1, called the MD and sent her out to the emergency room . The DON said all LVN A did from 5-6:00 A.M. was monitor Resident #1. The DON said LVN A should have called the MD and probably sent her out to the hospital. She said LVN A should have called the family, and she did not call anyone. She said LVN A was a DNR/do not return after this. She said she believed the resident was neglected by LVN A. The DON said from 5-6:00 A.M. Resident #1 had agonal breathing and a fast heart rate. The DON said LVN C called her 04/07/2025 at 7:17 A.M. to tell her what was going on with Resident #1. During an interview on 04/15/2025 at 10:37 A.M., LVN C said she got to the facility the morning of 04/07/2025 about 6:30 A.M. and LVN A gave her report. LVN C said LVN A told her the aide notified her about 5am that Resident #1 was not acting right, so she went to assess the Resident #1. LVN C said LVN A told her Resident #1's blood pressure was low; the resident's pupils were fixed and she was not responding. LVN C said LVN A said Resident #1 was on hospice and she told her she was not on hospice. LVN C said she asked LVN A if she had notified anyone about the change in condition of Resident #1 and she said no. LVN C said after she and LVN A were finished with report, she went to assess Resident #1 and she was not responding so she called 911. Then LVN C said she notified the NP of Resident #1's change of condition and Resident #1 was not responding. Then LVN C said she notified the family and the DON. LVN C said LVN A said she did not understand how that was a change in condition. LVN C said once she received report from LVN A, LVN A left the facility. During an interview on 04/15/2025 at 12:07 P.M., LVN A said CNA B was making her last rounds when she came and her told Resident #1 did not look right. LVN A said she went to assess Resident #1 and her vital signs were low. She said Resident #1 looked like she was actively dying. She said Resident #1 was a DNR. She said she saw there was a progress note from the social worker that said the family requested not to call at 3:00 A.M. or in the middle of the night. She said the social worker progress note was put in on the 04/05/2025. She said she monitored Resident #1 the rest of her shift and she did 15 minutes checks on her. She said eventually the next nurse came in. She said she was confused about if the resident was actively passing, because in her training if they were actively passing the nurse should do nothing if the resident was a DNR. She said she did not notify the MD or NP and she said she did not notify the family, because the social worker progress note said the family did not want to be contacted in throughout the night and early morning hours. She said felt like she did her job because she monitored the resident. During an interview on 04/15/2025 at 12:31 P.M., the SW said she usually worked in the facility 3 days a week, but it depends on what the census was. She said yes, she had an intern to put a progress note in PCC (electronic health record) for Resident #1 on 04/05/2025. The SW verified that there was a note that stated Resident #1's family requested not to be contacted in the middle of the night or early in the morning regarding the resident's care. During an interview on 04/15/2025 at 12:41 P.M., CNA B said when she did her last rounds, she noticed Resident #1 had not wet during the shift. She said she was not a heavy wetter but had not voided the whole shift and she had not rested well. She said she had worked for hospice before, and she knew that was not a good sign. She said she notified the nurse immediately. She said the nurse checked Resident #1's vital signs and told her she might be right, that something was going on with Resident #1. CNA B said Resident #1's eyes were already fixed. She said LVN A was agency staff, and she was agency staff also, but she had worked with Resident #1 for a while. She said she thought LVN A did not know Resident #1 well enough to know that there was a change in her condition on how she usually acts, she guessed. She said she thought LVN A may have received report on Resident #1 not feeling well. She said after she completed her last rounds, she went home. She said she thought LVN A should have sent Resident #1 out to the hospital. She said LVN A told her Resident #1 was on hospice and she told her she did not know she was on hospice. She said she thought to herself if Resident #1 was on hospice, she should have notified the hospice company. She said later she found out Resident #1 was not on hospice. She said if she was in LVN A's shoes she would have sent Resident #1 out to the hospital, with her breathing the way she was breathing. During an interview on 04/15/2025 at 2:07 P.M., the MD said it does not ever hurt to notify the MD. He said any time there was an emergency with a resident the nurse should notify the NP or MD. He said with the incident with Resident #1 having low vital signs and agonal breathing, he would have wanted to be notified and he would have given orders for the nurse to send Resident #1 out to the hospital. He said the incident occurred and it sound like the nurse did not do her job and got fired and that was appropriate. During an interview on 04/15/2025 at 3:05 P.M., the DON said when the nurse was notified of a change of condition with Resident #1, the nurse should have done her assessment, then based off of her assessment she should have notified the NP or the MD. She said after she notified them of the change in condition they would have given her further orders. She said she felt like the nurse neglected Resident #1 by not notifying the MD and taking no further actions for the resident. She said they try to keep check off agency staff when we are performing any kind of check offs and they are working in our building. She said the facility did in-services and the book stayed at the nurses' station and they are supposed to sign and read the in-services before they start work. During an interview on 04/15/2025 at 3:47 P.M., the ADM said as soon as the nurse knew that there was a change in condition with Resident #1 she should have called the NP. She said the NP could have told her what to do, but by her not calling him she made a decision that she was not allowed to make, which was to do nothing. She said LVN A should have notified Resident #1's family as well. She said if she would have notified the NP, she would have been able to tell the family what the NP said about the resident's condition. She said she felt like LVN A made a stupid decision in her heart and the resident's needs were not met. She said there are in-services over Change of Condition, Abuse, Neglect and Exploitation, and DNR at the front nurse station since the 04/08/2025 every nurse has been in serviced on this. She said if she or the DON is not in the facility the off-going nurses were responsible for in servicing the incoming nurses who had not been in serviced on the topics. During an interview on 04/16/2025 at 10:19 A.M., the ADM said on the in-services you have to go to PCC to work Stopwatch tool, but there was not an actual way to show what we have been working on. She said Stopwatch is noted to a specific person when they were flagged in PCC. She said the stopwatch tool was to the signature page. We have in serviced everyone on the physical tool. Record review of the facility's Change in a Resident's Condition or Status revised date 02/2021 indicated .Our community promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status . .1.The nurse will notify the resident's attending physician or physician on call when there has been a(an)significant change of condition is a major decline or improvement in the resident's status . The facility corrected the noncompliance on 04/08/2025 by the following: -All staff interviewed ( ADON, MDS Nurse, LVN C, CNA B, RN D, RN L, RN F, RN E,CNA G, CNA H, CWT I, CNA J, CNA K, SW, [NAME] M, CNA N, Maintenance O, DM P, Housekeeper Q, Housekeeper T, DA R, CNA S, CNA U and RN V ) on 04/16/2025 verbalized understanding of In-services on COC (Change of Condition). All staff verbalized understanding CNAs are to alert nurses and nurses are to alert representative and physician of any changes in the resident's medical/mental condition or status. - Completed 04/08/2025. -All staff interviewed ( ADON, MDS Nurse, LVN C, CNA B, RN D, RN L, RN F, RN E,CNA G, CNA H, CWT I, CNA J, CNA K, SW, [NAME] M, CNA N, Maintenance O, DM P, Housekeeper Q, Housekeeper T, DA R, CNA S, CNA U and RN V ) on 04/16/2025 verbalized understanding of In-services on DNR (do not resuscitate). All staff verbalized education on DNR and meaning, but voiced it does not mean that the facility will not treat the resident in the event of a change of condition and does not mean do not send the resident to the hospital for emergency treatment. - Completed 04/08/2025. -All staff interviewed ( ADON, MDS Nurse, LVN C, CNA B, RN D, RN L, RN F, RN E,CNA G, CNA H, CWT I, CNA J, CNA K, SW, [NAME] M, CNA N, Maintenance O, DM P, Housekeeper Q, Housekeeper T, DA R, CNA S, CNA U and RN V ) on 04/16/2025 verbalized understanding of in-service on ANE (Abuse, Neglect and exploitation). Staff was able to identify the different types of abuse, neglect, exploitation and who to report it to. -Completed 04/08/2025. -All staff interviewed ( ADON, MDS Nurse, LVN C, CNA B, RN D, RN E, RN L, RN F, CNA G, CNA H, CWT I, CNA J, CNA K, SW, [NAME] M, CNA N, Maintenance O, DM P, Housekeeper Q, Housekeeper T, DA R, CNA S, CNA U and RN V ) on 04/16/2025 verbalized understanding of Stop and Watch, Early Warning Tool (Interact). Staff verbalizing if they identified a change while caring for or observing a resident/patient, please circle the change and notify a nurse. -Completed 04/15/2025. -All nurses interviewed (DON, ADON, MDS Nurse, RN L, RN E, and LVN C) on huddles an ongoing process was when the nurses got together during shift change to talk about any changes to the resident, anything new with the residents, anything to watch for. They said they talked about any new wounds would need to be reported. They said they always reported things as they happened but would go over it again in the huddle. They showed this surveyor in PCC how to find the flags for high-risk residents and anything the residents had flagged for. We looked at several residents with flags. There was only one resident with an SBar since 04/07/2025.Ongoing process. - QAPI meeting held to discuss appropriate care interventions were not provided in a timely manner following a resident's change in condition. This failure to act accordingly may have contributed to a delay in an assessment, treatment, or escalation of care on 04/07/2025: -The resident exhibited clear signs of a change in condition, including agonal breathing, cold skin, eyes fixed vital signs:54/53, 54, 93%, 128. -Documentation indicates that the change was either not communicated promptly or not acted upon in accordance with facility protocol (i.e, call NP/MD/DON). -Care team did not initiate appropriate clinical interventions or notify the appropriate providers within the expected time frame. - Completed 04/08/2025. During an interview on 04/16/2025 at 2:00 P.M., Family Member#1 of Resident #1 said the care she received from the facility was not great. Family Member #1 said she had laryngitis and she could not talk. During an interview on 04/17/2025 at 9:43 A.M., RN D said she had only worked at the facility a couple of times. She said she could not remember the resident by name. She said that was her first time working on that hall, but the last day she worked which was 04/06/2025 none on her residents were in critical condition and she had no reports of a change of condition on any of them. She said if a resident had a change in condition, she would have notified the MD and sent the resident to the hospital and notified the family. During an interview on 04/17/2025 at 10:49 A.M., the DON said she felt like once LVN A had been notified of the change of condition with Resident #1 had occurred she should have assessed her, notified the NP or MD of the findings and followed the orders. She said she was totally mind blown by LVN A's reaction to what she was taught. She said LVN A said she thought she did not do anything wrong. She said the facility put a DNR (do not return) on LVN A and the agency terminated her as well. During an interview on 04/17/2025 at 11:08 A.M., the ADM said she felt that everything LVN C did should have been done during the incident with Resident #1. She said LVN A had the tools she needs at the facility and there was another nurse on duty to assist her for guidance and to help her. She said LVN A chose to monitor Resident #1. She said LVN A should have called the NP, she should have called anyone. She said she believed LVN A's biggest downfall was she did not call anyone. The ADM said she believed that Resident #1 was in a-fib (an irregular and often rapid heart rhythm, but they do not know, because LVN A did not make a phone call. She said LVN A should have made a phone call to the family of Resident #1. The ADM said if Resident #1 was her family, yes I would want to be notified of her condition. She said LVN A's reaction was unacceptable, and she would be referring her to the Texas board of nursing. The noncompliance was identified as PNC. The noncompliance began on 04/07/2025 and ended on 04/08/2025. The facility corrected the noncompliance before the survey began.

Based on interview and record review, the facility failed to ensure each resident received treatment and care in accordance with professional standards of practice for 1 of 6 resident's reviewed for quality of care. The facility failed to notify the physician/designee and or seek a higher level of care on 4/07/2025 5:00 a.m. - 6:00 a.m. when Resident #1 had a change of condition with agonal breathing, fixed pupils, no urine output and lethargic. The facility failed to ensure LVN A documented any additional assessments/monitoring of Resident #1 after the initial assessment on 4/07/2025 at 5:00 a.m. The facility failed to ensure LVN A initiated any interventions to prevent a further decline in Resident #1. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 04/07/2025 and ended on 04/08/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for not receiving timely medical intervention. The findings included: Record review of Resident #1's face sheet dated 04/15/2025 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of chronic atrial fibrillation (a heart condition where the upper two chambers of the heartbeat irregularly and rapidly, lasting longer than 12 months), repeated falls and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 which indicated moderate cognitive impairment. Resident #1 was usually understood by others and usually understands. Resident #1 required setup assistance for eating and moderate assistance for personal hygiene. Resident #1 required maximal assistance with bathing, dressing and dependent with toileting hygiene. Record review of Resident #1's care plan dated 10/17/2023, reflected I have chosen do not resuscitate status. Ensure resident wishes are followed as desired. Follow my advanced directive/code status. Record review of Resident #1's orders undated revealed advanced directives code status DNR (do not resuscitate). Record review of Resident #1's SW progress note date 04/05/2025 revealed, this social intern called the resident's family today. Family Member #1 asked not to be called at 3 A.M. unless it's an emergency, Resident #1 has passed or is in the emergency room . Record review of Resident #1's nurse progress note dated 04/07/2025 at 5:00 a.m., noted by LVN A said she was called by CNA this nurse to resident's room and upon assessment resident shows agonal breathing, skin is cold, eyes are fixed. Resident #1 vital signs were 54/53, 54, 93%, 128. Resident was a DNR and on hospice. Will continue to monitor. Record review of Resident #1 nurse progress note dated 04/07/2025 at 6:45 a.m., noted by LVN C said after receiving report at 6:30 a.m. this nurse assessed resident, resident lying in bed, eyes open pupils fixed, unresponsive to verbal/tactile stimuli, respirations shallow, unable to obtain blood pressure, skin cold to the touch. She documented at 6:53 a.m. EMS called at this time. Record review of Resident #1 nurse progress note dated 04/07/2025 at 7:00 a.m. noted by LVN C said NP called notified about resident's change in condition and EMS being called, ok with sending resident to ER for evaluation. Record review of Resident #1 nurse progress noted date 04/07/2025 at 7:05 a.m. noted by LVN C said EMS here resident's daughter notified at this time. Record review of Resident #1 nurse progress noted date 04/07/2025 at 7:17 a.m. noted by LVN C said DON notified at this time. Record review of Resident #1 nurse progress noted date 04/07/2025 at 7:20 a.m. noted by LVN C said resident transported to UT Quitman at this time. Record review of Resident #1's hospital records dated 04/07/2025 revealed death due to cardiopulmonary arrest. During an interview on 04/15/2025 at 8:50 A.M., the DON said CNA B reported the change of condition of Resident #1 to LVN A. LVN A only monitored Resident #1. LVN C the oncoming nurse assessed Resident #1, called the MD and sent her out to the emergency room . The DON said all LVN A did from 5-6:00 A.M. was monitor Resident #1. The DON said LVN A should have called the MD and probably sent her out to the hospital. She said LVN A should have called the family, and she did not call anyone. She said LVN A was a DNR/do not return after this. She said she believed the resident was neglected by LVN A. The DON said from 5-6:00 A.M. Resident #1 had agonal breathing and a fast heart rate. The DON said LVN C called her 04/07/2025 at 7:17 A.M. to tell her what was going on with Resident #1. During an interview on 04/15/2025 at 10:37 A.M., LVN C said she got to the facility the morning of 04/07/2025 about 6:30 A.M. and LVN A gave her report. LVN C said LVN A told her the aide notified her about 5am that Resident #1 was not acting right, so she went to assess the Resident #1. LVN C said LVN A told her Resident #1's blood pressure was low; the resident's pupils were fixed and she was not responding. LVN C said LVN A said Resident #1 was on hospice and she told her she was not on hospice. LVN C said she asked LVN A if she had notified anyone about the change in condition of Resident #1 and she said no. LVN C said after she and LVN A were finished with report, she went to assess Resident #1 and she was not responding so she called 911. Then LVN C said she notified the NP of Resident #1's change of condition and Resident #1 was not responding. Then LVN C said she notified the family and the DON. LVN C said LVN A said she did not understand how that was a change in condition. LVN C said once she received report from LVN A, LVN A left the facility. During an interview on 04/15/2025 at 12:07 P.M., LVN A said CNA B was making her last rounds when she came and her told Resident #1 did not look right. LVN A said she went to assess Resident #1 and her vital signs were low. She said Resident #1 looked like she was actively dying. She said Resident #1 was a DNR. She said she saw there was a progress note from the social worker that said the family requested not to call at 3:00 A.M. or in the middle of the night. She said the social worker progress note was put in on the 04/05/2025. She said she monitored Resident #1 the rest of her shift and she did 15 minutes checks on her. She said eventually the next nurse came in. She said she was confused about if the resident was actively passing, because in her training if they were actively passing the nurse should do nothing if the resident was a DNR. She said she did not notify the MD or NP and she said she did not notify the family, because the social worker progress note said the family did not want to be contacted in throughout the night and early morning hours. She said felt like she did her job because she monitored the resident. During an interview on 04/15/2025 at 12:31 P.M., the SW said she usually worked in the facility 3 days a week, but it depends on what the census was. She said yes, she had an intern to put a progress note in PCC (electronic health record) for Resident #1 on 04/05/2025. The SW verified that there was a note that stated Resident #1's family requested not to be contacted in the middle of the night or early in the morning regarding the resident's care. During an interview on 04/15/2025 at 12:41 P.M., CNA B said when she did her last rounds, she noticed Resident #1 had not wet during the shift. She said she was not a heavy wetter but had not voided the whole shift and she had not rested well. She said she had worked for hospice before, and she knew that was not a good sign. She said she notified the nurse immediately. She said the nurse checked Resident #1's vital signs and told her she might be right, that something was going on with Resident #1. CNA B said Resident #1's eyes were already fixed. She said LVN A was agency staff, and she was agency staff also, but she had worked with Resident #1 for a while. She said she thought LVN A did not know Resident #1 well enough to know that there was a change in her condition on how she usually acts, she guessed. She said she thought LVN A may have received report on Resident #1 not feeling well. She said after she completed her last rounds, she went home. She said she thought LVN A should have sent Resident #1 out to the hospital. She said LVN A told her Resident #1 was on hospice and she told her she did not know she was on hospice. She said she thought to herself if Resident #1 was on hospice, she should have notified the hospice company. She said later she found out Resident #1 was not on hospice. She said if she was in LVN A's shoes she would have sent Resident #1 out to the hospital, with her breathing the way she was breathing. During an interview on 04/15/2025 at 2:07 P.M., the MD said it does not ever hurt to notify the MD. He said any time there was an emergency with a resident the nurse should notify the NP or MD. He said with the incident with Resident #1 having low vital signs and agonal breathing, he would have wanted to be notified and he would have given orders for the nurse to send Resident #1 out to the hospital. He said the incident occurred and it sound like the nurse did not do her job and got fired and that was appropriate. During an interview on 04/15/2025 at 3:05 P.M., the DON said when the nurse was notified of a change of condition with Resident #1, the nurse should have done her assessment, then based off of her assessment she should have notified the NP or the MD. She said after she notified them of the change in condition they would have given her further orders. She said she felt like the nurse neglected Resident #1 by not notifying the MD and taking no further actions for the resident. She said they try to keep check off agency staff when we are performing any kind of check offs and they are working in our building. She said the facility did in-services and the book stayed at the nurses' station and they are supposed to sign and read the in-services before they start work. During an interview on 04/15/2025 at 3:47 P.M., the ADM said as soon as the nurse knew that there was a change in condition with Resident #1 she should have called the NP. She said the NP could have told her what to do, but by her not calling him she made a decision that she was not allowed to make, which was to do nothing. She said LVN A should have notified Resident #1's family as well. She said if she would have notified the NP, she would have been able to tell the family what the NP said about the resident's condition. She said she felt like LVN A made a stupid decision in her heart and the resident's needs were not met. She said there are in-services over Change of Condition, Abuse, Neglect and Exploitation, and DNR at the front nurse station since the 04/08/2025 every nurse has been in serviced on this. She said if she or the DON is not in the facility the off-going nurses were responsible for in servicing the incoming nurses who had not been in serviced on the topics. During an interview on 04/16/2025 at 10:19 A.M., the ADM said on the in-services you have to go to PCC to work Stopwatch tool, but there was not an actual way to show what we have been working on. She said Stopwatch is noted to a specific person when they were flagged in PCC. She said the stopwatch tool was to the signature page. We have in serviced everyone on the physical tool. Record review of the facility's Change in a Resident's Condition or Status revised date 02/2021 indicated .Our community promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status . .1.The nurse will notify the resident's attending physician or physician on call when there has been a(an)significant change of condition is a major decline or improvement in the resident's status . The facility corrected the noncompliance on 04/08/2025 by the following: -All staff interviewed ( ADON, MDS Nurse, LVN C, CNA B, RN D, RN L, RN F, RN E,CNA G, CNA H, CWT I, CNA J, CNA K, SW, [NAME] M, CNA N, Maintenance O, DM P, Housekeeper Q, Housekeeper T, DA R, CNA S, CNA U and RN V ) on 04/16/2025 verbalized understanding of In-services on COC (Change of Condition). All staff verbalized understanding CNAs are to alert nurses and nurses are to alert representative and physician of any changes in the resident's medical/mental condition or status. - Completed 04/08/2025. -All staff interviewed ( ADON, MDS Nurse, LVN C, CNA B, RN D, RN L, RN F, RN E,CNA G, CNA H, CWT I, CNA J, CNA K, SW, [NAME] M, CNA N, Maintenance O, DM P, Housekeeper Q, Housekeeper T, DA R, CNA S, CNA U and RN V ) on 04/16/2025 verbalized understanding of In-services on DNR (do not resuscitate). All staff verbalized education on DNR and meaning, but voiced it does not mean that the facility will not treat the resident in the event of a change of condition and does not mean do not send the resident to the hospital for emergency treatment. - Completed 04/08/2025. -All staff interviewed ( ADON, MDS Nurse, LVN C, CNA B, RN D, RN L, RN F, RN E,CNA G, CNA H, CWT I, CNA J, CNA K, SW, [NAME] M, CNA N, Maintenance O, DM P, Housekeeper Q, Housekeeper T, DA R, CNA S, CNA U and RN V ) on 04/16/2025 verbalized understanding of in-service on ANE (Abuse, Neglect and exploitation). Staff was able to identify the different types of abuse, neglect, exploitation and who to report it to. -Completed 04/08/2025. -All staff interviewed ( ADON, MDS Nurse, LVN C, CNA B, RN D, RN E, RN L, RN F, CNA G, CNA H, CWT I, CNA J, CNA K, SW, [NAME] M, CNA N, Maintenance O, DM P, Housekeeper Q, Housekeeper T, DA R, CNA S, CNA U and RN V ) on 04/16/2025 verbalized understanding of Stop and Watch, Early Warning Tool (Interact). Staff verbalizing if they identified a change while caring for or observing a resident/patient, please circle the change and notify a nurse. -Completed 04/15/2025. -All nurses interviewed (DON, ADON, MDS Nurse, RN L, RN E, and LVN C) on huddles an ongoing process was when the nurses got together during shift change to talk about any changes to the resident, anything new with the residents, anything to watch for. They said they talked about any new wounds would need to be reported. They said they always reported things as they happened but would go over it again in the huddle. They showed this surveyor in PCC how to find the flags for high-risk residents and anything the residents had flagged for. We looked at several residents with flags. There was only one resident with an SBar since 04/07/2025.Ongoing process. - QAPI meeting held to discuss appropriate care interventions were not provided in a timely manner following a resident's change in condition. This failure to act accordingly may have contributed to a delay in an assessment, treatment, or escalation of care on 04/07/2025: -The resident exhibited clear signs of a change in condition, including agonal breathing, cold skin, eyes fixed vital signs:54/53, 54, 93%, 128. -Documentation indicates that the change was either not communicated promptly or not acted upon in accordance with facility protocol (i.e, call NP/MD/DON). -Care team did not initiate appropriate clinical interventions or notify the appropriate providers within the expected time frame. - Completed 04/08/2025. During an interview on 04/16/2025 at 2:00 P.M., Family Member#1 of Resident #1 said the care she received from the facility was not great. Family Member #1 said she had laryngitis and she could not talk. During an interview on 04/17/2025 at 9:43 A.M., RN D said she had only worked at the facility a couple of times. She said she could not remember the resident by name. She said that was her first time working on that hall, but the last day she worked which was 04/06/2025 none on her residents were in critical condition and she had no reports of a change of condition on any of them. She said if a resident had a change in condition, she would have notified the MD and sent the resident to the hospital and notified the family. During an interview on 04/17/2025 at 10:49 A.M., the DON said she felt like once LVN A had been notified of the change of condition with Resident #1 had occurred she should have assessed her, notified the NP or MD of the findings and followed the orders. She said she was totally mind blown by LVN A's reaction to what she was taught. She said LVN A said she thought she did not do anything wrong. She said the facility put a DNR (do not return) on LVN A and the agency terminated her as well. During an interview on 04/17/2025 at 11:08 A.M., the ADM said she felt that everything LVN C did should have been done during the incident with Resident #1. She said LVN A had the tools she needs at the facility and there was another nurse on duty to assist her for guidance and to help her. She said LVN A chose to monitor Resident #1. She said LVN A should have called the NP, she should have called anyone. She said she believed LVN A's biggest downfall was she did not call anyone. The ADM said she believed that Resident #1 was in a-fib (an irregular and often rapid heart rhythm, but they do not know, because LVN A did not make a phone call. She said LVN A should have made a phone call to the family of Resident #1. The ADM said if Resident #1 was her family, yes I would want to be notified of her condition. She said LVN A's reaction was unacceptable, and she would be referring her to the Texas board of nursing. The noncompliance was identified as PNC. The noncompliance began on 04/07/2025 and ended on 04/08/2025. The facility corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 9 residents (Residents #1 and #2) reviewed for abuse. The facility failed to ensure CNA A did not sexually abuse Resident #1 during his shower earlier in the week of January 5, 2025 - January 9, 2025, when he allegedly placed his finger in his rectum. The facility failed to ensure CNA A did not sexually abuse Resident #2 during a shower provided during the period of December 28, 2024, and December 29, 2024, when he allegedly attempted to place his finger in his rectum. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) noncompliance began on 1/11/2025 and ended on 1/11/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for emotional distress, fear, decreased quality of life, and further abuse. Findings included: 1)Record review of a face sheet dated 1/21/2025 indicated Resident #1 was a [AGE] year-old male, who admitted on [DATE] with the diagnosis of blindness (loss of vision), major depressive disorder (clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest in normally enjoyable activities), and intellectual disabilities (condition that limits intelligence and disrupts abilities necessary for living independently). Record review of Resident #1's Annual MDS assessment dated [DATE] indicated Resident #1 in Section A1510 Level ll Preadmission Screening and Resident Review (PASRR) conditions was marked as having an intellectual disability. The MDS indicated Resident #1 usually was understood, and usually understood others. The MDS indicated Resident #1 had a severely impaired vision (no vision or sees only light, colors or shapes; eyes do not appear to follow objects). The MDS indicated Resident #1's BIMS score was 5 indicating severe cognitive impairment. The MDS indicated Resident #1 had no physical, verbal, or other behaviors directed at others. The MDS indicated Resident #1 had rejected care 1-3 days during the assessment period. The MDS in the section F Preferences for Customary Routine and Activities Resident #1 indicated it was very important to him to him choose between a tub bath, shower, bed bath, or sponge bath. The MDS in Section GG-Functional Abilities and Goals indicated Resident #1 required substantial/maximal assistance with bathing, and partial/moderate assistance with dressing and personal hygiene. Record review of Resident #1's comprehensive care plan dated 9/24/2021 and revised on 5/06/2024 indicated Resident #1 had an ADL self-care performance deficit related to his blindness. The care plan goal was Resident #1 would maintain his current level of function. The interventions of the care plan included Resident #1 would be allowed to perform tasks as much as possible, bathing/showering, and personal hygiene he required assistance of one staff. The care plan indicated Resident #1 used antidepressant medication related to depression. The goal of this care plan was Resident #1 would be free from discomfort related to the use of antidepressant therapy. The interventions for Resident #1 included to administer the antidepressant medication, and to monitor, document, and report any adverse reactions to the antidepressant, a change in behavior/mood/cognition, social isolation, and social isolation. Record review of a hospital emergency room discharge form dated 1/11/2025 indicated Resident #1 was seen at the local emergency room and discharged on [DATE] with the primary diagnosis of sexual assault of adult. The triage notes section of the discharge form indicated Resident #1 arrived by EMS from the nursing facility. The note indicated Resident #1 arrived with complaints of sexual assault for unknown amount of time. The note indicated Resident #1 stated his caregiver had penetrated his rectum with a finger during showers. The note indicated Resident #1 indicated the last event was last week, and he had been refusing showers since then. The note indicated the family requested the transfer to the emergency room for a SANE (Sexual Assault Nurse Examination) exam. The history and physical portion of the discharge note indicated Resident #1 had intellectual disability, chronic kidney disease, and legal blindness. The history and physical noted Resident #1 had a complaint of sexual assault for an unknown period of time with a caregiver in the nursing facility that penetrated the patient's rectum on multiple occasions with his finger while the patient (Resident #1) was showering. The note indicated the patient (Resident #1) had been refusing to shower the past week and his family requested a SANE exam. The note indicated the patient (Resident #1) endorsed rectum pain, denied abdominal or leg pain, dysuria, or blood in his stool. The note indicated the family indicated even if Resident #1 had blood stool he was unable to see the stool due to his blindness. The note in the Review of Systems portion indicated in the gastrointestinal section indicated Resident #1 was positive for rectal pain. Record review of the Provider Investigation Report dated 1/14/2025 indicated the state agency was notified on 1/11/2025 at 11:15 a.m., of the allegation of abuse occurring on 1/07/2025 with no time of day indicted occurring in the shower. The Provider Investigation Report indicated Resident #1 was independently ambulatory, able to be interviewed, but was unable to make decisions. The Provider Investigation Report indicated Resident #1 had a history of false allegations of embellishing tales of attention, refusing showers, and refusing medications. The Provider Investigation Report indicated the alleged perpetrator was identified by name, and was identified as CNA A. The Provider Investigation Report indicated CNA A denied the allegation. The Provider Investigation Report indicated Resident #1 was sent to the local hospital emergency room and the local police was notified with a case # 2500025. The Provider Investigation Report indicated Resident #1's physician, family member, and the ombudsman were notified. Record review of an Employee Timecard dated 1/11/2025 indicated CNA A worked on 1/01/2025 from 6:13 a.m. - 6:30 p.m., 1/02/2025 from 6:10 a.m. - 7:15 a.m., 1/06/2025 from 6:12 a.m. - 7:00 p.m., 1/07/2025 from 6:13 a.m. - 6:45 p.m., 1/10/2025 from 6:02 a.m. - 7:15 p.m., and on 1/11/2025 from 6:05 a.m. - 9:22 a.m. Record review of an undated ADL sheet indicated Resident #1 received a shower from CNA A 1/02/2025, and then again on 1/07/2025. The ADL sheet documentation had no further baths provided from 1/08/2025 - 1/21/2025. Record review of a daily staff schedule dated 1/06/2025 indicated CNA A was scheduled to work on halls 200, 300, and 400. Record review of a daily staff schedule dated 1/07/2025 indicated CNA A was scheduled to work on halls 200, 300, and 400. Record review of a daily staff schedule dated 1/10/2025 indicated CNA A was scheduled to work on halls 200, 300, and 400. Record review of a daily staff schedule dated 1/11/2025 indicated CNA A was scheduled to work with no specified halls. Record review of the Police Report dated 1/11/2025 at 9:43 a.m., indicated a crime/incident of aggravated sexual assault of another person was reported. The suspect was named as CNA A, and the victim was Resident #1, the reporter was LVN B. The report indicted he received the report from LVN B upon arrival that Resident #1 had identified CNA A as the individual who had inserted his finger into his rectum while taking a shower. The officer documented upon arrival at the facility, LVN B indicated she had to send CNA A home, then he was escorted to Resident #1's room. The officer wrote Resident #1 was accompanied with his family member. The officer wrote Resident #1 said yes, he wanted to make a report on a staff member. The officer wrote Resident #1 said he had a finger in my butt. The report indicated Resident #1 made a fist with his right hand and pointing his index finger straight out. The report indicated Resident #1 made a motion suggesting CNA A was inserting his finger in and out of his anus. The report indicated Resident #1 said when I take a shower, he put a finger in my butt. The officer documented when he asked Resident #1 how long this had occurred, he indicated a long time. The report indicated the family member said a couple of months ago when out of the facility Resident #1 complained his butt was sore. The report indicated Resident #1 indicated CNA A plays the music too loud in the shower too. The report indicated Resident #1 said, In the shower, he keeps the thing too loud, and when he is doing that thing in my butt with it. The report indicated the family member stated they could identify CNA A. The report indicated Resident #1 said he wanted to go to the hospital. The report indicated the officer spoke to the Administrator and gained information on CNA A. The Administrator was noted informing the officer Resident #1 had behaviors of telling falsehoods but never this severe. The report indicated LVN B indicated CNA A had played music on his phone. The officer ended the report with Resident #1 was transferred to the local hospital, but the hospital was not equipped with the specialized SANE nurse and therefore was transferred to a larger hospital. Lastly the report indicated the case was referred to the criminal investigation division for further investigation. During an observation and interview on 1/21/2025 at 10:54 a.m., Resident #1 was making his bed when the surveyor entered his dark room. Resident #1 said CNA A had given him a shower last week. Resident #1 said CNA A penetrated his rectum with CNA A's penis. Resident #1 was asked to clarify was it CNA A's penis or finger. Resident #1 again indicated he was penetrated in his rectum by CNA A's penis while he received his shower. Resident #1 also indicated the rock and roll music was too loud in the shower playing on CNA A's personal phone. Resident #1 was unable to cognitively express how the alleged actions of CNA A made him feel but said that was why he refused his next shower. During an interview on 1/21/2025 at 11:21 a.m., LVN B said Resident #1's family member came to her on Saturday 1/11/2025 and indicated Resident #1 refused his shower because he indicated CNA A's finger goes in and out of his butt when he was last showered. LVN B said she notified the Administrator immediately of the allegation, and was advised to send CNA A home immediately, to call 911 to send Resident #1 to the hospital, and then notify the local police. LVN B said she had not performed an assessment of Resident #1 prior to leaving with emergency personnel. During an interview on 1/21/2025 at 11:48 a.m., Resident #1's family member said she arrived for a visit with Resident #1 on 1/11/2025. The family said Resident #1 told her CNA A had touched his butthole making a moving motion and this was why he refused his shower. The family member said she went to the nurse and reported what Resident #1 had said. The family member said Resident #1 retold the same information to the local police officer, hospital staff, and the police officer who arrived at the hospital. The family member said the nurse performing the examination said Resident #1 had tearing around his anus. The family member said Resident #1 had never made any allegations in the past regarding sexual abuse, and this behavior of making this type of allegation was not his normal behavior. The family member said Resident #1's emotional behavior seemed scared to bathe. The family member indicated Resident #1 was usually very happy and cooperative. During an interview on 1/21/2025 at 11:58 a.m., CNA A said on Tuesday 1/07/2025 in the morning hours he took Resident #1 to the shower. CNA A said he provided Resident #1 with a shower and a shave that time and numerous other times. CNA A said Resident #1 could perform portions of his showers but required the physical assistance of making sweeping motions to Resident #1's buttocks and then said Resident #1 was able to perform cleansing of his genitals. CNA A said Resident #1 thanked him for the shower and shave afterwards. Therefore, he believed there were no issues. CNA A said on Saturday 1/11/2025 in the morning hours, he was providing care to another resident when he was approached by the nurse and advised he had to leave immediately there was an allegation of abuse. CNA A said after exiting the resident's room he was informed of the allegation that Resident #1 indicated in which he placed a finger in Resident #1's anus during a shower. CNA A then denied the allegations made by Resident #1. When asked about any other allegations of this nature CNA A indicated he had been named in an allegation in 2023 with the exact same allegation of putting a finger in the rectum. When asked about the findings of the previous allegations, he replied the resident was no longer residing in the facility, and the results were not confirmed because the resident did not like me. CNA A said he could not explain how two residents not knowing each other could have the exact same allegation against him. CNA A said an allegation of this type was considered sexual abuse, should be reported immediately to the abuse coordinator being the administrator immediately. CNA A said he had resigned his position as CNA on Wednesday 1/15/2025 and was not currently employed but was seeking employment elsewhere. CNA A said he had not been interviewed by the local police. 2)Record review of a face sheet dated 1/21/2025 indicated Resident #2 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, and Parkinson's disease (a movement disorder of the nervous system that worsens over time). Record review of a Significant Change MDS dated [DATE] indicated Resident #2 was understood and understands others. The MDS indicated Resident #2's BIMS score was a 13 indicating he had no cognitive issues. The MDS in Section E-Behaviors there was no indications Resident #2 had any physical, verbal, or other behaviors affecting others. The MDS also indicated Resident #2 had not refused care. The MDS in Section F-Preferences for Customary Routine indicated Resident #2 said it was very important for him to choose between a tub bath, shower, bed bath, or sponge bath. The MDS indicated in Section GG-Functional Abilities and Goals indicated Resident #2 required partial to moderate assistance with shower/bathe Record review of a Comprehensive Care Plan dated 7/04/2023 and a revision date of 1/12/2024 indicated Resident #2 had an ADL self-care performance deficit related to his Parkinson's disease. The goal of the care plan was Resident #2 would maintain his current level of function. The interventions included the provision of one staff for assistance with bathing, dressing, toileting, and transfers. Record review of a shower schedule dated 12/28/2024 indicated CNA C marked Resident #2 as showered. Record review of a Daily Staffing Schedule dated 12/28/2024 indicated CNA A was scheduled to work. The Daily Staffing Schedule had CNA A handwritten in for halls 200, 300, and 400. Record review of a Safe Survey dated 1/11/2025 at 11:08 a.m., the HR/BOM asked Resident #2: *Has someone (resident or staff) touched you in a way that made you feel uncomfortable example sexually? Resident #2's answer was marked no. *Has someone (resident or staff) made sexual comments or statements to you? Resident #2's answer was marked no. *Has someone (resident or staff) shown you pictures, videos, or other materials of sexual nature? Resident #2's answer was marked no. *Does staff treat you with respect? Sometimes, depends on the person or agency was Resident #2's answer. During an interview on 1/21/2025 at 1:35 p.m., Resident #2 was asked if he had ever been abused by anyone who worked at the facility. Resident #2 said, yes I have. Resident #2 seemed hesitant to explain when asked by pausing. Although we were in his room, and privately talking he would look past me watching the door. Resident #2 said approximately 3 weeks ago, CNA A provided him with a shower, and during the shower he attempted to put his finger in his rectum. Resident #2 said when CNA A was attempting to place his finger in his rectum, he quickly moved in the shower chair, so his anus was not exposed, and Resident #2 said CNA A stopped. When asked to further explain why he failed to tell staff when the staff asked about any abuse, Resident #2 said I did not tell them the truth and I should have told them the truth, but I felt as though they would have thought I was a troublemaker. Resident #2 went on to say he felt embarrassed to talk about it and said, I felt cheap. Resident #2 agreed to tell the staff when I returned with a team member. During an interview on 1/21/2025 at 1:40 p.m., the DON entered Resident #2's room with the surveyor. Resident #2 was asked to inform the DON what he had just reported. Resident #2 then said to the DON, I should have told you when I was asked about being abused but I thought I would be making trouble for CNA A. Resident #2 informed the DON that CNA A attempted to put his finger inside his rectum during a shower approximately 3 weeks ago. Resident #2 said he could not remember the exact day it occurred. Resident #2 said on that day he had made up his mind CNA A would never provide his shower again. During a telephone interview on 1/21/2025 at 2:22 p.m., CNA A said on occasion he had cared for Resident #2. CNA A said he could not remember providing Resident #2 a shower when he was assisting CNA C on the 100-hall. CNA A again denied any forms of abuse. CNA A again had no explanation as to why 3 male residents have made the same allegation. During an interview on 1/21/2025 at 2:28 p.m., CNA C said she had worked with CNA A in the recent past month. CNA C said she worked on the weekend shifts. CNA C said when CNA A worked the hall with her, she would take the female residents and CNA A took the male residents. CNA C said she would complete the documentation for all the residents. CNA C said she would only document a bath if she saw CNA A taking a resident to the shower room. CNA C said she had not witnessed CNA A abusing any resident. Record review of an undated ADL sheet indicated Resident #2 showers were offered but refused on 12/23/2024, 12/25/2024, 12/27/2024, 12/30/2024, 1/1/2025, and 1/06/2025. The ADL sheet indicated Resident #2 accepted a shower on 1/03/2024. During an interview on 1/21/2025 at 3:30 p.m., the ADON said when she informed the surveyor, she completed all the staffing assignments and there was no time since October 2024 that CNA A was assigned to work with Resident #2. The ADON said she had made a mistake and CNA A had been assigned to work with Resident #2 on 12/28/2024 and 12/29/2024. During an interview on 1/21/2025 at 5:15 p.m., the Administrator said although she could not confirm the allegations of sexual abuse, she said lightening can't strike twice. The Administrator said the same allegation with three residents seemed suspicious. The Administrator said abuse was monitored daily during rounds asking questions about abuse and monitor for abuse. The Administrator said she was the abuse coordinator. The Administrator said when she became aware of the allegation, we responded appropriately to protect the residents. The Administrator said safe surveys were conducted, and there were no other residents who voiced any abuse concerns. The Administrator said although CNA A resigned his position, the termination process for CNA A was already approved. The Administrator said the risk of affecting a resident's emotional wellbeing was at risk when abuse occurred and could be harmful over time. During an interview on 1/21/2025 at 5:19 p.m., the DON said she had called CNA A and spoke to him about the allegation regarding Resident #1. The DON said she discussed with CNA A the current allegation with Resident #2 and the previous allegation with the discharged resident in 2023 whether confirmed or not was cause for alert. The DON said she randomly makes walking rounds and asked staff members the abuse questions and monitors for residents for abuse. The DON said she as well believed once the facility learned of the allegation, they acted appropriately to protect all the residents. Record review of CNA A's personnel record revealed he was hired on 5/06/2022. There were no issues noted with the criminal history checks. The personnel record included a formal termination form indicating CNA A was terminated for violating the code of conduct regarding safety health, and security, and regarding preventing abuse and neglect. Record review of an Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated 2001 and revised in April 2021 indicated, the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of facility-wide commitment and resource allocation to support the follow objectives: 1. Protect residents from abuse, neglect, and exploitation or misappropriation of property by anyone including but not necessarily limited to: a. facility staff . Record review of the Abuse and Neglect-Clinical Protocol policy dated 2005 and revised in March 2018 indicated, .3. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. 4. Willful, as defined as used in the definition of abuse, means the individual must have acted deliberately, no that the individual must be intended to inflect injury or harm. The Administrator was notified of the IJ PNC on 1/21/2025 at 5:01 p.m., due to the above failures. The Administrator was provided the IJ template on 1/21/2025 at 5:01 p.m. via email. The surveyor confirmed the following actions had been implemented sufficiently to remove the immediacy by: *During a Record review on 1/21/2025 at 11:00 a.m., the Provider Investigation Report dated 1/11/2025 indicated the facility notified the family, physician, local police, and the ombudsman on 1/11/2025. *During a record review on 1/21/2025 at 11:00-12:00 Resident #1's clinical record indicated he was sent to the local hospital and a SANE exam was provided. *During an interview on 1/16/2025 at 1:18 p.m., the Victim's Advocate said Resident #1 was referred to the advocacy group for sexual crimes. *Record review of an Abuse and Neglect in-service was provided on 1/11/2025. The policy reviewed the definition of abuse and neglect as well as timeframes associated with reporting abuse and neglect to the state agency. The signature page had 32 signatures ranging from all shifts and all disciplines. *Record review of a Termination form dated 1/16/2025 for CNA A with the last day worked noted as 1/11/2025. *Record review of a Resignation letter dated 1/15/2025 for CNA A formal resignation of his role as a CNA. *Record review of a Facility counseling form indicating on 1/15/2025 CNA A was formally terminated with the criteria of not meeting job performance and or behavior expectation related abuse and neglect and violation of the code of conduct. *Review of the daily monitoring tool used for monitoring staff's knowledge of abuse and monitoring for abuse with the start date of 1/11/2025 and was current as of 1/21/2025. The monitoring tool had a staff members last name on each day. *Review of the resident safe surveys with no areas of concerns dated for 1/11/2025. *Review of Residents #1 and #2's allegations reported within the two-hour timeframe to the state agency. *Review of the police reports for Resident #1 (case# 25000025) and Resident #2 (case# 25000045). *Interviews with residents regarding abuse and neglect with a focus presented on sexual abuse revealed they all denied abuse with the exceptions of the above mentioned. *Interviews with staff indicated they had been in-serviced on abuse since 1/11/2025 and were able to define abuse, when to report, whom to report. The noncompliance was identified as PNC. The IJ noncompliance began on 1/11/2025 and ended on 1/11/2025. The facility had corrected the non-compliance before the survey began.

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent the abuse of residents for 1 of 7 residents (Resident #149) reviewed for abuse. 1. The facility failed to ensure the Administrator was notified immediately when Resident #149 accused CNA L of sexual abuse. 2. The facility failed to ensure Resident #149 and other vulnerable residents were protected from CNA L. CNA L was not immediately suspended and remained in the facility until the end of his shift. 3. The facility failed to ensure allegations of abuse were thoroughly investigated. The facility did not include evidence of Resident #149's interview, resident safe surveys, and LVN D's one-on-one education of the abuse policy in their provider investigation report. 4. The facility failed to ensure allegations of sexual abuse was reported to local law enforcement. An IJ was identified on 06/21/24. The IJ template was provided to the facility on [DATE] at 5:30 p.m While the IJ was removed on 06/23/24, the facility remained out of compliance at scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems. This failure could place residents at risk of abuse, neglect, physical harm, pain, mental anguish, emotional distress, and serious harm. Findings included: Record review of Resident #149's face sheet, dated 06/20/24, indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), depressive disorder (mood disorder causing persistent sadness and a loss of interest), mild cognitive impairment, anxiety disorder, Type 2 diabetes (chronic condition that affects how the body regulates and uses sugar), left below the knee amputation cerebrovascular disease (condition that affects blood flow to the brain) and left sided hemiplegia and hemiparesis following cerebral infarction (left sided mild weakness and severe paralysis due to a stroke). Resident #149 was discharged from the facility on 08/11/23. Record review of Resident #149's MDS assessment dated [DATE] indicated he had had moderately impaired cognition and required extensive one person assistance with toileting. Resident #150 had diagnoses of hypertension (high blood pressure), depression (mood disorder causing persistent sadness and a loss of interest), mild cognitive impairment, anxiety disorder, Type 2 diabetes (chronic condition that affects how the body regulates and uses sugar), left below the knee amputation cerebrovascular disease (condition that affects blood flow to the brain) and hemiplegia or hemiparesis (mild weakness or severe paralysis), and depression (mood disorder causing persistent sadness and a loss of interest). Record review of Resident #149's Care Plan dated 05/27/23 indicated he was abusive to staff, made false accusations. Interventions stated to allow resident to express his feelings about what he believed the situation might have been, give reassurance no one was trying to hurt him, interview other residents to verify if staff member was being abusive to them, investigate remarks resident made against staff, obtain statement from any witnesses that might have been present when such problem occurred (initiated 07/19/22). Resident #150 had an ADL self-care performance deficit related to cerebrovascular accident (bleeding in the brain) and interventions included he required one staff member to assist with toileting. Record review of Resident #149's progress notes dated 08/09/23 at 1:00 a.m. by LVN D indicated she spoke with CNA L about the complaint. CNA L asked LVN D to go into his room because the resident accused him of putting his finger up his butt. LVN D agreed and supervised all care that was done for the resident. There was no documentation in Resident #149's progress notes by LVN D to indicate she supervised the resident's care. Record review of Resident #149's progress notes by LVN D, after her entry on 08/09/23 at 1:00 a.m. to the end of her shift on 08/09/23 6:00 a.m., indicated there was no documentation she supervised the resident's care. A provider investigation report dated 08/11/23 signed by the DON indicated the incident with the allegation of abuse occurred in Resident #149's room on 08/08/23 at 11:00 p.m Resident #149 was interviewable with the capacity to make informed decisions and had no history of similar allegations. Resident #149 identified the alleged perpetrator CNA L by name. The Administrator was informed on 08/09/23 by CNA K that Resident #149 told him that CNA L stuck his finger up his butt and turned him in a rough manner on 08/08/23 during care. CNA K reported the incident to the Administrator. Resident #149 was assessed with no injuries then sent to the hospital. The facility notified the physician, responsible party, and Adult Protective Services. There was no documentation to indicate the facility notified the local police department. CNA L, the alleged perpetrator, was notified on 08/09/23; he was suspended pending the outcome of the investigation. CNA L denied the allegations. Provider action taken post-investigation indicated all nurses were in-serviced one on one regarding who the abuse coordinator was and when to call. LVN D received written counselling regarding reporting any reports of abuse or neglect and completed compliance education with test. The nurses were instructed to call if any verbal accusations are made no matter if they knew them to be unfounded. There was no witness statement for Resident #149 documented in the provider investigation report. Record review of LVN D's timecard for August 2023 indicated she clocked in at the facility on 08/08/23 at 5:44 p.m. and clock out on 08/09/23 at 6:11 a.m Record review of CNA L's timecard for August 2023 indicated he clocked in at the facility on 08/08/23 at 10:05 p.m. and clock out on 08/09/23 at 6:11 a.m Record review of LVN D's employee file indicated there was no documentation in her file she had received written counselling regarding reporting any reports of abuse or neglect related to Resident #149. During an interview on 06/21/24 at 2:08 p.m., Resident #149 said CNA L was cleaning him up after he had a bowel movement and stuck his finger in his asshole. Resident #149 said it felt uncomfortable like he was being raped. Resident #149 said he told CNA L what he had done, and his response was that he did not. Resident #149 said he did not recall seeing his nurse come in with CNA L when he checked on him a few times after that. Resident #149 said he transferred to another nursing facility a few days after the incident happened. Resident #149 said he felt safer in the facility that he was at now than in the other facility where the incident occurred. During a phone interview on 06/20/24 at 3:16 p.m., LVN D said she was the charge nurse and worked the 6:00 p.m. - 6:00 a.m. shift. LVN D said she worked on 08/08/23 and provided care to Resident #149. LVN D said sometime after midnight on 08/09/23, CNA L asked her if she would go with him into Resident #149's room when he needed to provide him care because the resident had accused him of sticking his finger up his butt. LVN D said she assessed Resident #149 after he made the allegation. LVN D said she never asked Resident #149 about the incident during her assessment, and he never mentioned it to her. LVN D said Resident #149 had no emotional distress and the only complaint he had was pain to the stump of his left below the knee amputation. LVN D said Resident #149 never mentioned the incident to her or showed emotional distress during her assessment. LVN D said she did not notify the Administrator because she felt that Resident #149 was not in any danger after she assessed him and decided to supervise CNA L's care with Resident #149. LVN D said she went into Resident #149's room with CNA L 2-3 more times before the end of her shift. LVN D said the facility contacted her about the incident and she was in-serviced one on one by the DON about the types of abuse and who to report it to. During an interview on 06/20/24 at 3:24 p.m., CNA L said he worked the 10:00 p.m. to 6:00 a.m. shift on 08/08/23 and provided care to Resident #149. CNA L said he provided incontinent care to Resident #149 after he had a bowel movement. CNA L said he was cleaning Resident #149's anal area when Resident #149 told him he had stuck his finger up his butt. CNA L said he told Resident #149 he did not and was having a difficult time getting the area cleaned because his bowel movement was like a thick paste. CNA L said he left Resident #149's room after he finished cleaning him up and told LVN D, Resident #149 had accused him of sticking his finger up his butt during incontinent care. CNA L said LVN D went into Resident #149's room with him 2-3 times during his shift. CNA L thought he would be sent home immediately after he told LVN D about Resident #149's allegations he made against him and thought it was odd he was allowed to complete his shift. CNA L said the facility notified him on 08/09/23 that he was suspended during the investigation. CNA L said he did not stick his finger up Resident #149's butt. During an interview on 06/20/24 at 3:34 p.m., the DON said she assisted the previous administrator with the investigation involving Resident #149 and CNA L. The DON said the facility first learned of the allegation on 08/09/23 during the 2:00 p.m.-10:00 p.m. when Resident #149 told CNA K that on 08/08/24 CNA L stuck his finger up his butt. The DON said CNA K notified the previous Administrator immediately and CNA L was notified he was suspended. The DON said LVN D did not call the administrator on 08/08/24 when she first learned of the allegation. The DON said CNA L remained in the facility until his shift ended and was not suspended until the following day. The DON said all staff were in-serviced on types of abuse and who to report it to. The DON said she did a one-on-one in-service on types of abuse and who to report it to with LVN D. The DON said when an allegation of abuse was made, the person identified as alleged perpetrator should be removed from the facility immediately and suspended during the facility's investigation to ensure residents are protected. The DON said Resident #149 and the other residents were at risk for abuse when CNA L was not suspended immediately on 08/08/24. During an interview on 06/20/24 at 3:46 p.m., the Administrator said she started working at the facility in February 2024. The Administrator said she was the abuse coordinator and expected staff to report an allegation of abuse to her immediately. The Administrator said when an allegation of abuse is made, the person who is identified as alleged perpetrator should be removed from the facility immediately and suspended at that time during the facility's investigation to ensure residents are protected. The Administrator said the police should be notified when there is an allegation of physical abuse or sexual abuse. The Administrator said the incident between Resident #149 and CNA L was investigated by the previous administrator. The Administrator said the previous administrator did not notify the police and she should have because it involved sexual abuse. During an observation and interview on 06/21/24 at 3:01 p.m. with the local police department's assistant at the front desk revealed (he/she) checked their database system and said they had no records on file that showed the facility called them on 08/09/23 to report an incident involving Resident #149. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated 04/2021 indicated, Residents have the right to be free from abuse .1. Protect residents from abuse .by anyone including, but no necessarily limited to: a. facility staff . Record review of the facility's Abuse Investigation and Reporting policy dated 04/2017 indicated, All reports of resident abuse .shall be promptly reported to local, state and federal agency (as defined by current regulations) and thoroughly investigated by facility management .Role of the Administrator: .4. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation Role if the Investigator: .d. Interview any witnesses to the incident. e. Interview the resident (as medically appropriate) .2. The following guidelines will be used when conducting interviews: .c. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it . The Administrator was notified on 06/21/24 at 5:25 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 06/21/24 at 5:30 p.m The facility's Plan of Removal was accepted on 06/22/24 at 6:08 p.m. and included: Identify responsible staff/ what action taken to prevent further abuse: o ADON, MDS coordinator and Administrator will conduct 100% resident rounds to determine if further allegations of abuse are alleged. This will be completed by 6/22/24. o Safe surveys will be conducted by Social Worker, Human Resources and Activity Director for all cognitive residents. This will be completed by 6/22/24. In-Service conducted o In-servicing was initiated by Regional Nurse Consultant, Administrator and ADON on 06/21/24 and will continue until it is complete. o In-service will be provided to all staff on Immediate Notification of Allegations to Facility Abuse Coordinator, Investigating Allegations of Abuse and Neglect, Reporting of Abuse Neglect and Misappropriation, and notification of proper local and state entities, education included that any individual accused of abuse would be escorted immediately out of the building and resident would be protected. o The Abuse Coordinator was educated on 6-21-24 by the Regional Director of Clinical Services on how to investigate allegations of abuse and the importance of a thorough investigation and written documentation of statements and in-services. o This will be completed by 6/22/24. o Agency staff that work in the facility or staff on PTO or LOA will have in-servicing completed prior to working the floor. o Abuse and Neglect training will be a part of the new hire orientation effective immediately. o Any staff member who is an alleged perpetrator for any allegation will be suspended immediately pending investigation and will be escorted out of the facility immediately by the senior staff member on duty or law enforcement and will not be allowed to return to the building until the investigation is complete. Implementation Date of Changes o 06/21/24 Involvement of Medical Director The Medical Director was notified about the immediate Jeopardy on 06/21/24. Involvement of QA QAPI will review and approve Plan of Removal On 06/23/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Verifying the Medical Director had been informed of the Immediate Jeopardy on 06/21/24 from documentation by the Administrator. Record review of in-services indicated all staff were educated on Immediate Notification of Allegations to Facility Abuse Coordinator, Investigating Allegations of Abuse and Neglect, Reporting of Abuse Neglect and Misappropriation, and notification of proper local and state entities, education included that any individual accused of abuse would be escorted immediately out of the building and resident would be protected. Record review of resident rounds for all cognitive residents indicated rounds were conducted and completed on 06/22/24. Documentation indicated there were no identified complaints or allegations of abuse. Record review of LVN D's Counseling Form dated 06/22/24 indicated she received a verbal and written warning for violating the abuse and reporting policy on 08/08/23 by not reporting an allegation of sexual abuse immediately. Interviews with 5 Licensed Nurses (6 a.m.-6 p.m., 6 p.m.-6 a.m. and Weekend Doubles including agency), 7 CNAs (6 a.m.- 2 p.m., 2 p.m.-10 p.m., 10 p.m.- 6 a.m. including agency), 1 Laundry Staff, 1 Housekeeping Staff, 1 Dietary Staff, and 1 Social Worker were performed on 06/22/24 and 06/23/24. All staff were able to correctly identify Immediate Notification of Allegations to Facility Abuse Coordinator, Investigating Allegations of Abuse and Neglect, Reporting of Abuse Neglect and Misappropriation, and notification of proper local and state entities, education including that any individual accused of abuse would be escorted immediately out of the building and resident would be protected. During an interview on 06/23/24 at 9:46 a.m., the Administrator said she was educated on how to investigate allegations of abuse, the importance of a thorough investigation, written documentation of statements and in-services. On 06/23/24, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems.

Based on observation, interview, and record review, the facility failed to ensure an MDS accurately reflected the resident's status for 2 of 2 dialysis residents (Residents #14 and #33) reviewed for MDS assessment accuracy. The facility failed to accurately code Resident #14 quarterly MDS assessment for Hemodialysis treatment on his quarterly MDS assessment dated [DATE], 2/29/2024, and 12/15/2024. The facility failed to accurately code Resident #33 quarterly MDS assessment for Hemodialysis treatment on his quarterly MDS assessment dated [DATE]. These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1. A review of Resident #14's face sheet and physician's orders for June 26, 2024, indicated Resident # 14 was [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis including, right leg below knee amputation, chronic kidney disease, type 2 diabetes, hypertension, congestive heart failure ( a condition in which the heart does not pup blood well), gastro-esophageal reflux disease (GERD), and End Stage Renal Disease (ERSD), a condition in which the kidneys lose the ability to remove waste and balance fluids). A review of Resident #14's in-patient hospital Physician progress notes dated 5/11/2023 indicated end-stage renal disease on hemodialysis: Nephrology input, continue maintenance hemodialysis Tuesday, Thursday and Saturday's. A review of Resident # 14's physician's orders dated June 26, 2024, indicated RD to eval and treat, order date 05/23/2023. Renal Diet (regular texture, regular consistency double protein portions at all meals), and 1000ml per 24 hours, order date 12/06/2023. Identified no documentation of hemodialysis facility orders. A review of Resident #14's quarterly MDS (Section O 0110 special treatment (J1) Dialysis, dated 03/03/2024, 2/29/2024, and 12/15/2024, coded (No) on admission, and coded (No) while a Resident. The MDS nurse confirmed that neither the quarterly MDS meeting, nor the care plans addressed the diagnosis of the resident's ESRD. A review of Resident #14's Admission/Readmission Evaluation dated 05/23/2024 (Section I) 1a. History and risk factors: 3. kidney disease checked and identified. Admission assessment was completed and signed by a staff RN. A review of Resident #14's Baseline Care Plans dated 05/23/2023, identified no documentation of hemodialysis care plans initiated or updated. The baseline care plan did not address Resident # 14 End Stage Renal Disease (ESRD), a condition in which the kidneys lose the ability to remove waste and balance fluids). A review of Resident # 14's dialysis communication forms dated 3/12/2024, 3/21/2024, and 06/25/2024 was completed by nursing facility staffs, signed by Resident #14, and sent with Resident to the dialysis center. During an observation and interview 06/25/2024 at 10:00a.m., Resident #14 was in a self-propelled wheelchair, fully dressed in clean personal clothing, alert and oriented times three. Resident # 14 arrived in Resident Council meeting late today said he would have to leave the meeting early because he was scheduled to for hemodialysis today. During an observation on 06/25/2024 at 10:35a.m. Observed Dietary Manager served Resident #14 lunch tray to room, Dietary Manager said Resident #14 is scheduled to have early lunch on his dialysis days. 2. A review of Resident #33's face sheet and physician's orders for June 26, 2024 indicated Resident #33 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis including, myocardial infarction (heart attack), heart failure, left hemiplegia (partial or complete paralysis of one side of the body), anxiety, chronic obstructive pulmonary disease (COPD), end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), chronic kidney disease, dependence on renal dialysis. A review of Resident #33's physician's orders dated 06/26/2024 indicated admitting diagnosis: END STAGE RENAL DISEASE dated 12/5/2023: Medical Management chronic kidney disease, dated 12/5/2023: Dr orders reviewed indicated an order dated 12/05/2023 to receive Dialysis treatment Monday, Wednesday, and Friday with the area Kidney Care unit. NO BLOOD PRESSURE OR VENIPUNCTURE ON EXTREMITY WITH DIALYSIS ACCESS SITE EXTREMITY, and every shift MONITOR DIALYSIS SHUNT. A review of Resident #33's quarterly MDS (Section O 0110 special treatment (J1) Dialysis, dated 3/8/2024 coded (No) on admission, and coded (No) while a Resident. A review of Resident #33's Admission/Readmission Evaluation dated 12/05/2023(Section I) 1a. History and risk factors: 1. Urinary disorders, 2. Bladder disorders, 3. kidney disease checked and identified. Admission assessment was completed and signed by a staff RN. A review of the facility's scheduled care plan meetings for Resident #33 held on 3/18/24 and 06/17/2024 meet with staffs to assist in establishing a formal plan of care. The baseline care plan did not address Resident # 14 End Stage Renal Disease (ESRD), a condition in which the kidneys lose the ability to remove waste and balance fluids). A review of a comprehensive care plans dated 04/22/2024, identified no documentation of hemodialysis care plans initiated or updated. During an observations and interview on 06/24/2024 at 10:43a.m. Resident #33 in room sitting up in bed, was well groom, call light was in reach, no signs of abuse/neglect. The resident said he goes to dialysis at 1:30a.m., stated his regular scheduled days are on Mondays, Wednesdays, and Fridays. Resident #33 said, he will eat a light lunch prior to going to dialysis. During an interview on 06/24/2024 at 11:00 a.m. Dietary Manager said she see's Resident # 33 every Monday, Wednesday and Fridays, to review if he wanted an early lunch or take a sack lunch to dialysis. She said the resident usually refuse to take a sack lunch but will eat a light lunch prior to dialysis. During an interview on 06 /26/2024 at 1:30p.m. The MDS Coordinator, said the RAI manual was use as the guideline for completing the MDS assessment, she said the policy would be to follow the Resident Assessment Instrument (RAI). She said the initial admission assessment are done by a Register Nurse and the DON co-signs the assessment. The MDS Coordinator said, Resident #14 and Resident #33, section O 0110 special treatment (J1) dialysis should had been coded as receiving Hemodialysis which would have led to the rest of the assessment being completed. The MDS nurse confirmed the doctor orders did not address hemodialysis. The MDS nurse confirmed that neither the quarterly MDS meeting, nor the care plans addressed the diagnosis of the residents ESRD. The MDS nurse confirmed that the resident's treatments of dialysis were not addressed on the admission assessment. During an interview on 6/26/2024 at 2:30: p.m., LVN E, said she had been an LVN for [AGE] years, and LVN C said she had been an LVN for four and half years. Both are agency nurses and today was their first day at this facility. Both nurses said they had been trained and in-serviced on taking care of dialysis Residents and would document on the dialysis communication form or the progress notes when the Residents returned to the facility. They both were able to verbalize teach-back communication on the assessment that would be completed, the access type assessment and how to report if any problems or concerns. During an interview on 06/26/2024 at 3:30p.m. The DON said a resident receiving dialysis, she expected the MDS assessment to be coded. The DON said not coding the hemodialysis could cause a discrepancy when completing the resident's care plan. The DON said the MDS Coordinator was responsible for ensuring the MDS assessments were accurate and said the RAI manual was use as the guideline for the MDS assessment, she said the policy would be to follow the Resident Assessment Instrument (RAI). The DON confirmed that neither the quarterly MDS meeting, nor the care plans addressed the diagnosis for Resident #14 and Resident #33 ESRD. The DON confirmed Resident #14 doctor orders did not address hemodialysis. The DON confirmed that Resident #14 and Resident #33 treatments of dialysis were not addressed on the admission assessment. 47204

Based on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 4 residents (Resident #11) reviewed for pharmacy services. 1.The facility failed to provide 7 (seven) of 11 doses of Resident #11's physician prescribed Lotemax (Loteprednol) Ophthalmic Suspension (eye drops used to treat conditions of the eye that cause itching) between the dates of 06/20/2024 - 06/25/2024. 2.There was documentation in the MAR indicating 2 of the 7 doses were administered when the Lotemax eye medication was not available in the facility. 3.The facility failed to utilize available resources to obtain and administer the initial dose of physician prescribed Lotemax Ophthalmic Suspension for almost 19 hours after being prescribed and for 3 (three) days after learning the medication was not in the facility resulting in a total of 7 missed doses of Lotemax Ophthalmic Suspension. These failures could place residents at risk for not receiving the intended therapeutic response of prescribed medications and not having accurate records of medication administration which could result in diminished health and well-being. Findings included: Record review of a face sheet dated 06/25/2024 indicated Resident #11 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Multiple Sclerosis (a disease in which the immune system destroys the protective covering of nerves resulting in nerve damage), Cerebral Infarction (stroke) with right sided paralysis, Depression (a mental health disorder characterized by a persistently depressed mood or loss of interest in activities), Anxiety (feelings of unease such as worry or fear), and Dementia (a general term for loss of memory). Record review of a quarterly MDS assessment dated [DATE] noted Resident #11 had a BIMS score of 12 indicating her cognition was moderately impaired. The same MDS indicated Resident was dependent on staff for bathing, mobility, and toileting. Record review of Resident #11's physician orders indicated an order was written on 06/20/2024 at 01:33 PM for resident #11 to receive 1 (one) drop in each eye twice daily of Lotemax Ophthalmic Suspension. Record review of Resident #11's MAR dated for June 2024 indicated LVN F administered the 06:00 PM scheduled dose of Lotemax Opthalmic Suspension on 06/20/2024 at 06:00 PM. Record review of the Pharmacy Packing Slip Proof of Delivery indicated the Lotemax eye drops were not delivered to the facility until 06/21/2024 at 05:10 AM. Record review of Resident #11's June 2024 MAR indicated she did not receive the initial dose of Lotemax eye drops until 08:15 AM on 06/21/2024, approximately 19 hours after being ordered by the physician. Record review of Resident #11's June 2024 MAR indicated the ADON was unable to administer the 09:00 AM scheduled dose of the Lotemax eye drops on 06/23/2024 because she could not locate the medication in the facility. Her documentation noted the Lotemax eye drops were unavailable. Record review of Resident #11's June 2024 MAR indicated LVN G administered a 06:00 PM dose of Lotemax eye drops on 06/23/2024 after the ADON had documented the eye medication was not in the facility earlier that day. Record review of Resident #11's June 2024 MAR for 06/24/2024 at 09:00 AM and 06:00 PM indicated LVN A did not administer those 2 (two) doses of the Lotemax eye drops because the nurse was unable to locate the medication. Record review of Resident #11's June 2024 MAR for 06/25/2024 at 09:00 AM and 06:00 PM indicated LVN A did not administer those 2 (two) doses of Lotemax eye drops because the nurse was unable to locate the medication. Record review of progress notes dated 06/25/2024 at 10:17 AM indicated the order for the twice daily administration of Lotemax Ophthalmic Suspension was placed on hold until delivered from pharmacy. Record review of the facility's Order Audit Report for Lotamax Ophthalmic Suspension indicated the medication was initially ordered from the pharmacy on 06/20/2024 at 01:13 PM. The report indicated no further requests to refill or replace the missing Lotemax Suspension until after surveyor was made aware the medication was not available for administration on 06/25/2024. During observation and interview of LVN A administering medications to Resident #11 on 06/25/2024 at 09:13 AM, LVN A said she could not administer Resident #11's Lotemax eye drops because she did not have them. She said she also did not have the eye drops the day before on 06/24/2024. She said she was going to tell the DON about it. During an interview on 06/25/2024 at 11:00 AM, LVN A said she told the DON about the missing Lotemax Ophthalmic Suspension and said the DON was going to obtain the eye drops from a local pharmacy. LVN A said she should have told the DON and notified the pharmacy on 06/24/2024 when she first realized the eye medication was not in the facility. She said she got busy and forgot. During an interview on 06/25/2024 at 11:31 AM, the DON said she tried to get the Lotemax medication delivered from a local pharmacy, but they did not have it in stock. She said the eye drop medication would be delivered early on 06/26/2024. The DON said the physician ordered the Lotemax Ophthalmic Suspension on 06/20/2024 after Resident #11 told the doctor her eyes were itching. The DON said she expected the nurses to notify her anytime a medication was not available for administration. She said neither LVN F, LVN G, nor the ADON had informed her of Resident #11 not having the ordered Lotemax medication available for use. The DON said the pharmacy should have been made aware of the needed medication and if the pharmacy could not deliver it timely, then the pharmacy would have contacted a local pharmacy for delivery of the medication. The DON said the nurses (LVN F and LVN G) who documented they administered the Lotemax Ophthalmic Suspension on 06/20/2024 at 06:00 PM and on 06/23/2024 at 06:00 PM, respectively, could not have administered the eye medication because it was not in the facility. She said she thought the nurses signed the MAR before they realized the medication was not there and then failed to make a correction to their entries. During an interview and observation on 06/25/2024 at 12:09 PM, Resident #11 said she had not received any eye drops. She said her eyes were scratchy. No eye redness or drainage was observed. During an interview on 06/25/2024 at 03:31 PM, the ADON said she could not find the Lotemax eye drops on 06/23/2024 for the 06:00 AM administration. She said she looked in both medication carts, the medication room, the refrigerator in the medication room, and the overflow medication storage but did not find the eye drop suspension. The ADON said she notified the physician of the missing medication and put in an order to the pharmacy to re-order the medication. She said the pharmacy did not deliver on Sunday. The ADON provided a copy of a late progress note entry dated 06/25/2024 for 06/23/2024 indicating she reordered the Lotemax medication from the pharmacy and notified the physician. The ADON said Resident #11 showed no adverse reaction for not receiving the prescribed eye drops as ordered. During an interview on 06/26/2024 at 02:21 PM, the Pharmacy Consultant said if the facility needed a medication for administration prior to the next pharmacy delivery, then the facility could request a stat (a common medical abbreviation for urgent, rush, or immediately) medication delivery. She said the facility did not request a stat delivery of the Lotemax Opthalmic Suspension on 06/20/2024 when it was first ordered nor on 06/25/2024 when it was re-ordered. The Pharmacy Consultant also said she found no record of a refill request on 06/23/2024. She also said the pharmacy had staff on duty at the pharmacy 24 hours a day, 365 days a year and was able to make deliveries 7 (seven) days a week. LVN F and LVN G were not present during the survey and attempts to reach out to them by phone were unsuccessful. A review of in-services for the last 6 months did not indicate any training had been done with the nurses on the process for acquiring medications when there was an inadequate supply on hand for administration. A review of the facility's policy dated 2001/Revised 2012 regarding medication administration indicated the following: Administering Medications Medications shall be administered in a safe and timely manner, and as prescribed 3. Medications must be administered in accordance with the orders, including any required time frame A review of the facility's contracted pharmacy's manual titled Policies and Procedures for Pharmacy Services indicated the following: 4.1.3. Urgent Orders New orders or refill orders requiring urgent delivery should be indicated on the order form or communicated verbally. The pharmacy has services available to deliver medications in a timely manner, depending on time and location of receiving facility. 5. Service Disruptions 5.1. Medication Shortages Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility should immediately initiate action to obtain the medication from pharmacy . 6.1 Delivery Schedules . Orders requiring more urgent delivery will be communicated by the facility to the pharmacy either by fax or verbally. The pharmacy will expedite delivery of those medications within a 4-hour window.

Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 7 residents (Resident #150) reviewed for abuse. The facility failed to ensure LVN H did not verbally abuse Resident #150 during shift change. This failure could place residents at risk of abuse, humiliation, intimidation, fear, mental distress, depression, and decreased quality of life. Findings included: Record review of Resident #150's face sheet, dated 06/19/24, indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of depressive disorder (mood disorder causing persistent sadness and a loss of interest), major depressive disorder with psychotic features single episode (mood disorder causing persistent sadness and a loss of interest along with hallucinations, delusions or a state of near-unconsciousness or insensibility), Parkinson's Disease (chronic and progressive disease that affects the brain and spinal cord causing tremors, slowness of movement, rigidity, and difficulty with balance), hypertension (high blood pressure), angina pectoris (chest pain or discomfort due to a lack of blood to the heart muscle), cerebrovascular accident (lack of blood flow or bleeding in the brain), acute myocardial infarction (blood flow to the heart muscle is abruptly cut off, causing tissue damage) and chronic diastolic congestive heart failure (the heart's left ventricle, main pumping chamber, becomes stiff and unable to fill properly). He was discharged from the facility on 07/17/23. Record review of Resident #150's Quarterly MDS assessment dated [DATE] indicated he was cognitively intact and used a wheelchair for mobility. Resident #150 had diagnoses of hypertension (high blood pressure), angina pectoris (chest pain or discomfort due to a lack of blood to the heart muscle), acute myocardial infarction (blood flow to the heart muscle is abruptly cut off, causing tissue damage), chronic diastolic congestive heart failure (the heart's left ventricle, main pumping chamber, becomes stiff and unable to fill properly), cerebrovascular accident (lack of blood flow or bleeding in the brain), Parkinson's Disease (chronic and progressive disease that affects the brain and spinal cord causing tremors, slowness of movement, rigidity and difficulty with balance) and depression (mood disorder causing persistent sadness and a loss of interest). Record review of Resident #150's Care Plan revised on 03/12/23 indicated he had delirium or acute confusional episodes and interventions included to reassure and deescalate the situation. Resident #150 had an attention seeking behavioral problem related to perceived medical conditions that was initiated on 04/13/23 and interventions included to anticipate and meet his needs and to de-escalate by educating on condition, notify the doctor and reassure. A provider investigation report dated 07/07/23 completed by the previous Administrator indicated on 07/03/23 at 8:00 a.m., Resident #150 reported to the Administrator on 07/02/23 at 6:00 p.m. that he was at the nursing station during shift change while LVN H was giving report to the oncoming nurse. Resident #150 said LVN H told him to leave because he was pissing him off and he returned to his room. The Administrator sent LVN H a text message for him to call her. He did not return her calls and he responded back indicating he quit. LVN H LVN H did not return to the facility after he clocked out at the end his shift on 07/02/23. The facility conducted resident safe surveys and in-serviced staff on their Abuse/Neglect policy and the types of abuse. The facility confirmed the allegation of abuse. A witness statement dated 03/13/2023 written by LVN D indicated LVN H told Resident #150 to go and pointed down the hallway. Resident #150 told LVN H that was rude and LVN H said because you are pissing me off. During a phone interview on 06/20/24 at 3:16 PM, LVN D said she was the charge nurse and worked the 6:00 p.m.-6:00 a.m. shift. LVN D said she worked on 07/02/23 and witnessed the incident between LVN H and Resident #150. LVN D said Resident #150 was at the nursing station while LVN H was giving report to the oncoming night shift nurse (unknown). LVN H told Resident #150 he needed to leave because he was giving report to the nurse. LVN D said Resident #150 did not leave and remained at the nursing station. LVN D said LVN H pointed down the hallway and told Resident #150 again he needed to leave. LVN D said LVN H did not yell or scream at Resident #150, but by the tone of his voice, she could tell he was frustrated and annoyed with the resident. LVN D said Resident #150 told LVN H that was rude. LVN D said a staff member cussing at, speaking rudely to, exchanging words or arguing with a resident was verbal abuse. LVN D said residents were at risk for mental distress or depression if they are verbally abused. During an interview on 06/20/24 at 3:46 PM, the Administrator said she was the abuse coordinator and expected staff to report an allegation of abuse to her immediately. The Administrator said she started working at the facility in February 2024 and the incident between Resident #150 and LVN H was investigated by the previous administrator. The Administrator said according to the provider investigation report the previous administrator confirmed the allegation of abuse had occurred. The Administrator said a staff member cussing at, speaking rudely to, exchanging words or arguing with a resident was verbal abuse. The Administrator said residents are at risk for mental distress or depression if they are verbally abused. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated 04/2021 indicated, Residents have the right to be free from abuse .1. Protect residents from abuse .by anyone including, but no necessarily limited to: a. facility staff .5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems .

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 residents that meet professional standards of quality care within 48 hours of the resident's admission for 2 of 2 dialysis residents (Residents #14, and Resident #33). The facility failed to ensure Residents # 14 and # 33's, baseline care plans included instructions to address both residents' admission diagnoses of ESRD and physician orders within 48 hours of admission. This failure could place newly admitted residents at risk of receiving inadequate care and services. Finding included: 1. A review of Resident #14's face sheet and physician's orders for June 26, 2024, indicated Resident # 14 was [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis including, right leg below knee amputation, chronic kidney disease, type 2 diabetes, hypertension, congestive heart failure ( a condition in which the heart does not pup blood well), gastro-esophageal reflux disease (GERD), and End Stage Renal Disease (ESRD), a condition in which the kidneys lose the ability to remove waste and balance fluids). A review of Resident #14's quarterly MDS assessments dated 03/03/2024, 2/29/2024, and 12/15/2024 revealed special treatments section for dialysis, was coded no on admission, and coded no while a resident. A review of Resident #14's Baseline Care Plans dated 05/23/2023 , identified no documentation of hemodialysis care plans initiated. The baseline care plan did not address Resident # 14 End Stage Renal Disease (ESRD). There were no updated care plans that addressed Resident # 14 End Stage Renal Disease (ESRD) or dialysis interventions, and goals. A review of Resident # 14's physician's orders dated June 26, 2024, indicated RD to eval and treat, order date 05/23/2023. Renal Diet (regular texture, regular consistency double protein portions at all meals), and 1000ml per 24 hours, order date 12/06/2023. Identified no documentation of hemodialysis facility orders. A review of Resident #14's in-patient hospital Physician progress notes dated 5/11/2023 indicated end-stage renal disease on hemodialysis: Nephrology input, continue maintenance hemodialysis Tuesdays, Thursdays, and Saturdays. A review of Resident #14's Admission/Readmission Evaluation dated 05/23/2024 history and risk factors: 3. kidney disease checked and identified. Admission assessment was completed and signed by a staff RN. A review of Resident # 14's dialysis communication forms dated 3/12/2024, 3/21/2024, and 06/25/2024 revealed they were completed by nursing facility staff, signed by Resident #14, and sent with Resident to the dialysis center. During an observation and interview on 06/25/2024 at 10:00a.m., Resident #14 was in a self-propelled wheelchair fully dressed in clean personal clothing, alert and oriented to times, place, and person. Resident # 14 arrived in Resident Council meeting late said he would have to leave the meeting early because he was scheduled to for hemodialysis that day. During an observation on 06/25/2024 at 10:35a.m. Observed Dietary Manager serve Resident #14's lunch tray to his room. Dietary Manager said Resident #14 is scheduled to have early lunch on his dialysis days. 2. A review of Resident #33's face sheet and physician's orders for June 26, 2024 indicated Resident #33 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis including myocardial infarction (heart attack), heart failure, left hemiplegia (partial or complete paralysis of one side of the body), anxiety, chronic obstructive pulmonary disease (COPD), end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), chronic kidney disease, dependence on renal dialysis. A review of Resident #33's quarterly MDS (Section O 0110 special treatment (J1) Dialysis, dated 3/8/2024 coded (No) on admission, and coded (No) while a Resident. A review of a baseline care plan 12/05/2023, did not address Resident # 14 End Stage Renal Disease (ESRD), a condition in which the kidneys lose the ability to remove waste and balance fluids). A review of a comprehensive care plans dated 04/22/2024, identified no documentation of hemodialysis care plans initiated or updated. A review of Resident #33's physician's orders dated 06/26/2024 indicated admitting diagnosis: END STAGE RENAL DISEASE dated 12/5/2023: Medical Management chronic kidney disease, dated 12/5/2023: Doctor orders reviewed indicated an order dated 12/05/2023 to receive Dialysis treatment Monday, Wednesday, and Friday with the area Kidney Care unit. NO BLOOD PRESSURE OR VENIPUNCTURE ON EXTREMITY WITH DIALYSIS ACCESS SITE EXTREMITY, and every shift MONITOR DIALYSIS SHUNT. A review of Resident #33's Admission/Readmission Evaluation dated 12/05/2023(Section I) 1a. History and risk factors: 1. Urinary disorders, 2. Bladder disorders, 3. kidney disease checked and identified. Admission assessment was completed and signed by a staff RN. A review of the facility's scheduled care plan meetings for Resident #33 revealed they were held on 3/18/24 and 06/17/2024. During an observations and interview on 06/24/2024 at 10:43a.m., Resident #33 was in his room sitting up in bed, was well groom, call light was in reach, no signs of abuse/neglect . The resident said he went to dialysis at 1:30 a.m He states his regular scheduled days are on Mondays, Wednesdays, and Fridays. Resident #33 said, he will eat a light lunch prior to going to dialysis. During an interview on 06/24/2024 at 11:00 a.m. The Dietary Manager said she saw Resident # 33 every Monday, Wednesday and Fridays, to review if he wanted an early lunch or take a sack lunch to dialysis. She said the resident usually refuse to take a sack lunch but will eat a light lunch prior to dialysis. During an interview on 06 /26/2024 at 1:30p.m. The MDS Coordinator said the RAI manual was used as the guideline for preforming the MDS assessment, she said the policy would be to follow the Resident Assessment Instrument (RAI). She said the initial admission assessment are done by a Register Nurse and the DON co-signs the assessment. The MDS Coordinator said Resident #14 and Resident #33, section O 0110 special treatment (J1), dialysis should had been coded as receiving hemodialysis ,which would have led to the rest of the assessment being completed. The MDS nurse confirmed that neither the quarterly MDS meeting, nor the care plan addressed the diagnosis of the resident's ESRD. The MDS nurse confirmed the doctor orders did not address hemodialysis. The MDS nurse confirmed that the resident's treatments of dialysis were not addressed on the admission assessments. During an interview on 6/26/2024 at 2:30: p.m ., LVN E said she had been an LVN for [AGE] years, and LVN C said she had been an LVN for four and half years. Both were agency nurses and today was their first day at this facility. Both nurses said they had been trained and in-serviced on taking care of dialysis residents and would document on the dialysis communication form or the progress notes when the residents returned to the facility. They both were able to verbalize teach-back communication on the assessment that would be completed , the assessment of the resident's fistula or the hemodialysis catheter, and how to report if any problems or concerns became apparent. During an interview on 06/26/2024 at 3:30p.m., The DON said with a resident receiving dialysis, she expected the MDS assessment to be coded. The DON said not coding the hemodialysis could cause a discrepancy when completing the resident's care plan. The DON said that she and the ADON were responsible for reviewing the admission care plans and updating the current plans. She said she was the nurse who reviewed Resident # 33's baseline care plan. The DON said the MDS Coordinator was responsible for ensuring the MDS assessments were accurate and said the RAI manual was use as the guideline for the MDS assessment , she said the policy would be to follow the Resident Assessment Instrument (RAI). The DON confirmed that neither the quarterly MDS meeting, nor the care plans addressed the diagnosis for Resident #14 and Resident #33 ESRD. The DON confirmed Resident #14 doctor orders did not address hemodialysis. The DON confirmed that Resident #14 and Resident #33 treatments of dialysis were not addressed on the admission assessment.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 Residents (Resident #11) reviewed for medical records accuracy. The facility failed to insure LVN F and LVN G accurately documented the administration of Lotemax Ophthalmic Suspension on 2 (two) occasions when they indicated the eye drops medication had been administered when the medication was not available in the facility. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: Record review of a face sheet dated 06/25/2024 indicated Resident #11 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Multiple Sclerosis (a disease in which the immune system destroys the protective covering of nerves resulting in nerve damage), Cerebral Infarction (stroke) with right sided paralysis, Depression (a mental health disorder characterized by a persistently depressed mood or loss of interest in activities), Anxiety (feelings of unease such as worry or fear), and Dementia (a general term for loss of memory). Record review of a quarterly MDS assessment dated [DATE] noted Resident #11 had a BIMS score of 12 indicating her cognition was moderately impaired. The same MDS indicated Resident was dependent on staff for bathing, mobility, and toileting. Record review of Resident #11's physician orders indicated an order was written on 06/20/2024 at 01:33 PM for resident #11 to receive 1 (one) drop in each eye twice daily of Lotemax Opthalmic Suspension. Record review of Resident #11's MAR dated for June 2024 indicated LVN F administered the initial dose of Lotemax Opthalmic Suspension on 06/20/2024 at 06:00 PM. Record review of the Pharmacy Packing Slip Proof of Delivery indicated the Lotemax eye drops were not delivered to the facility until 06/21/2024 at 05:10 AM. The Proof of Delivery Packing Slip was signed by LVN F. Record review of Resident #11's June 2024 MAR indicated she did not receive the initial dose of Lotemax eye drops until 08:15 AM on 06/21/2024. Record review of Resident #11's June 2024 MAR indicated the ADON was unable to administer the 09:00 AM scheduled dose of the Lotemax eye drops on 06/23/2024 because she could not locate the medication in the facility. Her documentation noted the Lotemax eye drops were unavailable. Record review of Resident #11's June 2024 MAR indicated LVN G administered a 06:00 PM dose of Lotemax eye drops on 06/23/2024 after the ADON had documented the eye medication was not in the facility earlier that day. Record review of Resident #11's June 2024 MAR for the next day, 06/24/2024, at 09:00 AM indicated LVN A could not administer the Lotemax eye drops because the medication was not available in the facility. Record review of the facility's Order Audit Report for Lotamax Ophthalmic Suspension indicated the medication was initially ordered from the pharmacy on 06/20/2024 at 01:13 PM. The report indicated no further requests to refill or replace the missing Lotemax Suspension until 06/25/2024. Review of Progress Notes dated 06/23/2024 through 06/25/2024 indicated Resident #11 did not have Lotemax Ophthalmic Suspension available in the facility for administration. During an interview on 06/25/2024 at 11:31 AM, the DON said the nurses (LVN F and LVN G) who documented they administered the Lotemax Ophthalmic Suspension on 06/20/2024 at 06:00 PM and on 06/23/2024 at 06:00 PM, respectively, could not have administered the eye medication because it was not in the facility. She said she thought the nurses signed the MAR before they realized the medication was not there and then failed to make a correction to their entries. During an interview on 06/25/2024 at 03:31 PM, the ADON said she could not find the Lotemax eye drops on 06/23/2024 for the 06:00 AM administration. She said she looked in both medication carts, the medication room, the refrigerator in the medication room, and the overflow medication storage but did not find the eye drop suspension. LVN F and LVN G were not present during the survey and attempts to reach them by phone on o6/26/2024 at 11:00 AM 03:06 PM were unsuccessful. Record review of a Pharmacy Packing Slip Proof of Delivery indicated the refill of the Lotemax eye drops were not delivered to the facility until 06/26/2024 at 05:08 AM. A review of the facility's policy regarding medication administration indicated the following: Administering Medications 19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication .

Based on observation, interview and record review, the facility failed to ensure that it was free of a medication error rate of 5 percent or greater. The facility had a medication error rate of 21.21%, based on 7 errors out of 33 opportunities, which involved 2 of 6 residents (Resident #13 and Resident #7) reviewed for medication administration. The facility failed to administer Resident #13's duloxetine (a medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) as ordered. The facility failed to administer Resident #13's furosemide (a medication used to treat fluid retention) as ordered. The facility failed to administer Resident #13's lisinopril Hydrochlorothiazide (a medication used to treat high blood pressure) as ordered. The facility failed to administer Resident #13's crestor (used in adults to slow the progression of atherosclerosis [a build-up of plaque in blood vessels that can block blood flow]) as ordered. The facility failed to administer Resident #7's sotalol (used to treat atrial fibrillation [an irregular and often very rapid heart rhythm that can lead to blood clots in the heart] and other conditions that cause an irregular heartbeat) as ordered. The facility failed to administer Resident #7's lisinopril (a medication used to treat high blood pressure) as ordered. The facility failed to administer Resident #7's systane ultra eye drops (a medication used for the temporary relief of burning and irritation due to dryness of the eye) as ordered. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: 1. Record review of Resident #13's face sheet, dated 04/17/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. He had diagnoses which included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing problems), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (higher than normal blood pressure), and chronic diastolic heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply). Record review of Resident #13's quarterly MDS, dated [DATE], indicated he was usually able to make himself understood and was usually able to understand others. He had a BIMS score of 12 which indicated moderately impaired cognition. He did not exhibit behaviors of rejection of care or wandering. He required supervision for all activities of daily living except dressing, which required limited assistance. The MDS indicated he had diagnoses which included heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), coronary artery disease (a narrowing or blockage of your coronary arteries, usually due to plaque buildup), and hypertension (higher than normal blood pressure). Record review of Resident #13's physician's orders, dated 04/17/23, indicated Resident #13 was ordered the following: *Crestor tablet 20mg, give 1 tablet by mouth one time a day (used in adults to slow the progression of atherosclerosis [a build-up of plaque in blood vessels that can block blood flow]) *Lisinopril hydrochlorothiazide tablet 20-25mg, give 0.5 tablet by mouth one time a day (a medication used to treat high blood pressure) *Duloxetine HCL capsule delayed release 60mg, give 1 capsule by mouth one time a day (a medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) *Furosemide tablet 40mg, give 1 tablet by mouth one time a day (a medication used to treat fluid retention) Record review of Resident #13's MAR, dated 04/19/23, indicated crestor 20mg was held and not administered on 04/17/23 and 04/18/23. Duloxetine 60mg was held and not administered on 04/17/23. Furosemide 40mg was held and not administered on 04/17/23. Lisinopril hydrochlorothiazide 20-25mg was held and not administered on 04/17/23 and 04/18/23. No other held doses for the medications were found for the month of April. 2. Record review of Resident #7's face sheet, dated 04/17/23, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. She had diagnoses which included essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), and atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart). Record review of Resident #7's annual MDS, dated [DATE], indicated she was usually able to make herself understood and was usually able to understand others. She had a BIMS score of 11 which indicated moderately impaired cognition. She did not exhibit behaviors of rejection of care or wandering. She required supervision assistance with all activities of daily living. Record review of Resident #7's physician's orders, dated 04/17/23, indicated Resident #7 was ordered the following: *Lisinopril tablet 20mg, give 20mg by mouth two times a day for hypertension (a medication used to treat high blood pressure) *Sotalol HCL tablet 80mg, give 0.5 tablet by mouth two times a day (used to treat atrial fibrillation [an irregular and often very rapid heart rhythm that can lead to blood clots in the heart] and other conditions that cause an irregular heartbeat). *Systane Ultra Solution 0.4-0.3%, instill 1 dop in both eyes in the morning for dry eyes (a medication used for the temporary relief of burning and irritation due to dryness of the eye) Record review of Resident #7's MAR, dated 04/19/23, indicated systane ultra eye drops were held and not administered on 04/17/23 and 04/18/23. Lisinopril tablet 20mg was held and not administered on 04/17/23 for both the AM and PM doses. Sotalol HCL tablet 80mg was held and not administered on 04/17/23 and 04/18/23 for both the AM and PM doses. No other held doses for the medications were found for the month of April. During an observation and interview on 04/17/23 at 08:41 AM, LVN J did not administer Resident #13's duloxetine, furosemide, lisinopril hydrochlorothiazide, or crestor medications. He said he was unable to find the medications in his cart. He said he marked the medications as held in the MAR. During an observation and interview on 04/17/23 at 09:06 AM, LVN J did not administer Resident #7's sotalol, lisinopril, or systane ultra eye drops medications. He said he was unable to find the medications in his cart. He said he marked the medications as held in the MAR. During an interview on 04/17/23 at 09:56 AM, LVN J said he checked the medication room for Resident #13's duloxetine, furosemide, lisinopril hydrochlorothiazide, and crestor and was not able to find the medications. LVN J said checked the medication room for Resident #7's sotalol, lisinopril, and Systane ultra eye drops and was not able to find the medications. LVN J said the medications were not delivered from the pharmacy. During an interview on 04/17/23 at 11:41 AM, LVN J said he ordered the missing medications on Thursday 04/13/23 when he last worked. He said he had looked for the held medications and he was unable to find them. He said there was an emergency kit and the kit contained medications they could use when they ran out. He said he thought the facility ran out of the medications because the nurse who worked over the weekend did not follow up with the pharmacy to ensure the medications were filled and delivered. During an interview on 04/17/23 at 02:09 PM, LVN J said he was going to call the pharmacy and see why the medications were not delivered. He said that Resident #13 and Resident #7 could have high blood pressures because they did not receive their lisinopril. He said Resident #7 could have an elevated heart rate because she did not receive her sotalol. He said Resident #13 could have increased fluid retention due to not receiving his furosemide. LVN J said he did not give the medications out of the emergency kit yesterday because he was busy, and he did not have access to the emergency kit. He said he did not report this to the DON or ADON. During an interview and record review on 04/17/23 at 04:02 PM, the ADON provided a copy of LVN J's medication administration competency dated 2/28/23. She said the section labelled Charting - EMAR: medications/treatment included medication administration training. Record review of LVN J's In-service training, dated 02/28/23, indicated that LVN J was trained on medication administration and ordering of medications. During an interview on 04/18/23 at 09:00 AM, LVN J said he did not call the pharmacy yesterday to check on the status of the missing medications. He said he was busy and was unable to contact the pharmacy yesterday. LVN J said the missing medications had not been delivered yet from the pharmacy. During an interview on 04/18/23 at 01:48 PM, the ADON said the duloxetine, furosemide, lisinopril hydrochlorothiazide, and crestor for Resident #13 had been ordered from the pharmacy. She said she was unable to see what day those medications were ordered. She said Resident #7's sotalol, lisinopril, and systane eye drops have been ordered. She said the charge nurses were responsible for reordering medications when the medications were low. She said the process for reordering medications was the nurses should have ordered the medication refills on the EMR which sends a message to the pharmacy that a refill of the medications was needed. The ADON said the charge nurse should have checked with the pharmacy to determine why the medications were not delivered. The ADON said they should have used the emergency kit when they ran out of Resident #13's and Resident #7's medications. She said if the nurse could not get through to the pharmacy, they should have notified the DON or ADON. She said Resident #13 could suffer from swelling/fluid overload by not receiving his furosemide. She said he could suffer high blood pressure or fluid overload because he did not receive his lisinopril hydrochlorothiazide. Resident #7 could have an elevated heart rate or high blood pressure because she did not receive her sotalol and lisinopril. She said LVN J should have notified the ADON or DON as soon as he realized he was out of the medications and he could not access the emergency kit. During an interview on 04/18/23 at 02:05 PM, LVN A said the process for reordering medications was she orders refills as soon as the medication had only one line left in the card. She said she would order refills through the charting system or call the pharmacy. She said if the medication was not on hand, she would check the emergency kit. She said if the medication was not in the emergency kit, she would call pharmacy and then she would notify the ADON. She said she would call the doctor to see if there was an alternative to the medication. She said she would keep calling the pharmacy and notifying the ADON. She said she would call the doctor if she had to hold resident medications such as furosemide. During an interview on 04/19/23 at 09:30 AM Pharmacist M said Resident #13's duloxetine, furosemide, and lisinopril hydrochlorothiazide were ordered and filled on 03/13/23 and 04/18/23. He said the crestor was ordered and filled on 03/13/23 and 04/17/23. He said the pharmacy did not receive an order for any of those medications between 03/13/23 and 04/17/23. He said Resident #7's sotalol and lisinopril were ordered and filled on 03/20/23 and 04/18/23. He said the pharmacy did not receive an order for those medications between 03/20/23 and 04/18/23. He also checked faxes and documented phone calls and did not find any record of medication orders for Resident #13 and Resident #7 between 03/13/23 and 04/18/23. During an interview on 04/19/23 at 10:07 AM, the ADON said the nurses were responsible for ordering medications before they ran out and no one monitored them to see if low medications were being reordered. She said as a nurse, she would have reordered the medication as soon as there were 7 days of medications left on the card. During an interview on 04/19/23 at 10:11 AM, the Administrator said the nursing staff were responsible for ensuring medications did not run out. She said the nursing staff were responsible for ordering the medications. She said she did not think anybody was assigned to monitor staff and ensure medications were being reordered timely. She said she expected the nursing staff to refill the medications and have them in the facility before they ran out. The administrator said the ADON and DON were ultimately responsible for ensuring the nursing staff were ordering medications and not running out of them. Resident #13 could potentially have a worsened condition because he did not receive the furosemide or lisinopril. She said there was a potential for harm to Resident #13 by omitting his medications during his medication pass. She said Resident #7 had potential for harm including increased heart rate and increased blood pressure because she did not receive the sotalol or lisinopril. During an interview on 04/19/23 at 11:20 AM, the DON said the direct care nurse was responsible for ordering medications when they were low. She said the DON was ultimately responsible for medication administration. She said the DON was responsible ultimately for ensuring medications were ordered and followed up on. She said the process for ensuring medications were not missed was that the direct care nurse should have ensured the medication was ordered, then they should have checked the emergency kit. She said if the nurse could not get the medication out of the emergency kit they were supposed to bring it to the attention of the DON. She said the nurses should have ordered a refill of the medication when there were around 4 days of the medication remaining. She said no one was monitoring the nurses to ensure medications were not running out or being missed. The process for ordering medications was nurses should order a medication refill through the chart, then the pharmacy receives the refill and sends the medication to the facility. The direct care nurses were responsible for checking with the pharmacy if medications were not delivered. She said if they could not reach the pharmacy then they should have notified the ADON or DON. She said Resident #13 could suffer worsened congestive heart failure or his blood pressure could be elevated, because his Furosemide and Lisinopril were missed. She said Resident #7 could experience elevated blood pressure and heart rate because her Sotalol and Lisinopril were missed. She said LVN J was a new nurse and did not yet have access to the emergency kit. Record review of the facility's undated Medication Administration Policy stated: .4. Dispensing Practices 4.1 Pharmacy Ordering Process . .4.1.2. Refill Orders The following forms or methods are accepted means of submitting refill orders to the pharmacy: For facilities with integrated EHR, the facility may transmit refill request via facility's EHR. In addition, the following may be used - Refill reorder form: prescription label stickers are placed on the reorder form and faxed to the pharmacy fax line . .[NAME] Link .the web portal where refill orders can be submitted to the pharmacy. The refill order may be called in if the circumstances require it. Refill orders will be delivered on the first respective facility run of the following business day . .4.1.4. Emergency Kits First Dose Medication Cabinet The pharmacy will provide the first dose medication dispensing cabinet (emergency kit) as the first dose solution. The emergency kit is intended to be used to ensure immediate medication availability when needed .

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 13 residents (Residents #3, #6, and #10) reviewed for incontinent care and wound care and 1 of 2 linen carts (Hall 200 cart) reviewed for infection control practices. 1. CNA F failed to change her gloves when going from a dirty to a clean procedure and when her gloves were visibly soiled when performing incontinent care on Resident #10. 2. The facility failed to store linen in a clean area. 3. CNA K failed to change her gloves prior to applying the clean brief and barrier cream to Resident # CNA K failed to perform hand hygiene in between glove changes when she provided incontinent care to Resident #3. 4. LVN A failed to clean Resident #6's wounds after placing the open wounds on the dirty pillow and before applying the clean dressings. These failures could place residents at risk for infections. Findings included: 1.Record review of the undated face sheet indicated Resident #10, a female, admitted [DATE], and readmitted [DATE]. Record review of the consolidated physician's orders dated April 2023 indicated Resident #10 was [AGE] years old with diagnoses that included: high blood pressure (the force of the blood in the artery walls is too high), cerebral infarction, (disruption in the blood supply in the brain), Multiple Sclerosis (the immune system eats away at the protective covering of the nerves), seizures (a burst of uncontrolled electrical activity in brain cells causing stiffness, twitching, or limpness), and depression (feelings of despondency, dejection, inadequacy, and guilt). Record review of the quarterly MDS dated [DATE] indicated Resident #10 had clear speech, was usually understood by others, and usually understood others. She had a BIMS score of 9 that indicated moderate cognitive impairment. Resident #10 required the total assistance of two or more staff for bed mobility. The MDS indicated she had not transferred in the 7-day lookback period. She was always incontinent of bladder and bowel. Record review of the care plan dated 1/13/23 indicated Resident #10 required staff to turn and reposition her in bed and she was bedfast all or most of the time. She required the use of a mechanical lift for transfers. The care plan indicated she had impaired cognitive function/dementia or impaired thought processes related to poor processing and a communication problem related to her cognition. The care plan indicated she had bowel and bladder incontinence. During an observation on 4/17/23 at 10:25 a.m., CNA F performed incontinent care on Resident #10 with the DON assisting. CNA F did not change her gloves after cleaning the front peri area of Resident #10. She put the gloves on Resident #10's hip and back to turn her to her side. While CNA F was cleaning Resident #10's back side she got stool on her gloves and did not change her gloves. She smeared stool from her gloves on Resident #10's right hip and leg. CNA F wiped off the stool that was smeared onto Resident #10 with wipes but did not change her gloves and continued with care. She continued to wipe Resident #10's bottom with her visibly soiled gloves. The gloves had stool on her left hand/glove at the end of the thumb and below the left finger outer palm. CNA F did not change her gloves until after she finished cleaning Resident #10's back side. During an interview on 4/17/23 at 10:47 a.m., CNA F said she had been working at the facility for about a month. She said she had been a CNA for 3 years. She said she should have changed her gloves after cleaning the front/peri area of Resident #10 and should not have touched Resident #10 because her gloves were dirty. She said she also should have changed her gloves when they were visibly soiled with stool. She said the danger of not changing her gloves was infection transmission. She said she had passed her CNA competencies since she had been at this facility. She said they did the competencies at hire prior to her working. She said she did not know why she did not change her gloves when she knew she was supposed to. During an interview on 4/17/23 at 11:12 a.m., the DON said she would have changed her gloves immediately if they had stool on them. She said CNA F did not change her gloves after cleaning the front/perineal area of Resident #10. She said she then touched the resident with her dirty/unchanged gloves when she went to turn her to her side. She said she should have changed her gloves immediately when she got stool on them. She said she considered telling her change her gloves a couple of times, but then she did not. She said maybe she should have told her to change her gloves, but she wanted to observe her to see what the facility needed to work on. She said the CNA not changing her gloves was an infection control risk that could cause UTI's (an infection in the bladder) and all sorts of bugs to spread through the facility. She said CNA F had been trained on incontinent care and handwashing and was trained when to change her gloves when they were dirty or visibly soiled. She said she had been trained at this facility prior to working. During an interview on 4/18/23 at 9:04 a.m., CNA G said when doing peri care you cannot change your gloves enough. She said after you clean the front of a resident you change gloves before touching the resident to roll them over to clean their back side. She said if you do not, then you have put dirty gloves on the resident. She said if she got stool on her gloves, she would change her gloves immediately and wash her hands. She said not changing out of dirty gloves was an infection control problem and could spread infections, sickness, and all the above because you don't know what was in urine or stool. She said she was retrained yearly on handwashing and peri-care. She said a nurse would observe her do a peri-care and if she had done handwashing and peri-care properly the nurse would check off each section and validate her proficiency. She said all the CNA's had to have a check-off at least yearly. During an interview on 4/18/23 at 10:53 a.m., the MDS nurse said after a CNA cleaned a resident's front side she should change her gloves before touching the resident or any bedding because her gloves were dirty. She said if the CNA did not change her gloves, she was putting dirty gloves on that resident and anything else she touched. She said not changing out of dirty gloves could spread infection. She said if a CNA got stool on her gloves during care the CNA should immediately take off the gloves, wash her hands and don new/clean gloves. She said not changing dirty gloves was a set up for the spread of infection. During an interview on 04/18/23 at 1:34 p.m., CNA H said when performing peri care after cleaning the front part of a resident you would have to change your gloves before putting your hands on a resident and turning them because your gloves would be dirty. She said if you turned a resident or touched a resident with dirty gloves, you could be spreading infection. She said if your gloves were visibly soiled you immediately stopped, washed your hands and changed your gloves. She said, It is a big no-no to continue once your gloves are visibly soiled, especially with stool. She said continuing with visibly soiled gloves presented a danger of spreading infection, viruses, and whatever else could make people sick. During an interview on 04/18/23 at 1:45 p.m., the administrator said she expected gloves to be changed anytime a staff went from dirty to clean. She said if a staff had performed peri care on the front part of a resident, they would have to change their gloves and clean their hands before turning or touching the resident because their gloves would be considered dirty. She said if the CNA turned the resident or touched a resident without changing their gloves there was a danger of infection control issues. She said if another staff was assisting and noticed the CNA had not changed gloves from a dirty to a clean procedure or continued peri care after noticeable stool was on her gloves, she expected the assisting staff to tell her/him she needed to change gloves and wash her hands. During an interview and record review on 04/19/23 at 10:42 a.m., the ADON showed this surveyor the verification of competency for CNA F for handwashing and perineal care. The ADON said she had verified CNA F's competency for handwashing and perineal care on 4/3/23 and indicated her signature was at the bottom of the pages. She said her signature at the bottom of the documents indicated CNA F was proficient in handwashing and perineal care. 45879 2. During an observation on 04/16/23 at 11:30 a.m., the clean linen cart was stored in the supply closet next to two dirty barrels in a room on hall two hundred. During an observation and interview on 04/16/23 at 12:07 p.m., CNA E observed the clean linen cart was next to two barrels in the supply closet. CNA E lifted both barrel tops and verified dirty items were in each barrel. CNA E said the clean linen cart and barrels were stored in the supply closet when they were not being used on the halls. CNA E said dirty barrels should not be stored with clean linen because of cross contamination. During an observation and interview on 04/16/23 at 12:09 p.m., Housekeeper D came into the supply closet to count linen. Housekeeper D said that was where she would usually locate the clean linen cart when not on the hallway. Housekeeper D said in the laundry room she was aware clean and dirty should not be stored together because of cross contamination but did not think about it being the same in the supply closet. During an interview on 04/16/23 at 12:12 p.m., CNA C said she was new to the facility and did not know where to store clean linen and dirty barrels so she stored them together. CNA C confirmed the linen cart was next to two dirty barrels stored in the supply closet on hall two hundred. CNA C said staff members did not show her where to store linen and barrels and she did not ask. CNA C said she knew the linen cart should not be next to the dirty barrels because of the risk for cross contamination but did not think about it until surveyor questioned. During an observation and interview on 04/16/23 at 12:17 p.m., the ADON opened the supply closet and verified clean linen was next to two dirty barrels. The ADON said the charge nurses should ensure staff knows where to store clean linen but she was the overseer as the infection preventionist. The ADON said clean linen should not be stored next to dirty barrels because of cross contamination. During an interview on 04/19/23 at 10:49 a.m., the DON said clean linen and dirty barrels should not be stored together. The DON said the charge nurses were responsible to ensure staff was not storing clean with dirty. The DON said clean linen and barrels should be stored separately because of cross contamination or infection risk. During an interview on 04/19/23 at 11:13 a.m., the administrator said all staff should know not to store clean linen with dirty barrels. The administrator said dirty barrels were to be stored in the shower room when not used. The administrator said the ADON/DON were responsible to ensure staff knew where to store dirty barrels. The administrator said clean linen next to dirty barrels could lead to cross contamination. Record review of the facility policy titled, Infection Control, dated October 2018 indicated, This facility infection control policies and practice are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections. #1 the facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and to the public. #4 all personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. Record review of the facility policy titled, New Linen, Clean Linen and Soiled Linen Storage, dated 9/5/2017 indicated, Clean linen should be stored in a clean ventilated area. Soiled linen inside the facility should be placed in a soiled linen barrel with a lid . and should be stored in the soil utility room. 46928 3. Record review of Resident #6's face sheet, dated 04/17/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included local infection of the skin, atrial fibrillation (irregular heart rate), and heart failure (heart muscle does not pump blood as well as it should). Record review of Resident #6's quarterly MDS, dated [DATE], indicated she was usually understood and usually understood others. Resident #6 had a BIMS score of 9, which indicated she had moderate cognitive impairment. Resident #6 required extensive assistance with bed mobility, dressing, personal hygiene, and bathing. Resident #6 was totally dependent on transfers and toileting. The MDS indicated Resident #6 had 3 unstageable pressure injuries presenting as deep tissue injury and was receiving pressure ulcer/injury care treatment. Record review of Resident #6's comprehensive care plan, dated 3/22/23, indicated Resident #6 had stage 3 pressure ulcers to right leg and right heel with goals for the ulcers to remain free from infection and show signs of healing. The care plan interventions included to administer treatments as ordered and to monitor for effectiveness. Record review of Resident #6's order summary dated 4/17/23, indicated she had the following orders: *Cleanse right calf with normal saline/wound cleanser, pat dry, apply calcium alginate, cover with dry dressing daily and as needed. *Cleanse right heel with normal saline/wound cleanser, pat dry, apply xeroform, cover with dry dressing daily and as needed. During an observation and interview on 04/17/23 at 3:12 p.m., LVN A entered Resident #6's room to provide wound care to her right calf and heel. LVN A washed her hands and donned gloves. LVN A removed Resident #6's dressing from her right calf and heel. LVN A placed Resident #6's leg on the pillow with the open wounds touching the pillow. LVN A picked up Resident #6's leg off the pillow and the pillow was visibly soiled with blood from the wounds. LVN A proceeded to cleanse the wound with wound cleanser. After cleaning the wounds, LVN A placed Resident #6's leg back on top of the soiled pillow. LVN A picked up Resident #6's leg off the pillow and applied the dressing to her right heel. LVN A failed to ensure the wound stayed cleaned prior to applying the dressing. LVN A placed Resident #6's leg back on the soiled pillow to remove gloves and perform hand hygiene. LVN A put on gloves and picked up Resident #6's leg off the pillow and applied a clean dressing to the wound to her right calf. LVN A failed to cleanse the wound with wound cleanser prior to applying the clean dressing. LVN A said she was hired a week and half ago and her competency for performing wound care had not been completed. LVN A said Resident #6 was not able to hold her leg up during the wound care, and she did not think to ask someone for assistance. LVN A said not providing proper wound care placed Resident #6 at risk for infection. During an interview on 04/19/23 at 09:50 a.m., the ADON said she expected LVN A to have asked for assistance from an aide or a nurse in holding Resident #6's leg up when she provided wound care. The ADON said LVN A could have also had placed a clean barrier on top of the pillow. The ADON said she expected LVN A to have cleaned the wounds again prior to applying the clean dressing as the wounds were considered contaminated. The ADON said not cleaning the wound prior to completing the treatment caused Resident #6 to be at risk for infection. During an interview on 04/19/23 at 10:10 a.m., the DON said she expected LVN A to have had used a barrier between Resident #6's leg and the pillow or she should have had asked for someone for assistance in holding Resident #6's leg up. The DON said she expected LVN A to clean Resident #6's wounds before applying the clean dressing. The DON said not cleaning the wound again after it became contaminated placed Resident #6 at risk for infection. During an interview on 04/19/23 at 10:45 a.m., the administrator said she expected wound care to be done as per physician orders. The administrator said she expected LVN A to have asked for assistance when she provided wound care to Resident #6 and not cleaning the wound prior to applying the clean dressing placed Resident #6 at risk for infection. Record review of LVN A's Treatment Nurse Competency Check Off, dated 4/17/23, indicted skill being met. Record review the facility's treatment and nurse competency check off indicated .18. If any area was contaminated, start over . 4. Record review of Resident #3's face sheet, dated 04/20/23, indicated a [AGE] year-old male who admitted to the facility on [DATE], with diagnoses which included cerebral palsy (congenital disorder of movement, muscle tone, or posture), diabetes (condition that affects the way the body processes blood sugar), Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors), essential hypertension (high blood pressure). Record review of Resident #3's quarterly MDS assessment, dated 03/10/23, indicated he was usually understood and usually understood others. Resident #3 had a BIMS score of 15 which indicated he had intact cognition. Resident #3 required extensive assistance with bed mobility and dressing and was totally dependent on staff with transfers, toileting, and bathing. Resident #3 was always incontinent of bowel. Record review of Resident #3's comprehensive care plan, revised on 02/13/23, indicated he had an ADL self-care performance deficit related to paraplegic (paralysis of the legs and lower body). The care plan interventions included Resident #3 required assistance of 2 for toileting needs, especially bowel movements. During an observation and interview on 04/17/23 at 3:19 p.m., CNA K and CNA O entered Resident #3's room and provided incontinent care because he had a bowel movement. CNA K removed Resident #3's pants and placed them in the trash bag. CNA K removed her gloves and reapplied clean gloves. CNA K failed to perform hand hygiene in between glove changes. CNA K unfastened Resident #3's brief and obtained disposable wipes. CNA K cleaned Resident #3's perineal area. CNA K removed Resident #3's soiled brief and applied a clean brief. CNA K used the dirty gloves to apply barrier cream to Resident #3's buttocks and to apply the clean brief. CNA K removed her gloves and reapplied clean gloves. CNA K failed to perform hand hygiene after removing her dirty gloves. CNA K completed Resident #3's incontinent care, removed her gloves and performed hand hygiene. CNA K said she should have performed hand hygiene in between glove changes. CNA K said she should have changed her gloves after she cleaned Resident # 3's perineal area, before applying the barrier cream and the clean brief. CNA K said she was responsible for providing proper incontinent care. CNA K said not providing proper incontinent care placed Resident #3 at risk for infection. During an interview on 04/19/23 at 09:50 a.m., the ADON said she expected CNA K to change her gloves when going from dirty to clean and again when she applied the barrier cream to Resident #3. The ADON said CNA K should have performed hand hygiene between glove changes. She said not changing her gloves and not performing hand hygiene in between glove changes placed Resident #3 at risk for infection. During an interview on 04/19/23 at 10:10 a.m., the DON said she expected CNA K to have changed her gloves when going from dirty to clean and she should have performed hand hygiene in between gloves changes when she provided incontinent care to Resident #3. The DON said not changing her gloves or performing hand hygiene placed Resident #3 at risk for infection. The DON said she was responsible for ensuring the staff was providing proper incontinent care and following the infection control policy. During an interview on 04/19/23 at 10:45 a.m., the administrator said she expected staff to change their gloves when going from dirty to clean and perform hand hygiene in between glove changes. The administrator said not doing so was an infection control issue and placed Resident #3 at risk for infection. The administrator said the administrative nurses were responsible for ensuring nursing staff provided proper incontinent care and performed hand hygiene. Record review of CNA K's perineal care competency evaluation, dated 4/4/23, indicated skill being met. Record review of the facility's policy titled, Perineal Care, revised February 2018, indicated .The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition 10. remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly or use hand sanitizer. 12. Put on clean gloves and apply protective ointment if needed and clean brief . Record review of the facility's policy, titled Handwashing/Hand Hygiene, revised August 2019, indicated .This facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand rub containing at least 62 percent alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . m. after removing gloves .

Based on interview and record review the facility failed to immediately consult with the physician regarding a significant change in resident's condition for 1 of 3 residents sampled for change in condition. (Reident#1) The facility failed to immediately consult the resident's physician when Resident #1 experienced a change in condition in which he began to have involuntary jerking movements. The facility failed contact Resdient #1' the physician when NP orders on 01/06/23 for a UA were not followed, and on 01/10/23 the resident was sent to the hospital septic from a UTI. An Immediate Jeopardy (IJ) situation was identified on 02/03/23 at 1:30 p.m. While the IJ was removed on 02/04/23 at 5:22 p.m., the facility remained out of compliance at a scope of isolated with actual harm, due to the facility's need to evaluate the effectiveness of the corrective systems This failure could place residents at risk for not receiving adequate care and treatment, hospitalization and possible death. Findings included: Record review of Resident #1's face sheet indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His admitting diagnoses were depression, diabetes, obesity, anxiety, high blood pressure, and kidney disease. Resident #1 also had a diagnosis of benign prostatic hyperplasia (an age associated prostate gland enlargement tach can cause urination difficulty.) Record review of Resident #1's quarterly MDS dated [DATE] indicated he had intact cognition. The MDS indicated he was extensive assist with bed mobility, and transfer with the assistance of two people. The MDS indicated for toilet use the resident was totally dependent and required two-person physical assistance. Record review of Resident #1's care plan dated 12/28/22 indicated the resident had a problem of being incontinent of bladder. One of the interventions was monitor and document for signs and symptoms of UTI, pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in eating patterns. Record review of nursing progress note dated 1/6/23 indicated Resident #1 was alert, lying in bed with involuntary jerking movements of the BUE, unable to hold cell phone in his hand. He denied any pain or discomfort. His vital signs were within normal limits. The NP was notified an indicated a new order for a UA with culture and sensitivity if indicated. If the resident condition got worse to notify the NP. Resident #1 and his family were notified. Written by LVN A. Record review of a physician telephone order dated 01/06/23 at 7:06 p.m. indicated Resident #1 was to receive a UA with culture and sensitivity if indicated one time only until 1/8/2023. Record review of nursing progress note dated 01/10/23 at 7:05 a.m., indicated Resident #1 was lying in bed, hard to arose resident would open eyes briefly, but not answer questions that were asked, involuntary jerking movements noted to BUE. His blood pressure was 128/54, his pulse was 75, his temp was 97.3, pulse oximetry was 88 on CPAP, blood sugar was 389. He was sent to the emergency room . Written by LVN A. Record review of Resident #1's hospital physician progress notes dated 01/11/2023 indicated Resident #1 was a [AGE] year-old male who presented to the hospital on 01/10 23 with Sepsis (a life-threatening complication of an infection). He presented to the hospital with altered mental status and hypoxia (absence of enough oxygen in the tissues to sustain body functions). Resident #1's oxygen saturation in the 80s on a CPAP (Continuous Positive Airway Pressure) and revealed his creatinine was 1.5 (normal level 0.74-1.35 high level indicated kidney failure.) the potassium was 6.8. (Normal lever 3.6 to 5.2- potassium levels higher than 6.0 can be dangerous and required immediate treatment). He was encephalopathic (altered brain function) but arousable and able to maintain airway. The notes indicated the resident had acute respiratory failure with hypoxia secondary to volume overload status. Chronic kidney disease stage 3 now with worsening renal function with a plan for dialysis. Resident #1 had acute metabolic encephalopathy and sepsis with evidence of Leukocytosis (high white blood cell count), tachypnea (fast breathing) secondary to UTI. During an interview on 01/12/23 a 10:20 a.m. LVN A said she worked at the facility since 2004. She said on 01/06/23 Resident #1 had some jerking motions. She said CNA C called her to his room who said he was shaking and had a large BM. She said she assessed Resident #1 and his vital signs were normal around 3 p.m. and he appeared fine. In a later interview she said she had gone back into his room around 7:00 p.m. and he was shaking quite a bit and unable to hold his cell phone. LVN A said she called the NP and received an ordered for a UA with culture and sensitivity. She did not contact the physician. She said she did not attempt to collect the UA because she did not have time. She was off work over the weekend. She said she came back on to work on 01/09/23 and Resident #1 was fine. She did not attempt the UA on Monday, 01/09/23 because she did not have time. The LVN said on 1/9/23 Resident #1 did not eat his lunch. She said Resident #1 said it was the same thing and it was not what he wanted for lunch. On the morning of 01/10/23 she sent Resident #1 to the hospital because he was basically unresponsive and his O2 stat was low. She called the NP and family. In a later interview LVN A said the NP did not write any order for a Stat UA but all they had to do was call the lab for a weekend pickup. LVNA said she did not notify the NP the lab was not collected. During an interview on 01/12/23 at 10:55 a.m. Resident #1's family member said they received a call on 01/06/23 saying his Resident #1 had shaking movements and a UA was ordered. He said on 01/10/23 they received a call saying Resident #1 was sent to the Hospital. When they arrived at the hospital, they were told Resident #1 was septic from a UTI and need to be placed on dialysis. He said Resident #1 was in ICU, and he was still shaking. During an interview o 01/12/23 at 2:20 p.m. the DON said on 01/06/23 someone told her Resident #1 was having some issues. She saw LVN A coming out of his room and the nurse said Resident #1 was fine. The DON said she found out later during her investigation the LVN had contacted the NP and received an order on 01/06/23. The DON said the protocol was for the nurse to let the DON know of any changes. The DON said she had specifically asked LVN A to let her know of any changes with Resident #1, but she did not. The DON said the first time she was aware of the NP order for a UA was on 1/9/23. She said LVN A said the resident was still in need of a UA because it had not been completed. The DON said LVN A had not completed the UA and had not tried. The DON said after the VA Representative contacted the facility on 01/10/23 they began their investigation. The DON said she started in services on that day on 01/10/23 and was developing a plan of action for QA as part of their QA measures for correction. During a telephone interview on 01/12/23 at 3:50 p.m. the NP said she was not informed the Resident #1's UA was not completed. She said she should have been notified and was not. During a telephone interview on 01/24/22 at 8:09 a.m. Resident #1 said he was sick all weekend prior to going to the hospital. He did not remember anyone trying to collect urine from him during the weekend. He said sometimes he felt better than others, but he felt sick the whole weekend. Resident #1 said he did not remember what happen on the morning of 01/10/23, he was mostly out of it. During an interview on 02/02/23 at 2:26 p.m. the MD said he was not made aware Resident #1 had a change in condition and did not receive his UA until after he went to the hospital. He said the UA was requested because when an elderly person had any change in condition it was most frequently due to a UTI. The MD said he was not aware of any issues related to Resident #1 having prostate problems, there was no indication he had a blockage. The MD said Resident #1 had a multitude of complex problems. He said the nurse could have suggested to the NP the UA be Stat. The MD said apparently, the nurse did not convey any emergency to have the UA done quickly. He said either way they wanted it done sooner rather than later. The MD said if Resident #1 had a UTI and it seemed apparent that he did. His condition would only decompensate the longer they waited to provide treatment. The MD said he had some concerns that it was not done within a day or so. The MD said that was what they expect of an order for a UA. He said usually the UA results would come back in a few hours or the next day. The MD said he and DON talked and would do better communication in the future. He said they would make sure UAs are done timely. During an interview on 02/03/23 12:10 p.m. the DON said she just did a verbal counseling with LVN A and a one on one in service with her. The DON said with this company they do not have anything written in regard to an empoyee's disciplinary actions. She said she had done some in servicing on 01/10/23 regarding labs and change in condition. However, she did not have a current system in place to train all agency staff. Record review of the facility's Change in a Resident's Condition or Status Policy revised February 2021 indicated our community promptly notified the resident, their attending physician, and the resident representative of changes in the resident's medical condition and status. The nurse would notify the residents attending physician or physician on call when there was a significant change in the resident's physical, emotional, or mental condition. If there was the need to alter the resident treatment significantly. A refusal of treatment or medications two or more consecutive times. The nurse would record in the resident's medical record information related to changes in the resident's medical or mental condition or status. The Administrator, MDS nurse, DON, and ADON were notified on 02/03/23 at 1:30 p.m. an Immediate Jeopardy (IJ) situation was identified due to the above failures and an IJ template was provided. The facility plan of removal was accepted on 02/04/23 at 3:22 p.m. was as follows: [The facility failed to notify the Physician of failure to obtain ordered labs. The Physician was not notified that lab was not drawn, resulting in a COC that resulted in his hospitalization on [DATE]. Identify residents who could be affected All Residents have the potential to be affected. The Facility census on 1/6/23 was 43. An audit was initiated on 2/3/23 and will be completed on 2/4/23 to ensure there are no further labs that have not been drawn. DON/Designee initiated and completed a round on all current residents on 2/3/23 to determine if there are any changes in residents condition. All findings were reported to Physician and orders obtained and carried out as required. . In-Service conducted All nurses will receive education on carrying out Physicians orders, education on procedures for notifying Physicians when an order is not able to be carried out and education on Identification and reporting to Physicians any change in resident's condition using the INTERACT tools. It is not acceptable to notify NP of an acute. change of condition Nurse aides will be educated on the Stop and Watch tool to help identify early signs of condition change. Implementation Date of Changes In-servicing was initiated on 2/3/23 by the DON and will continue until it is completed by the DON/Designee on 2/4/23. Agency staff and staff on leave that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. . Involvement of Medical Director The Medical Director, [name] was notified about the immediate Jeopardy on 2/3/23. Involvement of QA QAPI will review and approve Plan of Removal on 2/4/23 Who is responsible for implementation of process? Administrator and DON (Director of Nursing).] On 02/04/23 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of the facility employee roster indicated they have 5 full time LVNs, one part time LVN and two weekend RNs and the ADON who was an LVN. They have 9 nurse's total. They had 7 CNAs. During an observation and interview on 02/04/23 at 3:39 p.m. the DON said she had a binder with a list of Agency staff, their discipline, and when they received the training. She said she would monitor what agency staff had been trained and prior to each agency staff beginning work they would receive training if they were not in the book. Observation of the book showed the training, each staff, a list of training they received. There was a list of 5 agency LVNs and two agency CNAs indicating they had been trained on labs, physician notification, identification of change in condition and physician notification. During interviews on 02/04/23 between 3:30p.m. and 5:15 p.m. three CNAs said they were educated on the Stop and Watch tool (a form used by aides to identify changes in a resident such as different symptoms, change in need for assistance, eating less, agitated, more confused or change in skin color.) to help identify early signs of condition change to the charge nurse. They said they are to fill out the form and give it to the nurse, so they have verification they told the nurse of the change in condition. They were told they could make a copy of the form and place it under department heads doors if they felt their concerns were not addressed. During interviews on 02/04/23 between 3:3 0p.m. and 5:15 p.m. were conducted with 3 facility LVNs and 1 RN and 2 agency LVNs that indicated they were knowledgeable on following physician orders, identification of resident change in condition. The nurses said they would follow guidelines for monitoring. They would monitor residents with possible UTIs for any symptoms. If a resident refused treatment, they would educate the resident on possible consequences and let the physician know of the resident status. The nurses were able to demonstrate through interviews their understanding of those policies, procedures, and in services. Record Review of a Resident record identified as needing a UA was reviewed and the facility put measures in place, such as notifying the physician, getting a timely UA. Detailed documentation of the resident condition was noted in the record to include the INTERACT assessment tool(an assessment form that is used to help nursing staff evaluate the resident for change in condition). The physician was notified of the lab results and the resident place on an antibiotic. With additional physician orders. On 02/04/23 at 5:42 p.m. the Administrator, DON, and ADON were informed the IJ was removed; however, the facility remained out of compliance at level of actual harm with a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems that were put in place.

Based on observation, interview, and record review the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 3 residents reviewed for care and services. (Resident #1) *The facility did not complete a provider ordered UA on 1/6/23 until 1/10/23. The resident was admitted to the hospital on the morning of 1/10/23 with a diagnosis of sepsis due to UTI. *The facility failed to increase monitoring and provide accurate documentation of attempted UA collection. *The facility failed to identify signs and symptoms of a UTI. *The facility failed to notify the physician timely when they did not compete the UA. An Immediate Jeopardy (IJ) situation was identified on 02/03/23 at 1:30 p.m. While the IJ was removed on 02/04/23 at 5:22 p.m., the facility remained out of compliance at actual harm with a scope identified isolated, due to the facility's need to evaluate the effectiveness of the corrective systems This failure could place residents at risk for not receiving adequate care and treatment to prevent hospitalization and possible death. Findings included: Record review of Resident #1's face sheet indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His admitting diagnoses were depression, diabetes, obesity, anxiety, high blood pressure, and kidney disease. Resident #1 also had a diagnosis of benign prostatic hyperplasia(an age associated prostate gland enlargement tach can cause urination difficulty.) Record review of Resident #1's quarterly MDS dated [DATE] indicated he had intact cognition. The MDS indicated he was extensive assist with bed mobility, and transfer with the assistance of two people. The MDS indicated for toilet use the resident was totally dependent and required two-person physical assistance. Record review of Resident #1's care plan dated 12/28/22 indicated the resident had a problem of being incontinent of bladder. One of the interventions was monitor and document for signs and symptoms of UTI, pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in eating patterns. Record review of nursing progress note dated 1/6/23 Resident #1 was alert, lying in bed with involuntary jerking movements of the BUE, unable to hold cell phone in his hand. He denied any pain or discomfort. His vital signs were within normal limits. The NP was notified an indicated a new order for a UA with culture and sensitivity if indicated. If the resident condition got worse to notify the NP. Resident #1 and his family were notified. Written by LVN A. Record review of a physician telephone order dated 01/06/23 at 7:06 p.m. indicated Resident #1 was to receive a UA with culture and sensitivity if indicated one time only until 1/8/2023. Record review of the facility 24-hour report dated 01/06/23 indicated the following: *Evening shift: Resident #1 had involuntary jerking of the bilateral upper extremities his vital signs were within normal limits; the NP was notified a new order for a UA and notify the NP if the condition worsened. *Night shift: there was no mention of the UA or the resident's involuntary movement. Record review of nursing progress note dated 01/07/23 at 12:21 p.m. indicated Resident #1 was in bed with family at bedside. His respirations were even and unlabored. He denied pain and voiced no concerns. There was no involuntary jerking noted at this time. Vital signs were within normal limits and no mental status change or behaviors noted. Signed by ADON Record review of the 24-hour report dated 01/07/23 indicated the following: *Resident #1 needed a UA, call the lab for pick up( at the top of the page). *Day shift: was blank for Resident #1. *Evening shift: continue jerking monitor for jerking bilateral upper extremities. *Night shift: no involuntary jerking this shift, would continue to monitor BUE for jerking. There was no documentaion on the 24-hr report that indicated a UA was attempted. Record review of the facilities 24- hour report dated 01/08/23 indicated the following: on the *Day shift: Resident #1 needed a UA. No involuntary jerking noted this shift. *Evening shift: UA needed, no involuntary jerking this shift. *night shift: stable. Record review of the 24-hour report dated 01/09/23 indicated the following: *Day shift: Resident #1 had no change. *Night shift: gave bath and clean clothes; he left; was to leave the facility at 4:30 a.m.; UA needed. Record review of a nursing progress note dated 01/10/23 at 6:22 a.m. indicated the UA was collected. Written by an agency LVN B. Record review of nursing progress note dated 01/10/23 at 7:05 a.m., said Resident #1 was lying in bed, hard to arose resident would open eyes briefly, but not answer questions that were asked, involuntary jerking movements noted to BUE. His blood pressure was 128/54, his pulse was 75, his temp was 97.3, pulse oximetry was 88 on CPAP, blood sugar was 389. He was sent to the emergency room . Written by LVN A. Record review of nursing progress note created 1/10/23 at 8:23 a.m. titled late entry indicated on 01/9/23 at 11:39 a.m. Resident #1 was resting quietly in bed, he refused his lunch, with no involuntary movements to his BUE. His vital were within normal limits, no pain or distress noted at this time. Written by LVN A. Record review of nursing progress note created 01/10/23 at 11:24 a.m. titled late entry indicated on 1/6/23 at 9:00 p.m. Resident #1 had new order noted for collection of UA. An attempt was made was made but no results. Will continue to monitor and retry. Signed by the ADON. Record Review of nursing progress note created 01/10/23 at 3:52 p.m. titled late entry dated 1/7/23 at 12:20 p.m. indicated attempted to collect a UA from Resident #1 but was unsuccessful. The resident attempted to give a sample without being catharized at his request. Would continue to monitor. Written by ADON. Record review of nursing progress note created 01/10/23 at 3:49 p.m. titled late entry indicated on 01/08/23 at 11:42 a.m. Resident #1 was in bed with family at the bed side. He denied any problems at that time. He voiced no concerns. An attempt was made to collect the UA earlier in the shift but failed. The resident was requesting not to be catharized at this time, he said he would try to urinate on his own. Will continue to monitor. Signed by the ADON. Record review of Resident #1's hospital physician progress notes dated 01/11/2023 indicated Resident #1 was a [AGE] year-old male who presented to the hospital on 01/10 23 with Sepsis (a life-threatening complication of an infection). He presented to the hospital with altered mental status and hypoxia (absence of enough oxygen in the tissues to sustain body functions). Resident #1's oxygen saturation in the 80s on a CPAP (Continuous Positive Airway Pressure) and revealed his creatinine was 1.5 (normal level 0.74-1.35 high level indicated kidney failure.)the potassium was 6.8. (Normal lever 3.6 to 5.2- potassium levels higher than 6.0 can be dangerous and required immediate treatment). He was encephalopathic (altered brain function) but arousable and able to maintain airway. The notes indicated the resident had acute respiratory failure with hypoxia secondary to volume overload status. Chronic kidney disease stage 3 now with worsening renal function with a plan for dialysis. Resident #1 had acute metabolic encephalopathy and sepsis with evidence of Leukocytosis (high white blood cell count), tachypnea (fast breathing) secondary to UTI. Record review of the facility Provider Investigation Report dated 01/10/22 indicated the following: Investigation: On 01/06/23 the administrator informed the DON Resident #1 needed to have a COVID test because he had diarrhea like symptoms. At 6:00 p.m. the DON asked [ LVN A] about the resident and she said Resident #1 was fine. [ LVN A] was informed to make sure to contact the DON if there was any change in Resident #1's condition. A chart review indicated [ LVN A] contacted the NP on 01/06/23 at 7:00 p.m. and received a telephone order for a UA due to involuntary jerking movements. The LVN did not call the DON but waited until 01/09/23 to inform the DON of the change of condition and the new order for the UA. From1/6/23-1/8/23 the ADON checked on Resident #1 and attempted to obtain a urine sample per her report, but the resident was unable to give the sample and unwilling to have a straight catheter per her report. On 01/08/23 the DON went to the facility to provide wound care to Resident #1. He was in good spirits made no complaints and was in no distress. He asked for a sandwich after the treatment was competed. There were no jerking movements or abnormalities visible. On 01/09/23 during clinical meeting [ LVN A] reported there was a UA that needed to be collected on Resident #1. LVN A told the DON she received the order on 01/06/23 but Resident #1 was acting normal today. The DON was told [ LVN A] to contact the NP and tell her Resident #1 was doing okay. LVN A was told to ask the NP if Resident #1 still needed the UA or did it need to be discontinued. There was no documentation that the LVN contacted the NP as she was told to obtain the UA. On 01/10/23 at 6:22 a.m. the UA was finally collected by an agency nurse. On 01/10/23 at 7:45 a.m. Resident #1 was sent to the emergency room with altered mental status. On 01/10/23 at 2:00 PM the NP said her rationale for ordering the UA was Resident #1 had previously experienced jerking movements and the jerking movements were related a UTI. However, the UA had not been ordered as stat. The report indicated education was provided on UTI's and UA's which indicated when a nurse received the order for the UA. They must immediately contact the DON and attempt the same shift to obtain the urine sample. the nurse must not pass the order or the next shift hoping it will get done. Delaying care for possible infection can lead to complications such as sepsis. The plan of correction for the investigation was the DON would write LVN A up for failure to obtain the UA order. By her own admission she did not attempt to get the sample on 01/06/23 or 01/09/23[ LVN A] failure to communicate the change of condition and new order for UA immediately to the DON also delayed patient care. In the future the nurse who received the order would be responsible for obtaining the urine sample. Nurses must no longer pass the order to the next shift. The nurses should also utilize urine dipsticks per physician standard order while waiting for UA to return for quick results and contact the physician with the results. Record review of an in service dated 01/10/23 at 4:30 p.m. indicated nurses were trained on Education on UTI's and UA's, Change in Condition and Documentation, and Labs. The in service on Labs indicated, When we obtained an order for a UA or any other type of labs. You need to notify the DON by phone right away and family members. When trying to get a UA sample and not able to obtain it. Make sure you put a progress note about how many times you tried and the reason of why you were not able to obtain the sample. (signed by 7 nurses to include LVN A.) During an interview on 01/12/23 a 10:20 a.m. LVN A said she worked at the facility since 2004. She said on 01/06/23 Resident #1 had some jerking motions. She said CNA C called her to his room who said he was shaking and had a large BM. She said she assessed Resident #1 and his vital signs were normal around 3 p.m. and he appeared fine. She said she had gone back into his room around 7:00 p.m. and he was shaking quite a bit and unable to hold his cell phone. LVN A said she called the NP and received an ordered for a UA with culture and sensitivity. She did not attempt to collect the UA because she did not have time. She was off work over the weekend. She said she came back on to work on 01/09/23 and Resident #1 was fine. She did not attempt the UA on that 01/09/23 because she did not have time. The LVN said on 1/9/23 Resident #1 had not eaten his lunch. She said her said it was the same thing and it was not what he wanted. On the morning of 01/10/23 she sent Resident #1 to the hospital because he was basically unresponsive and his O2 stat was low. During an interview on 01/12/23 at 10:55 a.m. Resident #1's family member said they received a call on 01/06/23 saying his Resident #1 had shaking movements and a UA was ordered. He said on 01/10/23they received a call saying Resident #1 was sent to the Hospital. When they arrived at the hospital, they were told Resident #1 was septic from a UTI and need to be placed on dialysis. He said he was in ICU, and he was still shaking. During an interview on 01/12/23 at 11:30 a.m. CNA C said she went into Resident #1's room around 3 or 4 p.m. on Friday 01/06/23 to give him a bath. She said his eyes were rolled back and he was shaking. She got the assistance of CNA D to help her. Resident #1 had an extra-large BM. She told LVN A, and she came and assessed Resident #1. Resident #1 said he did not feel well. She said they finished cleaning him up and she left for the day. CNA C said she was off the weekend. During an interview on 01/12/23 at 2:00 p.m. the administrator said she had called an intake into the state agency regarding Resident #1. She said on 01/10/23 a VA Representative had informed her the facility had failed to notify the physician regarding Resident #1's change in condition. She said she felt an allegation of neglect had been made. She called it into the state and started an investigation into the incident. The Administrator said they did a review of Resident #1's record and started in servicing staff. The DON had completed in services on 01/10/23. During an interview o 01/12/23 at 2:20 p.m. the DON said on 01/06/23 someone told her Resident #1 was having some issues. She saw LVN A coming out of his room and the nurse said Resident #1 was fine. The DON said she found out later during her investigation the LVN had contacted the NP and received an order on 01/06/23. The DON said the protocol was for the nurse to let the DON know of any changes. The DON said she had specifically asked LVN A to let her know of any changes with Resident #1, but she did not. The DON said the first time she was aware of the NP order for a UA was on 1/9/23. She said LVN A said the resident was still in need of a UA because it had not been completed. The DON said LVN A had not completed the UA and had not tried. The DON said after the VA Representative contacted the facility on 01/10/23 they began their investigation. The DON said she started in services on that day and was developing a plan of action for QA as part of their QA measures for correction. During an interview on 01/12/23 at 2:55 p.m. the ADON said she worked Saturday, 01/07 23 and Sunday, 01/08/23 as the floor nurse. The ADON said she wrote late entry progress notes on Resident #1 because she did not have enough time to write during her shift. She could not say why the notes were written two days later; on the day the resident went to the hospital. She said during the weekend Resident #1 was fine and had no issues that she noted. The ADON said on 01/07/23 she tried to get the urine sample that morning and Resident #1 was not able to produce any urine. She asked if he wanted to do the straight catheter and he said no, he wanted to try and go in his own. She said later he had family and did not want to be bothered. She said he was happy because a friend had come to visit that he had not seen in a while. The ADON said she did not know how Resident #1 ate that day, but the family brought in food. The ADON on 01/08/23 Resident #1 had no complaints or issues. The ADON said she was in serviced on labs and physician notification. During a telephone interview on 01/12/23 at 3: 30 p.m. CNA E said on 01/07/23 Resident #1 said he was not feeling his normal self. She said she knew he did not eat breakfast very well. She had to help CNA F cleanup the bed. He spilled his cereal all over the bed due to his shaking. She said as the day went on, he appeared to feel better. CNA E said she heard CNA F tell the LVN H Resident #1 was not feeling well. She he was not her resident and she only helped out when needed because he was two person. During a telephone interview on 01/12/23 at 3:35 p.m. CNA F said she recalled Resident #1 was shaking and sick all day on 01/07/23. She said he did not really eat breakfast and was shaking badly. He spilled his cereal all over the bed due to his shaking. CNA F said they had to clean up the bed. Resident #1 requested a waited spoon to eat his lunch but even with that he did not eat well. She said she had reported to the nurse LVN H he was shaking and not feeling well. LVN H said okay and acted like she already knew the resident was not feeling well. CNA F said she had changed him through the day, and he did appear to be a little better as the day progressed. His family was with him most of the day and he did okay. She said she did not work on 01/08/23. During a telephone interview on 01/12/23 at 3:40 p.m. CNA G said on the morning of 01/07/23 Resident #1 was hard to arose. She said he did not have on his CPAP so that may have been the reason. However, she said after they got him awake, he did not have any other issues that she noted. She was the medication aide and did not really provide him any care. During a telephone interview on 01/12/23 at 3:50 p.m. the NP said she was not informed the Resident #1's UA was not completed. She said she should have been notified and was not. During an interview on 01/12/23 at 4:00 p.m. CNA D said on the evening of 01/06/23 he assisted CNA C with providing care to Resident #1. He said Resident #1 was shaking and CNA C went and got the nurse. He said by the time LVN A got there Resident #1 appeared better. He said the resident did shake some during the night. Resident #1 did not know when he had urinated but knew when he was wet. CNA D said he had gone back into his room at least two times during his shift. He said Resident #1 did not complain of anything and he changed him at least once maybe twice during his shift. CNA D said Resident #1 drank a lot of water and Dr. Peppers and voided frequently. He said Resident #1 did not have another BM, but he was incontinent of urine. During an interview on 01/17/23 at 10:30 a.m. the ADON said the UA was not collected on the weekend. It was ordered on Friday and the lab does not pick up on weekends. The ADON said she had worked that weekend and had not called the doctor because Resident #1 was doing fine. During an interview on 01/07/23 at 11:26 a.m. CNA C said she was out on Monday, 01/09/23. She had come in early on 01/10/23 to ride to another city for an appointment with Resident #1. She said on that morning he was mostly unresponsive. She helped to clean him up and they sent him to the hospital. During a telephone interview on 01/24/22 at 8:09 a.m. Resident #1 said he was sick all weekend prior to going to the hospital. He did not remember anyone trying to collect urine from him during the weekend. He said sometimes he felt better than others, but he felt sick the whole weekend. Resident #1 said he did not remember what happen on the morning of 01/10/23, he was mostly out of it. During an interview on 02/02/23 at 12:35 p.m. the DON said she was not aware Resident #1 had an order for a UA until Monday, 01/09/23. So, she was not aware of Resident #1 needed a UA. The DON said because she was unaware there was an order for the UA, she did not put any interventions in place. She was also not aware the UA was not completed for the same reason. The DON said she started to work in October 2022. She was not aware Resident #1 had issues with shaking related to a UA in the past. During interview on 02/02/23 at 12:50 p.m. the ADON said she did not get an order to monitor Resident #1 more closely. She worked as an aide one day over the weekend. She said Resident #1 would pull the light to be changed and did not appear to have a change in his urination patterns. She said the problem was by the time they got to the room he had already gone. The ADON said he was on blood pressure monitoring three times a day. They did not do anything else in regard to monitoring his behaviors. He seemed fine. She did not note any shaking and he did not complain. She said he was not a complainer. The ADON said she worked as an aide on 01/08/23, and when she went to his room, he was already wet. The ADON she tried to try and get the UA sample. She said Resident #1 refused an in and out cath. The ADON said she started working at the facility in October 2022. She was not aware Resident #1 had issues with shaking related to a UA in the past. The ADON said she was aware of the signs of a UTI in the elderly. During an interview on 02/02/23 at 1:30 p.m. agency LVN I said this was her third time working at the facility. When she first came she was given a brief overview of the nurses station. However she had not received any recent in service about labs or UAs. During aa interview on 02/02/23 at 1:47 p.m. LVN A said the NP did not write any order for a Stat UA but all they had to do was call the lab for a weekend pickup. LVNA said she did not notify the NP the lab was not collected. During an interview on 02/02/23 at 2:26 p.m. the MD said he was not made aware Resident #1 did not receive his UA until after he went to the hospital. He said the UA was requested because when an elderly person had any change in condition it is most frequently due to a UTI. The MD said he was not aware of any issues related to Resident #1 having prostate problems, there was no indication he had a blockage. The MD said Resident #1 had a multitude of complex problems . He said the nurse could have suggested to the NP the UA be Stat. The MD said apparently, the nurse did not convey any emergency to have the UA done quickly. He said either way they wanted it done sooner rather than later. The MD said if Resident #1 had a UTI and it seemed apparent, he did his condition would only decompensate the longer they waited to provide treatment. He said he had some concerns that it was not done within a day or so. The MD said that is what they expect of an order for a UA. He said usually a UA results will come back in a few hours or the next day. The MD said he and DON had talked and would do better communication in the future and make sure UAs are done timely. During a telephone interview on 2/2/23 at 2:37 p.m. the lab technician at the Laboratory company the facility utilized, said the UA's do not have to be Stat on the weekend. All the facility needed to do was call and they would pick them up. Record Review of the ADON's time sheet from 01/5/23 through 1/9/23 indicated that she was not at work on 01/06/23 at 9 p.m. ( ADON wrote a late entry note for that time.) During an interview on 2/2/23 at 2:50 p.m. with the HR Director and the ADON. The HR Director said the ADON clocked out on Friday, 01/06/23 at 6:28a.m. The HR Director said she did not return to work again until Saturday, 01/07/23 at 8:06 a.m. She said the ADON worked until 9:50 p.m. that day. The HR Director said on Sunday, 01/08/23 the ADON clocked in at 8:00 a.m., left for lunch from 2:30 p.m. to 3:30 p.m., clocked out at 9:06 p.m., and clocked back in at 10 23 p.m. to 11:44 p.m. The ADON said the time sheet could not be right, she worked during the time the nurses note was written. The HR Director said the pay period ended on 01/15/23 and missed punched needed to have been submitted by 01/16/23. The pay checks went out on 01/25/23 and she had no complaints about the ADON's check not being correct. The ADON continued to insist she had worked on Friday night 01/06/23. During an interview on 02/03/23 at 10:26 a.m. the ADON said she was not at the facility on Friday 01/06/23 on that night at 9:00 p.m. She said she was mistaken. The ADON said when she wrote the note, she was trying to put it in for Saturday 01/07/23. The ADON said at that time they had 3 shifts but recently switched to 12-hour shifts. She said she worked Saturday 6-2 charge nurse- from 3 to 10 as a medication aide. She said on Sunday she was CNA for first shift. The ADON said she was a CNA for first three hours on the second shift. She said she did not know why she was the only nurse that charted on Resident #1 failed attempts to get the UA. The ADON said Resident #1 did not like to be moved but he did not complain. During an interview on 2/3/23 at 11:45 a.m. LVN/treatment nurse said she was in-service on change in condition, when to call the DON and physician. She said they were to make sure to get labs timely. If unable to get a lab let the physician know and document attempts. During an interview on 02/03/23 12: 10 p.m. DON said she just did a verbal counseling with LVN A and a one on one in service with her. The DON said with this company do not have anything written. She said she had done some in servicing on 01/10/23 regarding labs and change in condition. However, she did not have a current system in place to train all agency staff. During a telephone interview on 2/3/23 at 12:22 p.m. LVN H said she remembered LVN A told her during report on 1/6/23 that Resident #1 was doing some jerking and needed a UA. She said she said not noticed any kind of jerking when she observed Resident #1. LVN H said she did not get the UA during her shift. She said when she got to Resident #1's room his brief was wet. LVN H said there was a note on the 24-hour report about getting the UA. LVN H said she could not remember if she had written a note regarding Resident #1 condition or failed attempt to obtain the UA or not. She said she really did not remember that incident well. LVN H said she received an in services regarding change in condition, and labs. LVN H said she would not have done anything any different with Resident #1. She said she let the next shift know she was unable to get the UA. This was determined to be an Immediate Jeopardy (IJ) in the area of Quality of Care on 02/03/23 at 1:30 p.m. The facility Administrator, MDS nurse, DON, and ADON were notified. The Administrator was provided with the IJ template on 02/03/23 at 1:30 p.m. The facility plan of removal was accepted on 02/04/23 at 3:22 p.m. was as follows. [The facility failed to provide timely laboratory services as ordered by the Physician on 1 Resident on 1/6/23. The Physician was not notified that lab was not drawn, resulting in a COC that resulted in his hospitalization on [DATE]. Identify residents who could be affected All Residents have the potential to be affected. The Facility census on 1/6/23 was 43. An audit was initiated on 2/3/23 and will be completed on 2/4/23 to ensure there are no further labs that have not been drawn. DON/Designee initiated and completed a round on all current residents on 2/3/23 to determine if there are any changes in residents' condition. All findings were reported to Physician and orders obtained and carried out as required. In-Service conducted All nurses will receive education on Following Physicians orders, education on procedures for notifying Physicians when an order is not able to be carried out and education on Identification and reporting to Physician any change in resident's condition using the INTERACT tools. Following Physician notification and the severity of the condition nurses will follow Physicians guidance for monitoring with a minimum of daily documentation as it relates to the change of condition and vital signs. In-servicing will be completed by DON/Designee. For residents with a suspected UTI monitoring each shift will consist of urinary output, change in mentation, flank pain and odor and color. In-servicing will be completed by DON/Designee. If a resident refuses treatment or catheterization for a UA they will be educated on the risks of not following Physician orders by the charge nurse and the physician will be notified. Nurse aides will be educated on the Stop and Watch tool to help identify early signs of condition change by the DON/Designee. Implementation Date of Changes In-servicing was initiated on 2/3/23 and will be completed by 2/4/23 Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. . Involvement of Medical Director The Medical Director, [name] was notified about the immediate Jeopardy on 2/3/23. Involvement of QA QAPI will review and approve Plan of Removal on 2/4/23 Who is responsible for implementation of process? Administrator and DON (Director of Nursing).] On 02/04/23 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of the facility employee roster indicated they have 5 full time LVNs, one part time LVN and two weekend RNs and the ADON who is an LVN. They have 9 nurses total. They had 7 CNAs. During an observation and interview on 02/04/23 at 3: 39 p.m. DON said she had a binder with a list of Agency staff, their discipline and when they received the training. She said she would monitor what agency staff had been trained and prior to each agency staff beginning work they would receive training if they were not in the book. Observation of the book showed the training a list of staff. There was a list of 5 agency LVNs and two agency CNAs indicating they had been trained on labs, physician notification, identification of change in condition and physician notification. During interviews on 02/04/23 between 3:30p.m. and 5:15 p.m. three CNAs said they were educated on the Stop and Watch tool (a form used by aides to identify changes in a resident such as different symptoms, change in need for assistance, eating less, agitated, more confused or change in skin color.) to help identify early signs of condition change to the charge nurse. They said they are to fill out the form and give it to the nurse, so they have verification they told the nurse of the change in condition. They were told they could make a copy of the form and place it under department heads doors if they felt their concerns were not addressed. During interviews on 02/04/23 between 3:3 0p.m. and 5:15 p.m. were conducted with 3 facility LVNs and 1 RN and 2 agency LVNs that indicated they were knowledgeable on following physician orders, identification of resident change in condition. The nurses said they would follow guidelines for monitoring. They would monitor residents with possible UTIs for any symptoms. If a resident refused treatment, they would educate the resident on possible consequences and let the physician know of the resident status. The nurses were able to demonstrate through interviews their understanding of those policies, procedures, and in services. Record Review of a Resident record identified as needing a UA was reviewed and the facility put measures in place, such as notifying the physician, getting a timely UA. Detailed documentation of the resident condition was noted in the record to include the INTERACT assessment tool( an assessment form that is used to help nursing staff evaluate the resident for change in condition). The physician was notified of the lab results and the resident place on an antibiotic. With additional physician orders. On 02/04/23 at 5:42 p.m. the Administrator, DON, and ADON were informed the IJ was removed; however, the facility remained out of compliance at level of actual harm with a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems that were put in place.

Based on interview and record review the facility failed to obtain timely laboratory services to meet the needs of 1 of 2 residents reviewed for laboratory services (Resident #1.) The facility failed to obtain an UA as ordered. Resident #1 did not receive a timely UA and was hospitalized due to sepsis. An Immediate Jeopardy (IJ) situation was identified on 02/03/23 at 1:30 p.m. While the IJ was removed on 02/04/23 at 5:22 p.m., the facility remained out of compliance at actual harm with a scope identified as isolated, due to the facility's need to evaluate the effectiveness of the corrective systems This failure could place residents at risk for a delay in identifying or diagnosing medical issues, hospitalization and possible death. Findings Included. Record review of Resident #1's face sheet indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His admitting diagnoses were depression diabetes, obesity, anxiety, high blood pressure, and kidney disease. Resident #1 also had a diagnosis of benign prostatic hyperplasia(an age associated prostate gland enlargement tach can cause urination difficulty.) Record review of Resident #1's quarterly MDS dated [DATE] indicated he had intact cognition. The MDS indicated he was extensive assist with bed mobility, and transfer with the assistance of two people. Record review of Resident #1's care plan Indicated the resident had a problem of being incontinent of bladder. One of the interventions was monitor and document for signs and symptoms of UTI, pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in eating patterns. Record review of nursing progress note dated 1/6/22 Resident #1 was alert, lying in bed with involuntary jerking movements of the BUE, unable to hold cell phone in his hand. He denied any pain or discomfort. His vital signs were within normal limits. The NP was notified an indicated a new order for a UA with culture and sensitivity if indicated. If the resident condition got worse to notify the NP. Resident #1 and his family were notified. Written by LVN A. Record review of a physician telephone order dated 01/06/23 at 7:06 PM indicated resident number one was to receive a UA with culture and sensitivity if indicated one time only until 1/8/2023. Record review of a nursing progress note dated 01/10/23 at 6:22 a.m. indicated the UA was collected. The note was signed by an agency LVN B. Record review of nursing progress note dated 01/10/23 at 7:05 a.m. said Resident #1 was lying in bed, hard to arose resident would open eyes briefly, but not answer questions that were asked, involuntary jerking movements noted to BUE. His blood pressure was 128/54, his pulse was 75, his temp was 97.3, pulse oximetry was 88 on CPAP, blood sugar was 389. He was sent to the emergency room . Written by LVN A. Record review of resident #1 hospital physician progress notes dated 1/11/2023 indicated Resident #1 was a [AGE] year-old male who presented to the hospital on 01/10 23 with Sepsis. (a life threatening complication of an infection) He presented to the hospital with altered mental status and hypoxia. (absence of enough oxygen in the tissues to sustain body functions.) oxygen saturation in the 80s on a CPAP (Continuous Positive Airway Pressure) and revealed his creatinine was 1.5 (normal level 0.74-1.35 high level indicated kidney failure.)the potassium was 6.8. (normal lever 3.6 to 5.2- potassium levels higher than 6.0 can be dangerous and required immediate treatment) He was encephalopathic (altered brain function) but arousable and able to maintain airway. The notes indicated the resident had acute respiratory failure with hypoxia secondary to volume overload status. chronic kidney disease stage 3 now with worsening renal function with a plan for dialysis. Resident #1 had acute metabolic encephalopathy and sepsis with evidence of Leukocytosis (high white blood cell count), tachypnea (fast breathing) secondary to UTI. Record Review of a report written by the DON regarding an investigation of why Resident #1'a labs were not completed. Stated, On 01/10/23 at 6:22 a.m. the UA was finally collected by an agency nurse. On 01/10/23 at 7:45 a.m. Resident #1 was sent to the emergency room with altered mental status. On 01/10/23 at 2:00 PM the NP said her rationale for ordering the UA was Resident #1 had previously experienced jerking movements and the jerking movements were related a UTI. However, the UA had not been ordered as stat. The report indicated education was provided on UTI's and UA's which indicated when a nurse received the order for the UA. They must immediately contact the DON and attempt the same shift to obtain the urine sample. the nurse must not pass the order or the next shift hoping it will get done. Delaying care for possible infection can lead to complications such as sepsis. The plan of correction for the investigation was the DON would write the LVN A up for failure to obtain the UA order. By her own admission she did not attempt to get the sample on 01/06/23 or 01/09/23. LVN A's failure to communicate the change of condition and new order for UA immediately to the DON also delayed patient care. In the future the nurse who received the order would be responsible for obtaining the urine sample. Nurses must no longer pass the order to the next shift. The nurses should also utilize urine dipsticks per MD standard order while waiting for UA to return for quick results and contact the physician with the results. During an interview on 01/12/23 a 10:20 a.m. LVN A said she worked at the facility since 2004. She said on 01/06/23 Resident #1had some jerking motions. She said CNA C called her to his room. She said she assessed Resident #1 and his vital signs were normal. He was shaking quite a bit and unable to hold his cell phone. LVN A said she called the NP and received an ordered for a UA with culture and sensitivity. She did not attempt to collect the UA. She was off work over the weekend. She said she came back on to work on 01/09/23 and Resident #1 was fine. She did not attempt to obtain a UA on 01/09/23. On the morning of 01/10/23 she sent Resident #1 to the hospital because he was basically unresponsive and his O2 stat was low. She called the NP and family. During an interview o 01/12/23 at 2:20 p.m. the DON said on 01/06/23 LVN A contacted the NP and received an order on 01/06/23. The DON said the first time she was aware of the NP order for a UA was on 1/9/23. The LVN said the resident was still in need of a UA because it had not been completed. The DON said LVN A had not completed the UA and had not tried. The DON said after the VA Representative contacted the facility on 01/10/23 they began their investigation. The DON said she started in services on that day and was developing a plan of action for QA as part of their QA measures for correction. During a telephone interview on 01/24/22 at 8:09 a.m. Resident #1 said he was sick all weekend prior to going to the hospital. He did not remember anyone trying to collect urine from him during the weekend. He said sometimes he felt better than others, but he felt sick the whole weekend. Resident #1 said he did not remember what happen on the morning of 01/10/23, he was mostly out of it. Record review of an in service dated 01/10/23 at 4:30 p.m. indicated nurses were trained on Education on UTI's and UA's, Change in Condition and Documentation, and Labs. The in service on Labs indicated, When we obtained an order for a UA or any other type of labs. You need to notify the DON by phone right away and family members. When trying to get a UA sample and not able to obtain it. Make sure you put a progress note about how many times you tried and the reason of why you were not able to obtain the sample. (signed by 7 nurses to include LVN A.) Record Review of the facility weekend lab policy indicated the company provided daily route services Monday through Friday. No routine draws will be collected on weekends to schedule of necessary Saturday and Sunday draws must be called into the laboratory. UA-C/s are not considered stat test. If a resident is in distress and or in a critical state, we will pick up a UA while we are there drawing blood on the weekend. Record review of the facility Lab and Diagnostic Test Results policy late revised November 2018. Indicated the physician will identify in order diagnostic and lab testing based on the residence diagnostic and monitoring needs. the team will process test requisitions and arrange for test. the laboratory, diagnostic radiology provider, or other testing sources will report test results to the facility. During an interview on 020/2/23 at 1:30 p.m. agency LVN I said this was her third time working at the facility. When she first came, she was given a brief overview of the nurses station. However, she had not received any recent in service about labs or UAs. During an interview on 02/02/23 at 2:26 p.m. 2:26 p.m. the MD said he was not made aware Resident #1 did not receive his UA until after he went to the hospital. He said the UA was requested because when an elderly person had any change in condition it is most frequently due to a UTI. The MD said he was not aware of any issues related to Resident #1 having prostate problems, there was no indication he had a blockage. The MD said Resident #1 had a multitude of complex problems. He said the nurse could have suggested to the NP the UA be Stat. The MD said apparently, the nurse did not convey any emergency to have the UA done quickly. He said either way they wanted it done sooner rather than later. The MD said if Resident #1 had a UTI and it seemed apparent, he did his condition would only decompensate the longer they waited to provide treatment. He said he had some concerns that it was not done within a day or so. The MD said that is what they expect of an order for a UA. He said usually a UA results will come back in a few hours or the next day. The MD said he and DON had talked and would do better communication in the future and make sure UAs are done timely. During a telephone interview on 2/2/23 at 2:37 p.m. the lab technician at the Laboratory company the facility utilized, said the UA's do not have to be Stat on the weekend. All the facility needed to do was call and they would pick them up. During an interview on 02/03/23 12: 10 p.m. DON said she just did a verbal counseling with LVN A and a one on one in service with her. The DON said with this company do not have anything written. She said she had done some in servicing on 01/10/23 about labs and change in condition. However, she did not have a current system in place to train all agency staff. During a telephone interview on 2/3/23 at 12:22 p.m. LVN H said she remembered LVN A told her during report on 1/6/23 that Resident #1 was doing some jerking and need a UA. She said she said not notice any kind of jerking. LVN H said she did not get the UA as order. She said when she got to Resident #1's room his brief was wet. LVN H said the note about getting the UA was in the 24-hour report as well. LVN H said she could not remember if she had written a note about Resident #1 or not, she really did not remember that incident well. LVN H said she received in services regarding change in condition, labs. LVN H said she would not have done anything any different with Resident #1. She said she let the next shift know she was unable to get the UA. This was determined to be an Immediate Jeopardy (IJ) on 02/03/23 at 1:30 p.m. The facility Administrator, MDS nurse, DON, and ADON were notified. The Administrator was provided with the IJ template on 02/03/23 at 1:30 p.m. The facility plan of removal was accepted on 02/04/23 at 3:22 p.m. was as follows. [Laboratory Services The facility failed to provide timely laboratory services as ordered by the Physician on 1 Resident on 1/6/23. The Physician was not notified that lab was not drawn, resulting in a COC that resulted in his hospitalization on [DATE]. Identify residents who could be affected All Residents have the potential to be affected. The Facility census on 1/6/23 was 43. A lab audit was initiated on 2/3/23, and no residents have been identified as having incomplete lab, and this will be completed by 2/4/23. In-Service conducted Nurses were in-serviced on 1/10/23 by DON when concern identified. All nurses will receive further education on the following: Carrying out Physicians/NP orders and education on procedures for notifying Physicians/NP when a lab order is not able to be carried out and any changes in condition related to inability to complete ordered lab. Implementation Date of Changes In-servicing was initiated on 2/3/23 and will be completed by 2/4/23. Agency staff, new nurses and nurses on leave that work in the facility will have in-servicing completed prior to working the floor. Involvement of Medical Director The Medical Director, Dr. [NAME] was notified about the immediate Jeopardy on 2/3/23. Involvement of QA QAPI will review and approve Plan of Removal on 2/4/23 Who is responsible for implementation of process? Administrator and DON (Director of Nursing).] On 02/04/23 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of the facility employee roster indicated they have 5 full time LVNs, one part time LVN and two weekend RNs and the ADON who is an LVN. They have 9 nurses total. They had 7 CNAs. During an observation and interview on 02/04/23 at 3: 39 p.m. DON said she had a binder with a list of Agency staff, their discipline and when they received the training. She said she would monitor what agency staff had been trained and prior to each agency staff beginning work they would receive training if they were not in the book. Observation of the book showed the training a list of staff. There was a list of 5 agency LVNs and two agency CNAs indicating they had been trained on labs, physician notification, identification of change in condition and physician notification. During interviews on 02/04/23 between 3:30p.m. and 5:15 p.m. three CNAs said they were educated on the Stop and Watch tool (a form used by aides to identify changes in a resident such as different symptoms, change in need for assistance, eating less, agitated, more confused or change in skin color.) to help identify early signs of condition change to the charge nurse. They said they are to fill out the form and give it to the nurse, so they have verification they told the nurse of the change in condition. They were told they could make a copy of the form and place it under department heads doors if they felt their concerns were not addressed. During interviews on 02/04/23 between 3:3 0p.m. and 5:15 p.m. were conducted with 3 facility LVNs and 1 RN and 2 agency LVNs that indicated they were knowledgeable on following physician orders, identification of resident change in condition. The nurses said they would follow guidelines for monitoring. They would monitor residents with possible UTIs for any symptoms. If a resident refused treatment, they would educate the resident on possible consequences and let the physician know of the resident status. The nurses were able to demonstrate through interviews their understanding of those policies, procedures, and in services. Record Review of a Resident record identified as needing a UA was reviewed and the facility put measures in place, such as notifying the physician, getting a timely UA. Detailed documentation of the resident condition was noted in the record to include the INTERACT assessment tool( an assessment form that is used to help nursing staff evaluate the resident for change in condition). The physician was notified of the lab results and the resident place on an antibiotic. With additional physician orders. During exit on 02/04/23 at 5:42 p.m. the Administrator, DON, and ADON were informed the IJ was removed; however, the facility remained out of compliance at level of actual harm with a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems that were put in place.

Based on observation, interview, and record review, the facility failed to ensure the environment remained as free of accident hazards as possible for 1 of 1 resident reviewed for accidents. (Resident #1) The AD did not ensure the roadway was clear before entering an intersection and the facility van was struck by an oncoming vehicle. Resident #1 sustained a subarachnoid hemorrhage, (bleeding from a damaged artery at the surface of the brain) closed fracture of right occipital condyle (jaw), hematoma (bruising) of scalp, multiple right rib fractures, closed fracture of [MEDICATION NAME] process of lumbar vertebra, closed nondisplaced fracture of first cervical vertebra, and closed displaced [MEDICATION NAME] fracture of right humerus (upper arm) from the accident. This failure contributed to Resident #1's subarachnoid hemorrhage and multiple broken bones. This failure could place residents at risk for injury and/or death. Findings included: A face sheet dated 11/06/18 indicated Resident #1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. Resident #1 was discharged to a local hospital on [DATE]. A care plan dated 09/17/18 indicated Resident #1 required assistance with ADLs. She experienced chronic pain and interventions included to limit/remove causes of pain and respond immediately to pain. The MDS dated [DATE] indicated Resident #1 understood others and made her needs known. She required extensive assistance with ADLs. She used a wheelchair for mobility. A provider report dated 10/22/18 indicated on 10/22/18, the AD picked up Resident #1 from the hospital and was involved in a motor vehicle accident. Resident #1 returned to the hospital with unknown injuries. The AD's driving privileges were suspended pending the outcome of the investigation. The AD received a citation for failure to yield right of way. The AD has applied to appeal the citation. All drivers will attend a driver in-service and the AD will attend a defensive driving class. An in-service dated 11/02/18 indicated facility van drivers attended a traffic safety in-service. A certificate dated 11/02/18 indicated the AD successfully completed a driver's education course. A crash report dated 10/22/18 indicated Unit #1 was approaching a green light at the interaction in the south bound lane. Unit #2 (AD and Resident #1) was north bound and stopped in the left turn lane. According to the witness, Unit #2 had a flashing yellow arrow and proceeded into the intersection to make a left turn and failed to yield to south bound traffic. Unit #1 struck Unit #2 on the right passenger side of the vehicle. The passenger in Unit #2 (Resident #1) was restrained in a wheelchair in the cargo area of the van. The driver of Unit #1 (AD) was charged with failure to yield to right of way. The Emergency Department Notes dated 10/22/18 at 2:19 p.m., indicated Resident #1 presented to the emergency department for evaluation after a motor vehicle accident. Resident #1 was diagnosed with [REDACTED]. (upper arm) Resident #1 was admitted to the hospital. During an interview on 11/06/18 at 8:57 a.m., the AD said on 10/22/18, she went to pick Resident #1 up from the hospital. She said she placed Resident #1 in the back of the facility van in her wheelchair, secured the wheelchair in the van with 4 clamps, and secured the resident with the lap and shoulder seatbelt. The AD said she approached the intersection to turn left and the light was solid yellow. She said she proceeded through the intersection and was hit by an oncoming vehicle. She said the van was hit on the right side. The AD said she got out of the van and immediately checked on Resident #1. She said Resident #1 was still secured in the wheelchair, but the resident did not answer questions. She said the police and ambulance arrived on the scene. The AD said she rode to the hospital with Resident #1. She said while at the hospital, the police issued her a citation for failure to yield the right of way. During an interview on 11/06/18 at 9:42 a.m., the witness to the vehicle accident said on 10/22/18 at approximately 1:30 p.m., the facility van was in the left turn land and he was 2 lanes over to the right and was going straight. He said the light to turn left was a blinking yellow arrow. He said the facility van proceeded to turn left and crossed 2 lanes of oncoming traffic. The witness said 2 vehicles were in oncoming traffic and one vehicle was able to stop in time not to hit the van, but another vehicle was not able to stop in time and broadsided the facility van. The witness said he was an RN and when he approached the facility van, Resident #1 was unconscious. He said Resident #1 was alert by the time she was transported from the scene by ambulance. During an interview on 11/06/18 at 9:06 a.m., the administrator said on 10/22/18 she contacted the hospital Resident #1 was taken to and was told they thought Resident #1 broke her arm. She said Resident #1 did not return to the facility. The administrator said she immediately removed the AD from her transportation duties and summoned the AD to be drug tested . She said the drug test was negative. The administrator said the facility van was totaled due to the accident. During an interview on 11/06/18 at 11:29 a.m., Resident #1 said on 10/22/18 she was in a car accident and had been hospitalized since then. She said she had multiple broken bones from the accident but was unable to say what was broken. She said there was a possibility that she may have surgery due to her injuries. Resident #1 said she was in the facility van when the accident occurred. She said she was not paying attention to the light at the intersection and did not remember much about the accident. During an observation on 11/07/18 at 2:06 p.m., at the intersection, where the accident occurred on 10/22/18, the light sequence for the left turn was green arrow, solid yellow arrow, red light, blinking yellow arrow, solid yellow area, and red light. According to www.cityoftyler.org accessed 11/06/18, .a green arrow indicated that motorists have the right of way to turn left. A flashing yellow arrow indicated that turning left is permitted after yielding to oncoming traffic and pedestrians. A solid yellow arrow tells motorists that the signal is about to turn red . A vehicle assignment agreement signed by the AD on 06/10/18 indicated .I agree to be responsible for all traffic and parking violations that occur while the vehicle is assigned to me . The undated motor vehicle safety policy indicated .the company is committed to promoting a heightened level of safety awareness and responsible driving behavior in its employees. Our efforts and the commitment of employees will prevent vehicle accidents and reduce personal injury and property loss claims .

Based on observation, interview, and record review, the facility failed to ensure 1 of 5 residents reviewed for accidents received adequate supervision and assistance devices to prevent accidents. (Resident #1) The facility did not provide 2 persons to transfer Resident #1 in accordance with the plan of care. CNA transferred Resident #1 alone. The resident fell and sustained a pelvic fracture. This failure could place 33 residents required assistance with transfers at risk for injury. The findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], and readmitted [DATE] with [DIAGNOSES REDACTED]. The latest fall risk assessment dated [DATE] indicated Resident #1 was at moderate risk for falls. A physician order [REDACTED].#1 may be transferred with a Hoyer lift every shift related to generalized muscle weakness. The most recent care plan dated 9/27/16 indicated Resident #1 had cognitive deficits with short term memory loss and required 2 staff for bed mobility and transfer, occasionally requested Hoyer lift. The latest MDS dated [DATE] indicated Resident #1 had severe cognitive impairment and required extensive assistance of 2 or more staff for transfer. A Provider Investigation Report signed 12/6/16 indicated on 12/1/16 Resident #1 was dropped during a transfer by CNA A. The report indicated the resident was transferred to the local hospital and diagnosed with [REDACTED]. The report indicated staff was in-serviced on abuse and neglect, safe resident handling, gait belt and Hoyer lift transfers, and reporting all resident injuries to the nurse immediately. During an interview on 12/13/16 at 10:19 a.m., LVN B said Resident #1 required a Hoyer lift for transfers. LVN B said on 12/1/16 she went into Resident #1's room at the request of CNA A and noted feces and a diaper on the resident's floor. LVN B said CNA A told her the resident fell on to the floor while she was out of the room seeking assistance to transfer the resident. LVN B said CNA A said she moved the resident to the bed with the Hoyer lift by herself. LVN B said she told CNA A she was not to move a resident that had fallen until a nurse assessed the resident. LVN B said she asked CNA C who was working at the time if CNA A asked for assistance in transferring Resident #1 with the Hoyer lift and CNA C said, no. LVN B said she assessed Resident #1 and gave her pain medication. LVN B said Resident #1 told her CNA A attempted to transfer her by herself from her wheelchair to the recliner and she fell . LVN B said Resident #1 complained of pain of a 9 on a 0-10 pain scale (with 0 being no pain and 10 being the worst pain possible) in her left hip and lower back. She said Resident #1 was transferred to the hospital for evaluation. During an interview on 12/13/16 at 10:31 a.m., the ADON said on 12/1/16 she assisted LVN B in assessing Resident #1. She said Resident #1 had pain in her left hip and was sent to the emergency room . The ADON said Resident #1 told her she asked CNA A to go get help before she transferred her, but CNA A refused. The ADON said Resident #1 said CNA A picked her up and was unable to hold her and dropped her on the floor and Resident #1 asked CNA A to go get help to get her off of the floor and CNA A still did not get another staff member to help. The ADON said Resident #1 told her CNA A transferred her from the floor to the bed with the Hoyer lift by herself. A History and Physical dated 12/1/16 indicated Resident #1 was admitted to the hospital after a fall during a transfer. The History and Physical indicated the resident complained of severe left hip pain, had an acute pelvic fracture, pneumonia, and a urinary tract infection. During an interview on 12/13/16 at 9:23 a.m., the administrator said Resident #1 went to the hospital after a fall on 12/1/16 and was still in the hospital because she had pneumonia. She said Resident #1 fell during a transfer and CNA A moved Resident #1 into her bed with a Hoyer lift without the assistance of a second staff. She said CNA A said Resident #1 fell on her own, but Resident #1 said she fell when CNA A was transferring her by herself. The administrator said CNA A was terminated for transferring Resident #1 improperly. During an interview on 12/13/16 at 9:25 a.m., the DON said CNA A transferred Resident #1 alone on 12/1/16 instead of with two staff as required. The DON said the resident fell during the transfer and then CNA A transferred Resident #1 from the floor to her bed with the Hoyer lift without assistance of a second staff. The DON said all direct care staff had been in-serviced on abuse and neglect, transferring with a Hoyer lift, gait belt policy and procedures, and assessing a resident after a fall. During an interview on 12/13/16 at 11:10 a.m., PTA D said Resident #1 required the use of a Hoyer for transfers. During an interview 12/13/16 at 9:48 a.m., CNA E said Resident #1 required a Hoyer lift transfer. She said she had been in-serviced regarding proper transfer techniques. During an interview 12/13/16 at 9:52 a.m., CNA F said Resident #1 was a Hoyer lift transfer. She said she had been in-serviced regarding proper transfer techniques. During an interview 12/13/16 at 10:52 a.m., CNA H said Resident #1 was a Hoyer lift transfer. She said she had been in-serviced regarding proper transfer techniques. An in-service report dated 12/1/16 indicated staff was in-serviced on abuse and neglect. An in-service dated 12/1/16 indicated staff was in-serviced on Hoyer lift transfers. An in-service dated 12/1/16 indicated staff was in-serviced on abuse and neglect. An in-service dated 12/1/16 indicated staff was in-serviced on gait belt transfers. An Employee Termination Form dated 12/2/16 documented CNA A was terminated on 12/2/16. The CMS 672 dated 12/13/16 indicated 33 residents required the assistance of one or two staff with transfers.

Based on observation, interview, and record review, the facility failed to provide care and services to assess and intervene during respiratory distress for 1 of 4 residents sampled for a change of condition while on oxygen therapy. (Resident #2) On 5/12/11 Resident #2 wore a nasal cannula connected to an oxygen tank that was not turned on, even though she required continuous oxygen. Resident #2 was in respiratory distress, taking rapid shallow breaths and her fingers were bluish-purple. This was the second time this resident's oxygen tank had been left turned off in the past 2 weeks. Failure to provide Resident #2 with oxygen contributed to the resident's prolonged oxygen deprivation and respiratory distress and constituted an Immediate Jeopardy that was identified 5/12/11. While the Immediate Jeopardy was removed on 5/13/11, the facility remained out of compliance at a pattern of actual harm due to the facility's need to monitor and evaluate the effectiveness of the corrective systems. This failure could place 22 other residents who received oxygen at risk of respiratory distress or death. Findings included: Physician orders [REDACTED]. According to the orders, her oxygen saturation was to be checked every shift and she was to receive oxygen at 2 lpm per nasal cannula to maintain her oxygen saturation above 90%. A care plan dated 4/26/11 indicated Resident #2 was at risk for shortness of breath, fatigue and wheezing, and oxygen would be administered as ordered. An MDS dated [DATE] indicated Resident #2 could make her needs known with prompting, was dependent on staff for ADLs, and required oxygen therapy. During an observation and interview on 5/12/11 at 11:35 a.m., Resident #2 was sitting in her wheelchair near the nursing station wearing a nasal cannula connected to an oxygen tank. Resident #2 was lethargic, had bluish-purple fingers (cyanosis) and rapid, shallow breathing (signs of respiratory distress). The oxygen tank was turned off. After surveyor intervention, the DON checked the resident's oxygen tank. The DON said, "Oh no, it should not be off," and turned the oxygen tank on at 2 lpm. The DON said Resident #2 could at times make her needs known, was dependent on oxygen, and was recently admitted to hospice for heart failure. The DON pushed Resident #2's wheelchair to her room and left the room without assessing the resident. Resident #2 continued breathing very rapidly and exhibited signs of distress. Resident #2 said, "water" and pointed to her throat. The surveyor asked Resident #2 if she could breathe and she shook her head, "No." During the observation on 5/12/11 at 11:37 a.m., after surveyor intervention, the DON returned to the resident's room and gave the resident water. The DON did not assess Resident #2's labored breathing, her bluish-purple fingers or increase her oxygen. No vital signs were taken. Resident #2 was drowsy and sluggish and closed her eyes when questioned. She continued to have rapid respirations. The DON said she would ask LVN A about Resident #2's oxygen saturation from earlier in the shift. At 11:38 a.m., following surveyor intervention, the DON checked Resident #2's oxygen saturation. The oxygen saturation was 71%. No vital signs were taken. The DON took another oxygen saturation. The second oxygen saturation was 82%. During an interview on 5/12/11 at 11:48 a.m., LVN A said that around 10:45 a.m. she and CNA B assisted Resident #2 from bed to her wheelchair. She said the resident was not in respiratory distress at that time and was alert. LVN A said Resident #2 was dependent on oxygen or her saturation would drop immediately. She said the resident had an oxygen tank for oxygen administration while she was in her wheelchair. The LVN said the oxygen tank was on 2 lpm when they "placed" her at the nursing station. She said she did not know the oxygen tank was turned off or that the resident was in respiratory distress. LVN A said she had not checked the oxygen since they transferred the resident to the wheelchair. During an observation on 5/12/11 at 11:50 a.m., Resident #2 continued to exhibit signs of respiratory distress and was receiving oxygen at 2 lpm. The DON and LVN A checked Resident #2's vital signs. Her blood pressure was 128/52, heart rate 77, respirations 44, and oxygen saturation 84%. Resident #2's fingers were bluish-purple. LVN A and CNA C transferred Resident #2 to bed. The LVN connected the nasal cannula to the oxygen concentrator and set the oxygen flow at 3 lpm. The DON said CNAs were never to turn oxygen on and off or adjust the flow. During an interview on 5/12/11 at 12:05 p.m., CNA C said before breakfast she transferred the resident to the wheelchair, turned the oxygen on and set the tank at 2 lpm. The CNA said Resident #2 was alert and did not have labored breathing or purplish fingers at that time. During an interview on 5/12/11 at 1:46 p.m., CNA C said aides were allowed to turn the oxygen tanks and concentrators on and off and adjust the settings. During an interview on 5/12/11 at 12:07 p.m., CNA B said around 10:30 a.m., before lunch, she and LVN A assisted Resident #2 to the wheelchair. She said the resident depended on oxygen and used oxygen "all the time." CNA B said she connected the resident's nasal cannula to the oxygen tank, turned the tank on, and set the oxygen at 3 lpm. She said she pushed Resident #2 to the nursing station. The CNA said Resident #2's breathing was not labored and her fingers were not discolored. During an interview at 1:50 p.m., CNA B said she knew CNAs were not allowed to set the oxygen administration levels on tanks or concentrators; however, they did turn oxygen on and off and adjust the settings, and the nurses were aware. During an interview on 5/12/11 at 12:15 p.m., LVN A said Resident #2's oxygen saturation would quickly drop without receiving continuous oxygen. LVN A said Resident #2 had no signs of distress earlier that day and her oxygen saturation had been above 90%. LVN A said a week or two ago, Resident #2 experienced a similar episode of respiratory distress. She said the therapist notified her that the resident had labored breathing, purple fingers, and her O2 tank was turned off. She said Resident #2's oxygen saturation was 80% at that time. She said she had not documented the incident. During an interview on 5/12/11 at 12:55 p.m., the COTA said about a week or two ago, Resident #2 came to therapy after lunch. The COTA said Resident #2 was breathing "pretty fast," had purple fingers, and was more confused than usual. He said the resident wore a nasal cannula connected to an oxygen tank that was turned off. The COTA said he notified LVN A and she took the resident to her room. During an observation on 5/12/11 at 1:05 p.m., Resident #2 was lying in bed wearing a nasal cannula connected to an oxygen concentrator set at 3 lpm. The resident had purplish fingers and rapid, shallow respirations. LVN A checked the resident's vital signs. Resident #2's blood pressure was 92/56, heart rate 45, respirations 36, and oxygen saturation 76%. LVN A said although the resident was in respiratory distress, she had to have a physician order [REDACTED]. Nursing notes dated 5/12/11 at 1:00 p.m. indicated Resident #2 was lying in bed with her eyes closed. Her respirations were slightly labored and her finger tips continued to have a purple tint. Her blood pressure was 92/56, pulse 79 and her oxygen saturation was 76%. At 1:10 p.m., the physician was notified of Resident #2's low oxygen saturation and an order was received to increase the oxygen as needed to keep her oxygen saturation above 90%. At 1:30 p.m. Resident #2 continued to have labored respirations. Her fingers were blue and she was receiving oxygen at 4 lpm via nasal cannula. According to the Clinical Nursing Skills, Basic to Advanced Skills, Smith, Duell, and Martin, Fifth Edition, 2000; pages 732, 735, 736: "Cyanosis - bluish or grayish discoloration of the skin resulting from significant reduction of oxygen saturation of the blood [MEDICAL CONDITION] - lack of adequate amount of oxygen transported to the tissues The most common clinical manifestations indicative of inadequate ventilation are tachypnea, restlessness, use of accessory muscles for breathing, change in cognition or level of response ... Normal oxygen saturation - 96-100% Changes in the respiratory system may be gradual with the elderly; oxygen saturation is decreased to 93%-94%. Early symptoms of [MEDICAL CONDITION] - restlessness, confusion or change in behavior, tachypnea (increased breathing >24 respirations/minute). Advanced symptoms of [MEDICAL CONDITION] - [MEDICAL CONDITIONS], cyanosis." Immediate Jeopardy The survey team determined failure to provide oxygen and ensure the oxygen tank was turned on for Resident #2 constituted an Immediate Jeopardy. The lack of oxygen on 5/12/11 contributed to the deterioration of Resident #2's condition with respiratory distress and development of a life threatening situation. The administrator, DON, and ADON D were informed of the Immediate Jeopardy situation on 5/12/11 at 2:38 p.m. During an interview on 5/12/11 at 5:15 p.m., the administrator from a sister facility said she was there to assist the DON with training and writing the plan of removal. On 5/12/11 at 6:15 p.m. the facility's plan of removal was accepted as follows: Plan of Removal The resident who was affected by the deficient practice was administered oxygen immediately by a licensed nurse. A licensed nurse assessed the resident and reported the results to the resident's physician. The resident's oxygen saturation levels are being monitored every one hour and oxygen is adjusted as ordered per parameters by physician. All residents who were receiving oxygen by oxygen tanks or concentrators were evaluated by the DON and ADON. The oxygen equipment was working properly and the residents were observed having no signs or symptoms of respiratory distress. All staff were immediately in serviced by the DON and ADON; that only licensed nurses can administer and adjust oxygen, also licensed nurses were in serviced on the protocol for assessing residents on oxygen therapy, including checking equipment and any signs and symptoms of respiratory distress. A form has been implemented to be completed every one hour by the charge nurses who are administering and checking on each resident on oxygen. The form will be a visual and physical assessment of the resident to ensure that no change of condition has occurred and that the equipment is working properly. The nursing staff has been in serviced by the ADON on the use of the form. During an interview on 5/13/11 at 11:25 a.m., the DON from a sister facility said she was there to assist the DON with training of staff and monitoring of the residents with oxygen. On 5/13/11 the survey team reviewed the facility's implementation of the plan of removal. Staff members were interviewed and were knowledgeable about oxygen administration equipment, oxygen administration, signs of respiratory distress, and the roles of the CNAs and LVNs. They said they had received an in-service related to oxygen use and equipment. Review of the staffing and in-service records confirmed that all nursing staff had received the required training. The survey team determined the facility had implemented its plan of removal sufficiently to remove the Immediate Jeopardy. The administrator and DON were informed the Immediate Jeopardy was removed on 5/13/11 at 1:30 p.m. Although the immediate jeopardy was removed on 5/13/11, the facility remained out of compliance at a pattern of actual harm. The deficient practice remained uncorrected due to the need for the facility to monitor and evaluate whether the systems put into place were effective. A list dated 5/12/11 indicated 23 residents received oxygen therapy.