Every finding on record at Mont Belvieu Rehabilitation & Healthcare Center

Based on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for assistive devices to prevent accidents. The facility failed to ensure Resident #1 had both fall mats in place the morning of 08/07/26. Resident #1 was found on the floor next to her bed (the second floor mat was not in place) and had received a right nasal bone and nasal septum fractures and a laceration on her face. The noncompliance was identified as past noncompliance that began on 08/07/26 and ended on 08/13/26. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of injury, diminished quality of life and hospitalization.Findings included: Record review of Resident #1's face sheet, dated 08/26/26, indicated she was an [AGE] year-old female, admitted on [DATE], and her diagnoses included dementia (decline in mental abilities), essential hypertension (high blood pressure), and cognitive communication deficit (difficulties in communication). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she was rarely/never able to make herself understood and rarely/never understood others. No BIMS assessment was conducted because she was rarely/never understood. She was dependent for rolling left to right. History of falling was noted under additional diagnoses. Record review of Resident #1's care plan, no date, indicated Resident #1. The resident has had an actual fall [NAME] at risk for fall related injuries related to Poor Balance, Poor communication/comprehension.The resident will resume usualactivities without further incident through the next 90 day review date. Revision on: 06/08/2026 Target Date: 09/05/2026.Ensure fall mats are at the bedside when resident is in bed. Check for placement every 2 hours during shift. every shift for Increased risk for fall. Record review of Resident #1's incident report, dated 08/07/26, indicated .Person preparing report: [LVN B].Nursing Description: At approximately 0508 {05:09 a.m.}, [Hospice CNA], entered residents' room and found resident on the floor. [Hospice CNA], immediately sought nursing assistance. This nurse was notified by another nurse and entered resident's room at approximately 0510 (05:10 a.m.). Resident was observed on the floor laying on her right side in the fetal position covered in a blanket. A laceration to the forehead, bleeding from the nose, and guarding the left arm was noted. Resident appeared to be in pain. Vital signs obtained: BP 162/71, pulse 91, temperature 97.6 [degrees Fahrenheit], and SpO2 97% on room air. Resident's fall mat was noted to be tucked away in the corner of the room and was not positioned on the floor at the time the resident was found. Bed was in the lowest position. Resident was noted to have a soiled brief. During this nurse's previous visit to the room at approximately 0100, the fall mat was observed to be properly positioned on the right side of the bed. Resident was covered with a blanket when found. Air conditioning was on in the room, and resident felt cold to the touch. Due to apparent head injury, nasal bleeding, left arm guarding, and appearance of pain, emergency medical services were contacted at approximately 0512 for further evaluation and transport to the hospital. [Hospice Company], DON, ADON and MD were notified via voice mail, of the incident. [RP], was notified that resident was being sent to the hospital for further evaluation. Prior to discovery of the resident on the floor, this nurse had made rounds at 0340 through the hallway and visually checked resident's rooms. No unusual findings were observed in residents' room at that time. Resident Description: Resident Unable to give Description Was this incident witnessed: N.Immediate Action Taken Description: Sent resident to the hospital Resident Taken to Hospital? Y Injuries Observed at Time of Incident Injury Type Injury Location No Injuries observed at time of incident. Level of Pain: 4. (moderate pain that is distracting) Record review of the facility's investigation report, dated 08/07/26, revealed in the early morning hours of 08/07/26 the Administrator reviewed the incident report written by LVN B. It revealed, At approximately 0508 {05:08 a.m.), Hospice CNA entered resident's room and found resident on the floor. The Hospice CNA immediately sought nursing assistance. The nurse was notified by another nurse and entered resident's room at approximately 0510. Resident was observed on the floor laying on her right side in the fetal position covered in a blanket. A laceration to the forehead, bleeding from the nose, and guarding the left arm was noted. Resident appeared to be in pain. Vitals sings obtained: BP (blood pressure), pulse 91, temperature 97.6 (degrees Fahrenheit), and SpO2 97% on room air. Resident's fall mat was noted to be tucked away in the corner of the room and was not positioned on the floor at the time the resident was found. Bed was in the lowest position. Resident was noted to have a soiled brief. During this nurse's previous visit to the room at approximately 0100, the fall mat was observed to be properly positioned on the right side of the bed. Resident was covered with a blanket when found. Air conditioning was on in the room, and resident felt cold to the touch. Due to apparent head injury, nasal bleeding, left arm guarding, and appearance of pain, emergency medical services were contacted at approximately 0512 for further evaluation and [Hospice Company], DON, ADON, and MD were notified via voicemail of the incident. Resident's FM was notified that resident was being sent to hospital for further evaluation. Prior to discovery of the resident on the floor, this nurse made rounds at 0340 through the hallway and visually checked resident's rooms. No unusual findings were observed in residents' room at that time. The investigation included a statement from CNA A which reflected, I changed her at 3 cause my last round is at 5 and the hospice aide found her and her mat has been on the side of the closet when I go in there and I usually put it on the floor but last night I didn't but I did put her bed low. Record review of a screen shot of text messages between the DON and CNA A regarding the incident on 08/07/26, no date, CNA A texted, I changed her at 3 {03:00 a.m.) cause my last round is at 5 (05:00 a.m.) and the hospice aide found her and her mat has been on the side of the closet when I go in there and I usually put it on the floor but last night I didn't but I did put her bed low. Record review of Resident #1's hospital records dated 08/07/26 indicated .fall, initial encounter; closed fracture of nasal bone, initial encounter; injury of head, initial encounter; facial laceration, initial encounter. During an observation and an attempted interview on 08/26/26 at 9:01 a.m., revealed Resident #1 was lying in bed. Her room was the first room closest to the nurse's station. Fall mats were on both sides of her bed. Her bedside table was against the wall away from her. An attempt to interview her was made, but she did not respond to any questions. She was sleeping, opened her eyes closed them. There were no signs of pain observed. There were no signs of injury on her nose, there was a scab about the size of a dime on her forehead and a small amount of light brown bruising. An attempt was made to call CNA A on 8/28/26 at 1:06 p.m., without success. During an interview on 08/26/26 at 12:17 p.m., the Administrator stated his investigation revealed one fall mat was not placed properly the morning of the fall. The Administrator stated the expectation was for fall mats to be in place on both sides of the bed, when Resident #1 was in bed. He stated even if the bed was low, the fall mats should be in place. He stated, We think she rolled out of bed. He stated Resident #1 was sent out (to hospital) immediately after the fall. The nursing department and maintenance observed the room to ensure there were no other hazards in the room. He stated all fall mat rooms were checked, an audit was done regarding fall mats, and all staff were re-in-serviced on fall mat expectations. The in-service covered ensuring fall mats were in place, if the resident was in bed and required them. During an interview on 08/26/26 at 2:22 p.m., the DON said she asked CNA A about the placement of the mat, and CNA A stated she normally placed them how they were supposed to, and she didn't know why she didn't that morning. The DON stated she went to all rooms to check floor mats, checked to ensure all orders were in place, and all care plans were updated to include fall mats (if needed). The DON stated staff knew if fall mats were required because there were orders for them and there was a list at the nurses' station of the residents that required them. The DON stated after this incident, all staff were re-in-serviced on abuse and neglect and fall mat expectations. She stated the fall mat was placed in case the resident had a fall, to help cushion, to decrease any injury. The DON stated this resident was on hospice previous to the fall and was already declining. She stated she was actively transitioning (actively dying). Record review of CNA A's Employee Disciplinary/Counseling Report, dated 8/7/26, indicated, .Type of Disciplinary Action: .written counseling.reason for corrective action: CNA failed to place fall mats next to bedside after witnessing the fall mats placed against the wall. Corrective plan of action, including time frames: CNA will verify placement of all fall mats during each round made on residents. If CNA sees a fall mat not placed correctly, she will immediately place the fall mats in the correct location for the safety of the resident. Record review of all nursing staff training titled, Fall Mats, dated 08/07/26, indicated, .1. Nurses need to make rounds during shift to ensure that all fall mats that are to be in place are in place. 2. CNA' need to replace fall mats if moved for things such as hoyer (mechanical device with wheels and a hammock-like sling used to safely lift ) use, bathing, ect. 3. Staff needs to review Kardex (electronic record) to know if fall mats are listed for residents. Multiple observations on 08/26/26 between 09:00 a.m. and 1:00 p.m. of Resident #1, Resident #2, Resident #3, and Resident #4's rooms revealed all fall mats were in place as ordered when the residents were in bed. Record review of proof for the fall mat audit and fall mat walking rounds done by the DON (list of all residents with fall mats and observations of the same residents with fall mats), dated 08/06/26, and fall mat orders and care plans addressing fall mats, dated 08/13/26. Interviews with nursing staff regarding fall mat expectations starting on 08/26/26 at 12:56 p.m., revealed all staff confirmed they were re-trained regarding fall mats. All staff interviewed were able to verbalize where to find whether a resident required a fall mat and to check placement of fall mats during rounding. All staff confirmed fall mats should be in place when the resident was in bed. The staff interviewed included CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, LVN L, LVN M, LVN N, and LVN O. Interviews were completed by 2:15 p.m. Record review of the facility's Falls and Fall Risk, Managing, revised 12/23, indicated .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling.7. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling.

Based on interviews and record reviews, the facility failed to utilize the services of a RN for 8 consecutive hours 7 days a week and designate a RN as a DON on a full-time basis for 1 of 1 facility reviewed for nursing services.The facility failed to ensure an RN worked for 8 consecutive hours for 4 of 30 days reviewed in February and March 2026.The facility failed to designate an RN as a DON on a full-time basis for 2 of 2 months reviewed in February and March 2026. These failures could place residents at risk of not having their nursing and medical needs met, and other direct care staff not receiving sufficient oversight.Findings included:During an interview on 03/18/26 at 12:45 p.m. with the facility HR Director and record review of the facility's RN staff payroll hours for the period of 02/17/26 - 03/18/26 indicated no RN Services on the following dates: 02/26/26, 03/11/26, 03/12/26, and 03/16/26. The HR Director said the facility had not hired a full-time DON and the last day of employment for the previous DON was 2/17/2026. The HR Director said the facility Administrator was responsible for making sure the facility had RN coverage daily and hiring a DON. The HR Director said the Administrator had conducted interviews with DON Candidates but had not hired anyone.Record review of Incidents & Accidents for 02/26/26, 03/11/26, 3/12/26 and 03/16/26 did not reveal any negative outcomes to residents related to not having RN services.During an interview on 03/17/26 at 1:00 p.m., LVN C said she had worked for the facility for 6 months and the DON quit last month. LVN C said she had felt the lack of RN and DON was a concern as LVN because on certain occasions it could pose a challenges like needing the DON or RN to physically look at a patient to do a more in depth assessment. She said, although the facility occasionally employed RNs and DONs, there were periods when neither was present. LVN C said in such instances, she would seek supervisory guidance by consulting the ADON, physicians, or Nurse Practitioner. LVN C mentioned that, when appropriate, she would seek advice from the pharmacy or dietitian as well. LVN C said there were no negative outcome because of no DON because you could still call someone.During an interview on 03/17/26 at 1:00 p.m., the ADON said she was a LVN and the facility had been without a fulltime DON since 02/17/26. She said the nursing staff had corporate oversight, and she was in the building 2-3 days a week and had been available by telephone to her. The ADON said she had 24/7 access to the corporate nurse(Director of Clinical Operations) for any questions. The ADON said the Administrator had been reviewing the staffing schedule and was the one responsible for hiring a DON. The ADON said the DON had a critical role in a nursing facility, noting that the DON was responsible for overseeing nursing staff, providing guidance as needed, and ensuring compliance with regulations, policies, and procedures to maintain quality of care. She also mentioned the importance of RNs in such settings, as they provided guidance, support, and performed nursing tasks beyond the scope of CNAs and LVNs. The ADON further stated, without a DON the negative outcome could be that no one in the role positioned to articulate nursing-related issues and facilitate discussions aimed at improving the quality of care and residents' quality of life.During an interview on 03/18/26 at 1:00 p.m., the Administrator said he was aware the facility did not have RN coverage or an acting DON. He said he expected the facility to have an RN working eight consecutive hours a day every day of the week. He said he expected there to be an acting DON or full-time DON in the facility. The Administrator said the previous DON quit 02/17/26 with no notice and the facility had been actively advertising for the DON position. He said the facility had been attempting to hire and a DON, advertising the position on different platforms, and just recently added incentives to make the position more desirable. He said they had one or two applicants to interview for DON next week. He said his desire to hire someone more experienced in management of resident care and staff, led to the failure of the DON position not to be filled. The Administrator said the facility had corporate oversight from an RN, but that RN had not worked forty hours a week at the facility. He said he was the one who was responsible for making sure there was a DON and the facility had RN coverage. The Administrator said he was not aware there was no RN coverage on those dates(02/26/26, 03/11/26, 3/12/26 and 03/16/26). The Administrator said the Director of Clinical Operations was available on-call as needed and was in person in the facility 2-3 days a week doing DON work reviewing nursing systems. The Administrator said he was aware of the importance of having an RN at the facility for clinical management. The Administrator said the Director of Nurses was responsible for ensuring RN coverage as required and notifying Administrator of non-coverage. He stated there was improvement to be made and the management was aware of the issue prior to today.During an interview on 03/18/26 at 11:49 a.m., the Director of Clinical Operations said it was the DON's responsibility to ensure and scheduled an RN for 8 consecutive hours every day, but in the absence of the DON it was the responsibility of the Administrator. The Director of Clinical Operations said she was not the full-time DON for the facility and she only visited the facility 2-3 times a week to review systems and was available to the facility via phone 24/7 for any care concerns. The Director of Clinical Operations said that there were no reported quality concerns attributable to the lack of RNs or DONs. She said there were no residents who had missed services or treatment because an RN was not onsite. She said that staff contacted her, the physician or nurse practitioner depending on the situation. The Director of Clinical Operations said the facility had sufficient RNs to cover their 8 consecutive hours shift every day and did not know why it was not done. She said it was important to have a RN coverage because they were more skilled than an LVN and were able to assess patients differently. She said they were interviewing one or two candidates for an RN DON at the end of the week.Record review of the facility's policy titled Director of Nursing Services, dated August 2006, read in part: Policy Statement: The Nursing Services department is under the direct supervision of a Registered Nurse.1. The Nursing Services Department is managed by the director of nursing services. The director is a registered nurse licensed by this state and has experience in nursing service administration rehabilitation and geriatric nursing. #2 the directors employed full-time 40 hours per week.Record review of Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP Guidance to Surveyors for Long Term Care Facilities (February 2023 Revision). F727: RN 8 Hrs./7days/Wk., Full Time DON . Policy read in part . Except when waived . the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week .

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for essential equipment. The facility did not ensure the gas stove was in safe operating condition. This failure could place the residents at risk of a fire and not receiving their meals in a timely manner.Findings included: During an observation and interview on 03/16/2026 at 8:39 a.m., the DM said 1 burner (front right burner) was not functionable, the control knob was removed and gas line to that burner was disconnected. He said they use the other 5 burners. He turned on the 5 burners and 3 (the back burners) did not light with the pilot lights. The DM picked a long stem lighter that was next to the stove and lit those 3 burners. There was no smell of escaping gas. He said maybe the vent-a-hood blew out the pilot lights this morning and he would have maintenance check the burners. He said the stove needs to work properly so there are no delays with meals. During an observation of the kitchen on 03/16/2026 at 12:00 p.m., there was no smell of gas in the kitchen. During an interview on 03/16/2026 at 3:30 p.m., The administrator said he was informed the 3 burners did not light with the pilot light and the DM used the long stem lighter to light the burners. He said the pilot lights should light the burners. During observations on 03/17/2026 from 10:08 a.m. to 11:00 a.m., there were no gas odors in the kitchen. During an observation on 03/17/2026 at 11:30 a.m. the DM turned on 5 burners and 1 of 5 burners (the back middle burner) did not light with the pilot light and he immediately turned it off and said he would get maintenance adjust the pilot light. He said he might have bumped into the pilot light this morning when he was cleaning the grates on the stove. There was no gas odor. During an interview on 03/17/2026 at 3:30 p.m., the Administrator said the sixth burner (the right front burner) was fixed before we entered on Monday. He said they had deactivated that burner all together before we entered the building and the 3 burners had been fixed on 03/16/2026 after the DM and surveyor observed it. During an interview on 03/18/2026 at 1130 a.m., the Maintenance Supervisor said he had not been told the burners were not working with the pilot light until after surveyor intervention. He said the pilot light was lit but the pilot light was turned away from the burner, and his expectation was for the kitchen staff to notify him when equipment was not working properly. Record review of the Maintenance of Equipment-Stove Top Burner policy dated March 2026. Policy Statement Maintenance service shall be provided to all areas of the building, grounds, and equipment, including stoves, ovens, and cooktops. The Maintenance department is responsible for ensuring that all equipment is maintained in a safe and operable condition at all times . c. Any kitchen equipment malfunction or repair need to be reported immediately by the Dietary Manager or dietary staff to the Maintenance Director for timely repair of replacement.

Based on observation, interview, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 1 of 23 residents (Resident #14) reviewed for dental care. The facility did not assist Resident #14 with obtaining dental services when she had dental concerns of missing, broken and loose teeth. This failure could cause the resident unnecessary dental pain.Findings included: Record review of Resident #14's admission record dated indicated she was [AGE] years old, admitted on [DATE] with diagnoses which included congestive heart failure, skin cancer and diabetes (high blood sugar). Record review of Resident #14's Physician orders for March 2026 indicated a diet order for Mechanical Soft-Ground texture diet was ordered on 08/27/2025. Record review of Resident #14's admission MDS assessment, dated 05/27/2025, reflected a BIMS score of 14 indicating she had intact cognitive ability. Her Functional Ability assessment indicated she was dependent on staff for bathing and was able to feed self. The oral and dental section did not indicate obvious or likely cavity or broken natural teeth, inflamed or bleeding gums or loose natural teeth and mouth or facial pain, discomfort or difficulty with chewing. Record review of Resident #14's quarterly MDS assessment, dated 01/28/2026, reflected a BIMS score of 13 indicating she had intact cognitive ability. Her Functional Ability assessment indicated she was dependent on staff for bathing, was able to feed self and required substantial assistance with brushing her teeth. Mechanically altered diet was indicated. The oral and dental section did not indicate discomfort or difficulty with chewing. Record review of Resident #14's care plan, dated 01/29/2026, indicated she had an ADL self-care performance deficit and limitations in physical mobility related to impaired balance, limited mobility. She required extensive assistance with oral care and supervision with eating. During an observation and interview on 03/16/2026 at 9:35 a.m. Resident #14 said she had not seen a dentist since she came here and would like to. She said when they give her chopped meat, she does not have pain. Resident #14 pointed in her mouth at her bottom jaw there was 2 teeth were broken into gum line. The 4 other teeth on her bottom jaws were crooked and loose. Resident #14 touched the 4 teeth and they moved freely. She said the top jaw was missing teeth as she pointed to them and closed her mouth. During an interview on 03/18/2026 at 12:56 p.m., the ADON said the DON and the SW were responsible for addressing dental concerns and making dental appointments, but it was overlooked. She said the DON and social worker both quit. She said the administrator was helping with appointments. The ADON said the resident risk of not being referred to dental services was pain and weight loss. She said the referral would be made today. During an interview on 03/18/2026 at 1:30 p.m., the Administrator said his expectation was for dental referral to be done as needed. He reviewed the list of residents who had seen the dentist and he said Resident #14 was not on the list, however the facility would work on a referral today. Record review of the Dental Services policy dated December 2016 indicated . Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment.

Based on observation, interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 23 residents (Resident #14) reviewed for MDS assessment accuracy. The facility incorrectly coded Resident #14's admission MDS assessment dated [DATE] and the most recent MDS quarterly assessment 01/28/2026 to ensure Resident #14 dental status when she had missing teeth and dental concerns. This failure could place residents at risk of not receiving care and services to meet their needs. Findings include: Record review of Resident #14's admission Record dated indicated she was [AGE] years old, admitted on [DATE] with diagnoses which included congestive heart failure, skin cancer and diabetes (high blood sugar). Record review of Resident #14's physician orders for March 2026 indicated a diet order for Mechanical Soft-Ground texture diet was ordered on 08/27/2025. Record review of Resident #14's admission MDS assessment, dated 05/27/2025, reflected a BIMS score of 14 indicating she had intact cognitive ability. Her functional ability section of the assessment indicated she was dependent on staff for bathing and was able to feed self. The oral and dental section did not indicate obvious or likely cavities or broken natural teeth, inflamed or bleeding gums or loose natural teeth and mouth or facial pain, discomfort or difficulty with chewing. Record review of Resident #14's quarterly MDS assessment, dated 01/28/2026, reflected a BIMS score of 13 indicating she had intact cognitive ability. Her functional ability section indicated she was dependent on staff for bathing, was able to feed self and required substantial assistance with brushing her teeth. Mechanically altered diet was indicated. The oral and dental section did not indicate discomfort or difficulty with chewing. Record review of Resident #14's care plan, dated 01/29/2026, indicated she had an ADL self-care performance deficit and limitations in physical mobility related to impaired balance, and limited mobility. She required extensive assistance with oral care and supervision with eating. During an observation and interview on 03/16/2026 at 9:35 a.m. Resident #14 said she had not seen a dentist since she came to the facility and would like to. She said when they give her chopped meat, she does not have pain. Resident #14 pointed in her mouth at her bottom jaw there were 2 teeth broken into gum line. The 4 other teeth on her bottom jaws were crooked and loose. Resident #14 touched the 4 teeth and they moved freely. She said the top jaw was missing teeth as she pointed to them and closed her mouth. She said she had dental issues when admitted to the facility. During an interview and observation on 03/18/2026 at 9:45 a.m., LVN C went to Resident #14's room and checked her dental concerns after surveyor intervention. LVN C said Resident #14 needs to be on the dental referral list. She said Resident #14 had not complained of pain or concerns and said it was missed. During an interview on 3/18/26 at 10:00 a.m., the MDS nurse said Resident #14 should have been triggered for dental issues on her MDS assessments as she assessed Resident #14's mouth. During an interview and record review on 03/18/2026 at 1:09 p.m., the Director of Clinical Operations said the DON was responsible for ensuring the MDS was accurate. She said the DON left without notice on 2/17/2026. She said the dental concerns for Resident #14 must have been overlooked. The Director of Clinical Operations said the resident risk of dental issues not being coded correctly could lead to the dental concerns not being addressed and could have potential adverse reaction including pain or weight loss. She said her expectation was all dental concerns to be coded on the MDS and addressed. She said they used the Resident Assessment Instrument Manual for their policy. During an interview on 03/18/2026 at 1:30 p.m., the Administrator said his expectation was for MDS to be correct and for dental referral to be done as needed. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1 dated October 2024Steps for Assessment 1. Ask the resident about the presence of chewing problems or mouth or facial pain/discomfort. Check L0200B, no natural teeth or tooth fragment(s) (edentulous): if the resident is edentulous/lacks all natural teeth or parts of teeth. Check L0200D, obvious or likely cavity or broken natural teeth: if any cavity or broken tooth is seen.Check L0200E, inflamed or bleeding gums or loose natural teeth: if gums appear irritated, red, swollen, or bleeding. Teeth are coded as loose if they readily move when light pressure is applied with a fingertip. Check L0200F, mouth or facial pain or discomfort with chewing: if the resident reports any pain in the mouth or face, or discomfort with chewing.

Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications for 1 of 18 residents (Resident #55) reviewed for unnecessary medications. The facility did not monitor Resident #55's apixaban (blood thinner) medication for side effects. This failure could place residents at risk for unintended, harmful events attributed to the use of medication without monitoring for side effects.Findings included: Record review of a face sheet dated 03/16/2026 indicated Resident #55 was an [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Her diagnoses included atrial fibrillation (a heart condition where the upper chambers of the heartbeat irregularly and can lead to ineffective blood pumping increasing the risk of blood clots). Record review of a physician order for Resident #55 dated 01/12/2026 indicated she was prescribed apixaban 2.5 mg two times a day for atrial fibrillation, created by LVN B on 01/12/2026 and revised by the Director of Clinical Operations on 02/22/2026. Record review of the physician orders for Resident #55 dated 03/17/2026 indicated she was prescribed apixaban 2.5 mg two times a day for atrial fibrillation with a start date of 01/12/2026 and did not indicate monitoring for side effects. Record review of Resident #55's admission MDS assessment dated [DATE] indicated she had a BIMS score of 10, indicating moderately impaired cognition. The assessment indicated she had a diagnosis of Atrial fibrillation and was taking an anticoagulation medication during the lookback period. Record review of the electronic record of Resident #55 from 01/12/2026 to 3/18/2026 did not indicate monitoring for side effects of the anticoagulant medication apixaban. Record review of the Medication Administration Record of Resident #55 dated 03/18/2026 indicated she received apixaban 2.5 mg two times a day for atrial fibrillation with a start date of 01/12/2026. Record review of Resident #55's care plan with a target date of 05/15/2026 indicated she received anticoagulant therapy related to atrial fibrillation with interventions that included administering the medication as ordered, monitor and document side effects and effectiveness every shift. Record review of Consultant Pharmacist's Medication Regimen Review for Resident #55 dated 02/09/2026 indicated to add anticoagulant monitoring. During observation and interview on 03/16/2026 at 11:45 a.m., Resident #55 was sitting in her recliner and said she was treated well and took a blood thinner medication, apixaban and had no bruising or bleeding concerns.During a record review and interview on 03/18/2026 at 8:23 a.m., RN A said she was providing care for Resident #55 today. She said Resident #55 received the anticoagulant medication apixaban and should be monitored for side effects but was not. RN A said she was educated to monitor all anticoagulant medication for side effects. She said the charge nurse putting the order in the computer system was responsible for adding the monitoring into the computer system and the ADON was the back up to double check to ensure the monitoring was added. RN A said Resident #55's monitoring was overlooked. She said the resident risk of an anticoagulant not monitored for side effects was potential bleeding. During an interview on 03/18/2026 at 8:26 a.m., the ADON said Resident #55's anticoagulant medication should have been monitored for side effects and all the nurses were all educated on adding side effect monitoring into the computer system for anticoagulant medication. She said she was the back up to ensure monitoring was added into the computer system. She said Resident #55's monitoring was overlooked. The ADON said Resident #55 went to the hospital and the anticoagulant monitoring may not have been added back into the computer system on her return. She said the DON was responsible for addressing Resident #55's pharmacy recommendation on 02/06/2026 and adding monitoring to the anticoagulant medication into the computer system but it was overlooked. She said she was now responsible for the pharmacy consultant recommendations. The ADON said the resident risk of a pharmacy recommendation being missed was that the anticoagulant medication was not monitored with a potential for bleeding. During a phone interview on 03/18/2026 at 11:51 a.m., LVN B said she no longer worked at the facility. She said she overlooked adding the side effect monitoring into the computer system when she put the order for Resident #55's anticoagulant medication into the computer system. She said she was educated on adding side effect monitoring to anticoagulant medication orders. LVN B said the resident risk of not monitoring an anticoagulant medication for side effects was the potential for bleeding. During an interview and record review on 03/18/2026 at 12:12 p.m., the Director of Clinical Operations said the charge nurse receiving the physician order was responsible for adding the side effect monitoring for an anticoagulant into the computer system and ADON and pharmacy consultant were the back up to ensure the monitoring was added. She said the nurses were educated on adding side effect monitoring when a resident was ordered an anticoagulant medication. She said she revised Resident #55's Apixaban order and updated the diagnosis. The Director of Clinical Operations said Resident #55's monitoring for side effects for his anticoagulant medication was overlooked. The Director of Clinical Operations said the DON was responsible for addressing the pharmacy consultant recommendations from 02/09/2026. She said the DON left without notice on 02/17/2026. She said the pharmacy recommendation was overlooked. The Director of Clinical Operations said her expectation was anticoagulant medication administered as directed by the physician and monitored for bleeding and other side effects of anticoagulants and all pharmacy recommendations addressed and carried out completely. During an Interview on 03/18/2026 at 1:20 p.m., the Administrator said the charge nurse receiving the physician order was responsible for adding the monitoring for side effects into the computer system and the ADON was the back up to double check for monitoring. He said Resident #55's monitoring for side effects was overlooked. The Administrator said the resident risk of an anticoagulant medication not monitored for side effects was potentially bleeding. The Administrator said the DON was responsible for addressing the pharmacy consultant recommendations from 02/09/2026. He said the DON left without notice on 02/17/20266. He said the pharmacy recommendation was overlooked. He said his expectation was physician orders be followed including monitoring and follow up as appropriate and all pharmacy recommendations addressed timely. Record review of the facility policy titled Medication Regimen Reviews revised May 2019 indicated the following,. The Consultant Pharmacist reviews the medication regimen of each resident at lease monthly.4. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication.d. inadequate monitoring for adverse consequences; . Record review of the facility policy titled Administering Medications revised dated April 2023 indicated the following.Medications are administered in a safe and timely manner, and as prescribed. 12. Medications which require special monitoring will be listed on the Nurses Medication Administration Recor for assessment/ recording. These medications include . c. Anticoagulant/ Antiplatelet (blood thinning) Medications.)

Based on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one of four residents (Resident #1) reviewed for accident hazards/supervision/devices. The facility failed to ensure CNA A used a gait belt when transferring Resident #1 from her wheelchair to the bed on 03/10/2026. This failure could place the residents at risk for discomfort, pain, falls, injuries, and skin tears.Findings included: Record review of Resident #1's face sheet, dated 03/11/2026, indicated a [AGE] year-old female, admitted [DATE]. Diagnoses included dementia (loss of cognitive functioning), cognitive impairment, dysphagia (difficulty swallowing), history of falls, anxiety disorder (persistent and excessive worry that interferes with daily activities) and depression (mental illness that negatively affects how you feel, the way you think and how you act). Record review of Resident #1's MDS, dated [DATE], indicated she was unable to complete a brief interview for mental status. She had short- and long-term memory problems and was severely impaired cognitively. Record review indicated she was dependent on staff for chair to bed transfer. She was always incontinent with urine and bowel. She had sustained two falls without injury and one fall with minor injury since the prior assessment. Record review of Resident #1's care plan, dated 02/27/2025, indicated Resident #1 had a self-care performance deficit and was dependent on staff for most ADLs. Record review indicated an intervention for ADL care transfers, bathing, bed mobility, toileting, dressing, personal hygiene, oral care and locomotion required total assistance by one (1) staff to provide care. During an observation on 03/10/2026 at 3:45 p.m., Resident #1 was observed being assisted from her wheelchair to the bed by CNA A. Resident #1 was able to hold to the side rail of the bed but required extensive assistance to stand up with CNA A's arm around her body (chest area) and pulling her up to standing position, pivoted her close to bed and then lowered her to the bed, and picked up her feet removed shoes and placed her feet on the bed assisted her to a lying position in bed. Resident #1 was very unsteady and shaky during the transfer. No gait belt was used during the transfer. Resident #1 did not express any signs of pain or discomfort during or after the transfer. During an interview with the DOR on 03/11/2026 at 12:15 p.m., she said the facility does annual transfer training and with specific staff and residents as the need arises. She said Resident #1 had received therapy services due to a history of falls. She said therapy does participate in care plan meetings and determined transfer status. She said she is a speech language pathologist, and the physical and occupational therapist does most of the transfer training and it would be best to interview with one of them regarding transfer training. During an interview with COTA B on 03/11/2026 at 2:15 p.m., she said she assisted with providing facility staff transfer training annually and with specific staff and residents as the need arises. She said Resident #1 had received therapy services due to a history of falls. She said therapy does participate in care plan meetings and determined transfer status. She said Resident #1 required assistance of one (1) staff with transfers. She said staff should be utilizing a gait belt during Resident #1's transfers. She said it was not acceptable to lift someone under their arm pits or around chest area (bear hug technique) due to the potential for injury not only to the resident but also to the caregiver/staff. She said staff should use a gait belt with all manual lifting of residents for safety. She said not using a gait belt or proper transfer technique could increase the risk of falls or injuries. During interviews with direct care staff (CNA F, CNA G, CNA H, CNA J, CNA K, CNA L, LVN M, LVN N, LVN O, LVN P) on 3/11/2026 from 9:30 am to 3:00 pm staff said that they were to utilize a gait belt for residents requiring one-or two-person manual transfers. During an interview with CNA A on 03/11/2026 at 3:00 p.m., she said she should have used a gait belt for the transfer with Resident #1 and not utilized the bear hug transfer technique because it could cause injury to her arms/shoulders. CNA D said she tried not to put her hand directly under Resident #1's arm pits to prevent injury. She said she got nervous about being observed during the transfer and forgot to use a gait belt. She said she had been trained on using a gait belt during transfers. She said she notified the ADON and administrator she did not utilize a gait belt during the transfer observation and they placed her on immediate suspension until she could be properly trained on performing a safe transfer by therapy staff. She said she remains on suspension awaiting a call from facility therapy department for her transfer training scheduled appointment. During an interview with the ADON on 03/11/2026 at 3:15 p.m., she said she expected staff to use a gait belt when manually transferring a resident. She said the risk of staff not following the correct procedure for transfers was injury to a resident's shoulders and arm and or the risk of the resident falling causing an injury. She said she and the administration had talked with CNA A regarding her observed transfer of Resident #1 on 3/10/2026 and she acknowledged she did not use a gait belt during the transfer. The ADON said CNA A was placed on suspension on 3/10/2026 immediately upon notification of not utilizing a gait belt during the transfer and was scheduled to meet with therapy department for one-on-one transfer training and she would not be allowed to return to work until her training was completed and proper technique demonstrated. She said a safe lifting and movement of residents' in-service with all the staff will be conducted to ensure staff were providing correct transfer techniques. During an interview with the Administrator on 03/11/2026 at 4:15 p.m., he said the facility staff should utilize and follow safe transfer practices, which would include utilizing a gait belt during manual transfers. He said staff should utilize appropriate techniques and devices to lift and move residents properly and safely. He said not using the proper devices to manually lift residents could cause pain, falls, and possible injury. Record review of CNA A's personnel file indicated she was rehired on 07/27/2025 and the staff education/orientation checklist indicated she had received training on safe transfers on 07/27/2025 and had met the criteria for proper technique. Record review of the facility's policy, Safe Lifting and movement of Residents revised July 2017, indicated, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include the following: a. Resident's preferences for assistance; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing ability; e. Cognitive status; f. Whether the resident is usually cooperative with staff; and g. The resident's goals for rehabilitation, including restoring or maintaining functional abilities. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices.

Based on 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 to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #1) reviewed for infection control. RN A failed to properly dispose of used sharps on [DATE] and they were left hanging attached to an IV pole. On [DATE], EMS B was stuck by the used sharps when she grabbed the IV pole to utilize during CPR. This failure could place residents and staff at risk of exposure to communicable diseases and infections. Findings included: Record review of Resident #1' face sheet dated [DATE] indicated he was a [AGE] year-old male admitted on [DATE], and his diagnoses included encephalopathy (damage or disease that affects the brain), anemia (deficiency of red blood cells), diabetes (blood sugar is too high), depression (mental health condition), anxiety (excessive worry), heart disease, kidney disease, and liver transplant status. Record review of Resident #1's physician orders dated [DATE] indicated may insert IV on [DATE] and change to clysis (medical introduction of fluids into the body, typically by injection, to replace lost fluids, provide nutrients, or maintain blood pressure.) Record review of Resident #1's progress note dated [DATE] at 10:14 p.m. by RN A indicated the clysis that was inserted into the left upper arm was dislodged. The site was leaking clear fluid and was cleansed and patted dry. MD was notified. During an interview on [DATE] at 1:15 p.m., RN D said on [DATE] she attempted to insert an IV to administer IV fluids for Resident #1 and was not successful. She said she obtained order to change the IV to clysis. She said she left her shift on [DATE] at approximately 6:30 p.m. and Resident #1 was receiving fluids as ordered. She said she returned to work her shift at 6:00 a.m. on [DATE] and was informed the clysis had been dislodged. She said the MD did not order re-insertion of the clysis. She said on [DATE] Resident #1 was found unresponsive and emergency CPR was initiated. She said EMS arrived and took over. She said she heard EMS E tell EMS B there was an IV pole. She said EMS B grabbed the IV pole and screamed she was stuck. RN D said she removed the bag of saline and used sharps from the IV pole and disposed them into the garbage bin at the nurse station. She said she knew she should dispose of the sharps into the used sharps container but she was waiting until EMS looked over the bag and used sharps. She said EMS B and EMS E checked the bag to make sure there was no medications included in the saline solution. RN D said she then disposed of the used sharps in the sharps container and the bag of saline was disposed of into the trash. She said the used sharps should have been disposed of in the sharps container immediately and not left on the IV pole in Resident #1's room. She said Resident #1 did not have a room mate. She said other residents and staff were at risk of exposure to communicable diseases and infections if sharps were not disposed of correctly. During an interview on [DATE] at 1:43 p.m., the ADON said all used sharps should have been disposed of in the sharps container and not left on the IV pole in Resident #1's room. She said Resident #1 did not have a room mate. She said other residents and staff were at risk of exposure to communicable diseases and infections if sharps were not disposed of correctly. During an interview on [DATE] at 2:09 p.m., the Administrator said the used sharps should have been disposed of correctly in the sharps container. He was not made aware of incident when EMS B was stuck with the used sharps when it occurred on [DATE]. He said he received an email from the Fire Marshall regarding the incident on the evening of Sunday [DATE] that he did not open until Monday [DATE]. During an interview on [DATE] at 2:13 p.m., RN A said CNA F came and told her Resident #1's clysis was dislodged on [DATE]. She said there was no order to re-insert. She hung the tubing and used sharps high on the IV pole. She said she was going to go back and dispose of the used sharps and saline but she got busy with other residents and forgot to dispose of the used sharps in the sharps container. She said the used sharps should have been disposed of in the sharps container and not left on the IV pole in Resident #1's room. She said other residents and staff were at risk of exposure to communicable diseases and infections if sharps were not disposed of correctly. During an interview on [DATE] at 9:14 a.m., EMS B said she went into Resident #1's room and took over CPR on [DATE]. She said an epi drip (intravenous infusion of epinephrine used to support blood pressure, heart rate, and cardiac output in critically ill or anaphylactic patients) was started and she was holding the bag when EMS E noticed the IV pole. She said the IV pole had a bag of saline hanging on it. She said she was removing the bag of saline when she was stuck with the sharps. She said there was subcutaneous sharps attached that she did not see when she grabbed the bag of saline. She said RN D took the bag of saline and attached tubing and sharps from the room. She said she pulled up her glove and put a bandage over the area where she was stuck by the sharps. She said the CPR was continued until Resident #1 was pronounced deceased . She said she went to the nurse station and asked RN D to see the bag. She said RN D said she threw it away and when she asked to see it, RN D went to the trash and pulled the bag and used sharps out of the trash. She said RN D did not dispose of the used sharps into a sharps container. Record review of the facility's Sharps Disposal policy dated 2001 (revised [DATE]) indicated This facility shall discard contaminated sharps into designated containers. 1. Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers. 2. Contaminated sharps will be discarded into containers that are: a. Closable; b. Puncture resistant; c. Leakproof on sides and bottom; d. Labeled or color-coded in accordance with our established labeling system; and e. Impermeable and capable of maintaining impermeability through final waste disposal. 7. Whoever observes incorrect disposal or handling of contaminated sharps should report the information to the Infection Preventionist (or designee).

Based on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment significantly for one (Resident #1) of 10 residents reviewed for changes in condition. The facility failed to notify the responsible party (RP) for Resident #1 when he developed small pleural effusion requiring antibiotic therapy. These failures could place residents at risk for a decline in health, for family members not knowing the health status of the resident, being informed of and participating in care decisions.Findings included: Record review of face sheet dated [DATE] indicated Resident #1 was admitted on [DATE], was a [AGE] year-old male with diagnoses that included acute kidney failure (when kidneys stop working suddenly), muscle weakness, dysphagia (difficulty swallowing), thrombocytopenia (low platelet count), gastrostomy status (a tube directly into the stomach for feeding), septic (infected with microorganisms, especially harmful bacteria), carcinoma (cancer) of oral cavity, diabetes type 2 (chronic condition that affects the way the body processes blood sugar), atrial flutter (heart rhythm disorder), acute embolism (blood clot in blood vessels, partially or completely blocking blood flow) and thrombosis (blood clot forms in a blood vessel) of deep veins of left lower extremity. Record review of Resident #1's clinical admission assessment dated [DATE], authored by RN J indicated he was alert and oriented x 3, oriented to person, time and place. Respiratory status indicated lungs clear throughout bilaterally, no difficulty breathing and no cough noted. Pain assessment indicated no pain or hurting. Record review of Resident #1's care plan indicated it was cancelled as of [DATE] (deceased as of [DATE]) and did not include RP notification for change of condition. Record review of Resident #1's progress health status note dated [DATE] authored by RN H indicated he reported shortness of breath and diarrhea and received orders for bowel rest, hold his g-tube feeding, obtain labs, nebulizer treatments as needed and chest x-ray. There was no documentation the RP was notified. Record review of Resident #1's progress health status note dated [DATE] authored by LVN A indicated chest x-ray sent to MD indicated small pleural effusion (small amount of fluid accumulates in the pleural space, the area between the lungs and the chest wall). MD ordered levofloxacin (a)750 mg antibiotic for 5 days. There was no documentation the RP was notified. Record review of Resident #1's x-ray results dated [DATE] indicated a small pleural effusion. Record review of Resident #1's death certificate dated [DATE] indicated he passed away on [DATE] due to probable acute pulmonary thromboembolism (blood clot travels to and blocks the pulmonary arteries in the lungs). During an interview on [DATE] at 10:30 a.m., the DON said the charge nurse was responsible for notifying the resident RP/family of change of condition, test orders such as an x-ray, test results, and new medication orders. The DON stated her expectation was for nursing staff to notify the family of any change in condition. She stated the family of Resident # 1 should have been notified when he first had a change of status. She said nursing staff should document in the electronic record that the RP/family was notified. In an interview on [DATE] at 10:20 a.m., the Administrator said it was the DON's responsibility to ensure RP/family notification was completed. It was his expectation, if there was a change of condition, the family should be notified as soon as possible. He stated it was important for the family to know what was going on with the resident. The surveyor made two attempts to call LVN A on [DATE] at 12:05 p.m. The number was not available. The facility had no additional contact numbers. The surveyor attempted to call RN H on [DATE] at 12:10 p.m. There was no answer. The surveyor left a voicemail with contact information. RN H did not respond as of the investigation exit. The surveyor attempted to call Resident #1's RP on [DATE] at 11:28 a.m. and 11:30 a.m. There was no answer. The surveyor left a voicemail with contact information. The RP did not respond as of the investigation exit. During an interview on [DATE] at 11:38 a.m., Family Member F said Resident #1's RP was not notified of his change of condition, the x-ray, or the x-ray results. Record review of the facility's Resident Rights policy dated 2001 (revised [DATE]) indicated .be notified of his or her medical condition and of any changes in his or her condition; . Record review of the facility's Change in a Resident's Condition or Status dated 2001 (revised [DATE]) indicated Our facility 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 (e.g., changes in level of care, billing/payments, resident rights, etc.). 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: b. there is a significant change in the resident's physical, mental, or psychosocial status; . 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.

Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and other officials including to the State Survey Agency in accordance with State law through established procedures for 2 of 10 residents (Residents #2 and #3) reviewed for reporting allegations of abuse. The facility failed to report an allegation of misappropriation within 24 hours after Resident #2's RP reported Resident #2's wallet with $375.40 was missing on 08/06/25. The facility failed to report an allegation of verbal abuse within 2 hours on 08/11/25 when Resident #3's friend reported DA K called Resident #3 a bitch. These failures could place residents at risk of unreported abuse, neglect, exploitation, and a decreased quality of life.Findings included: Record review of Resident #2's face sheet dated 11/04/25 indicated she was a [AGE] year-old female, admitted on [DATE], and her diagnoses included hypoglycemia (low blood glucose level), diabetes (body doesn't make enough insulin or can't use it properly), depression (persistent feeling of sadness), and anxiety (feeling of uneasiness and worry). Record review of Resident #2's admission MDS assessment dated [DATE] indicated she was able to make herself understood and understood others and had moderate cognitive impairment (BIMS-10). There were no noted behaviors. Record review of Resident #2's care plan dated 08/15/25 indicated she had decided to have a surveillance camera in her room[KS1] . Record review of a grievance form dated 08/06/25, indicated Family Member X [KS2] reported to a charge nurse that Resident #2's wallet with $375.35[KS3] was missing. The wallet and money were in a dresser drawer between clothes upon admission on [DATE]. Family Member X indicated she checked the wallet daily and on 08/06/25, the wallet was no longer in the dresser drawer. The missing wallet and money were reported to the Administrator on 08/06/25. The Administrator noted on 08/11/25 he spoke to Resident #2 regarding the missing money. She stated she wasn't sure how or when her wallet went missing. When asked if she felt safe or worried, she said she was fine and showed no emotional distress. The administrator searched Resident #2's room, closet, and drawers and nothing was found. The administrator and DON interviewed all staff assigned to the area including nursing, housekeeping, laundry, and dietary regarding the missing money for several days. All staff were unaware of the grievance and recalled no concerns/distress from Resident #2. On 08/12/25 the Administrator spoke with Resident #2 again to see if she recalled anything and to make sure she still felt safe. She stated everything was fine and showed no signs of distress. On 8/13/25 the Administrator spoke to Resident #2's responsible party and family member T. The Administrator informed her of the investigation process, lack of findings to date and what potential outcomes may be. She confirmed the initial report that stated the only visitor that Resident #2 had recently was family member R, which happened to be on the same day as the wallet came missing but didn't believe she would have taken it. The Administrator informed her the facility would continue to interview staff regarding the missing money and would also be providing re-education to staff regarding abuse and neglect and theft. The RP was satisfied with our efforts and current outcome. Investigation/search would continue. There was no indication that the allegation of misappropriation was reported to HHSC. Record review of Resident #2's progress note dated 08/20/25, completed by LVN A indicated Resident #2 was discharged on to hospital and did not return to the faiclity. Record review of Resident #3's face sheet dated 11/04/25 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included nonrheumatic aortic valve stenosis (the valve is narrowed and doesn't open fully), cognitive communication deficit (communication challenge), anxiety (feeling of uneasiness and worry), unspecified intellectual disabilities, and persistent mood (affective) disorder (chronic form of depression). Record review of Resident #3's quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and understood others and was cognitively intact (BIMS-15). There were no noted behaviors. Record review of Resident #3's care plan dated 09/14/25 indicated no focus related to the allegation. Record review of Resident #3's progress not completed by RN M indicated Resident #3 passed away on 10/02/25[KS4] . Record review of a grievance dated 08/11/25 reported to the DON, indicated Resident #3 claimed DA K was rude and called her a bitch. The administrator was notified on 08/11/25. The Administrator noted on 08/18/25 he spoke with Resident #3's [KS5] family member N. Resident #3's family member N stated he wasn't sure exactly what was said while staff member(s) were talking to Resident #3 from across the room from the kitchen door. He said he was aware of Resident #3's request for additional butter or something but he wasn't aware of anyone using the b word nor was he aware of who the staff was including if it was DA K. The Administrator spoke with DA K and he denied the allegation. DA K stated he would never use that type of language. He insisted that he did not approach Resident #3 but merely spoke to her from the kitchen door about getting additional butter. He stated other staff members were speaking as well but doesn't recall anyone using the b word towards her. The Administrator followed up with Resident #3 and discussed his findings regarding DA K and other staff members. The Administrator informed her that DA K stated he would never have done that and was willing to apologize to her if that is what she thought. The Administrator informed Resident #3 that customer service and communication were very important and would be reviewed again with the entire team. Resident #3 was satisfied with the outcome. There was no indication the allegation of verbal abuse was reported to HHSC. During an interview on 11/03/25 at 9:40 a.m., the Administrator said he was the abuse coordinator. He said all allegations of abuse, neglect and misappropriation would be reported to him or the designee immediately. He said the facility was required to report allegations of abuse, neglect, misappropriation within the required timeframe[KS6] to HHSC. During an interview on 11/03/25 at 4:02 p.m., the Administrator said he did not report the allegations of misappropriation or abuse. He said when he followed up on Resident #3's RP and friend, Resident #3 was fine and he based his decision to not report the allegation of verbal abuse on his inquiries. He said he could not prove DA K called Resident #3 a bitch. He said he could not prove who took Resident #2's wallet and money so he did not report the allegation of misappropriation. During an interview on 11/04/25 at 10:30 a.m., the DON said she reported the allegation that DA K called Resident #3 a bitch to the Administrator immediately. She said all allegations of abuse were reportable to HHSC within two hours. During an interview on 11/04/25 at 1:51 p.m., DA K denied calling Resident #3 a bitch. He said he was passing by her table, and she asked for cream cheese, and he told her there was none. He said he did not hear any staff use the b word. Record review of the facility's Abuse, Neglect, and Exploitation Policies and Procedures dated 2001 (revised July 2017) indicated .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury

Based on observation, interview, and record review the facility failed to store and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure expired foods were discarded. 3. The facility failed to store foods in accordance with professional standards. These failures could place residents who ate the food from the kitchen at risk for food-borne illness and a diminished quality of life. Findings included: During observation and interview on [DATE] at 8:25 a.m., an initial tour of the kitchen was conducted with the Dietary Manager, the following was observed: Refrigerator #2 indicated: (1) gallon bag of [NAME] Creek Sliced American cheese with no date opened and exposed to air. Prep-refrigerator indicated: (1) tray of 18- 8ounce cups of white liquid substance with plastic wrapped lids with no label of what the item was or date prepared. [NAME] substance was identified by Dietary Manager as milk. Dry pantry indicated the following: (1) 750ml bottle of Barrel & Bean vanilla-hazelnut sugar-free syrup ,d+[DATE] used with a manufacture best by date of ,d+[DATE]. (1) 1-gallon bottle of distilled white vinegar ,d+[DATE] used with no date when opened (1) 1- pound bottle of Smucker's Raspberry dessert topping ,d+[DATE] used with a manufacture best by date of ,d+[DATE]. The Dietary Manager said both were used to decorate cakes, but may not have the same taste if used after the best by date. (1) 1-bowl used as a scoop left in the brown sugar container. During an interview on [DATE] at 8:59 a.m., the Dietary Manager said the expectation for dating items in the refrigerator and freezer were for all items to have a handwritten date received and if the items were opened then a date opened. She said she and the kitchen aides were responsible for making sure staff in the kitchen put the items in bags and if taken out of their original boxes and making sure the items were labeled and dated when they arrived and when they were first opened. The Dietary Manager said the food must be labeled and dated properly to prevent cross contamination from using spoiled foods. She said eating outdated foods could make residents sick. The Dietary Manager said the staff were trained to properly store food by labeling it when it was opened and sealing it to reduce its exposure to the elements. Record review of Food Ordering, Receiving and Storage revised [DATE] reflected, Policy Interpretation and Implementation . 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date) 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) Review of the Food and Drug Administration Food Code, dated 2022, reflected, XXX,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food ,d+[DATE].11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview, and record review, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 2 residents (Resident #32) reviewed for enteral feeding. The facility failed to ensure LVN C mixed crushed medications with water and administered one medication at a time when giving medications to Resident #32 through her G-tube (a tube inserted through the wall of the abdomen directly into the stomach which allows the delivery of nutrition, fluids, and medications directly into the stomach). The facility failed to ensure LVN C administered Resident #32's G-tube medications by gravity, and instead she pushed the medications using the plunger of the syringe. These failures could place residents receiving enteral nutrition and medications at increased risk of not receiving proper nutrition, infection, and aspiration. Findings include: Record review of a face sheet dated 01/07/24 indicated Resident #32 was a [AGE] year-old female and admitted to the facility 12/14/20. Her diagnoses included dysphagia (difficulty or discomfort swallowing) and aphasia (affects the ability to communicate) following cerebrovascular disease (a group of conditions that impact the brain's blood vessels and blood flow). Record review of the most recent quarterly MDS dated [DATE] indicated Resident #32 had no speech and was sometimes understood and usually understood most conversation. She had a BIMS score of 0 indicating severe cognitive impairment, required partial/moderate assistance with most ADLs, and required a feeding tube for all nutrition and fluid intake. Record review of a care plan last revised 12/05/25 indicated Resident #32 required a feeding tube related to dysphagia and was at risk for aspiration (breathing in a foreign object such as food). Interventions included to dissolve each medication in 10 cc (cubic centimeter equal to a volume of one milliliter) water and flush with 10cc water between each medication. Record review of physician orders dated January 2025 indicated Resident #32 was NPO (nothing by mouth) and was to receive all feedings, water and medications via G-tube. Orders indicated flush tubing with 30 cc water before and after medication administration and dissolve each crushed medication in 10 cc water and flush with 10cc water after each medication. During an observation of medication administration on 01/07/25 at 9:20 a.m., LVN C crushed eight medication tablets together and poured them in a medication dose cup. She washed her hands and gowned and gloved. She checked placement of the G-tube by aspirating stomach contents and flushed the tubing with 30 cc water. She poured the dry crushed medications into the syringe with the water used to flush the tubing. The fluids and medications stopped flowing into the tubing. LVN C poured the contents of the syringe into a cup and used the plunger of the syringe to force the tube open. She removed the plunger and poured the contents of the cup back into the syringe. The G-tube leaked a small amount and then flowed per gravity drainage. She then added 30 cc of water and began administration of feeding of 375 cc DiabetaSource AC (specialized nutrition solution). The gravity flow of the feeding slowed, and she used the plunger of the syringe to hasten the flow. The feeding was completed, and she flushed the tubing with 30 cc water. During an interview on 01/07/25 at 2:02 p.m., LVN C said she normally dissolved each medication in water and administered one medication at a time. She said she should have crushed Resident #32's medications separately and dissolved each medication in 10 cc water and given them one at a time, but she was so nervous being watched that she didn't follow her normal procedure. She said she shouldn't have used the plunger of the syringe to unclog the tubing and that G-tubes should only be flushed by adding water and letting the water flow by gravity. She said crushing all the medications together and not mixing them with water had caused the tube to stop up. She said flushing the G-tube using a plunger could cause irritation to the resident's stomach. She said she had received training on G-tubes during her orientation and yearly at the facility. She said the facility did yearly skills check offs that included G-tubes. During an interview on 01/07/25 at 02:53 p.m., the DON said he expected all nurses to follow facility policy when administering G-tube medications. He said the policy indicated to administer one medication at a time diluted by water and to never use the piston (plunger) of the syringe when flushing the G-tube or administering medications. He said by giving one medication at a time the nurse would know what medication did not enter the stomach if the G-tube clogged. He said using the plunger of the syringe to unclog or flush the G-tube could cause rupture of the stomach. He said LVN C was observed yearly giving G-tube medications and during the observations she administered one medication at a time diluted in water and flushed the G-tube with water using gravity flow. Record review of a skills observation of administering medications/feedings through an enteral feeding tube dated 09/24/24 indicated LVN C diluted each medication with water and gave each medication separately and allowed all fluids given to administer by gravity flow. Record review of the facility policy titled Administering Medications through an Enteral Tube revised March 2024 indicated .10. Dilute medication: a. Remove plunger from syringe. Add medication and appropriate amount of water to dilute. b. Dilute crushed (powdered) medication with prescribed amount of water. 11. Administer each medication separately. 12. Reattach syringe (without plunger) to the end of the tubing. 13. Administer each medication by gravity flow: a. Pour diluted medication into barrel of the syringe while holding the tubing slightly above the level of insertion. B. Open the clamp and deliver medication slowly. C. Begin flush before the tubing drains completely

41057 Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 6 residents observed for oxygen management. (Resident #76) The facility failed to keep the oxygen concentrator (machine that takes air from your surrounding and extract oxygen and filter it into purified oxygen to breath) filter clean for Resident #76 and humidifier bottle (oxygen can be drying to your nose so some patients use a humidifier bottle to moisten the oxygen you breath) filled with water. These failures could place residents at risk of a significant reduction in the quality of oxygen being delivered, inadequate oxygen support, and decline in health. Findings included: Record Review of Resident #76's face sheet dated 01/06/25, indicated he was a [AGE] year-old male admitted on [DATE] with a diagnosis of atherosclerotic heart disease (a build of fatty deposits in the inner lining of the coronary arteries that may cause shortness of breath). Record Review of Resident #76's most recent quarterly MDS assessment dated [DATE] indicated he had a BIMS score of 10 which indicated moderate cognitive impairment. The assessment indicated a medical diagnosis of atherosclerotic heart disease. Record Review of Resident #76's care plan revised 11/20/24 indicated he had altered cardiovascular status with interventions of requires oxygen use, ensure setting and delivery method are appropriate and correct. A care plan indicated he had oxygen therapy with an intervention to monitor for signs and symptoms of respiratory distress. Record Review of Resident #76's Physicians Order Summary dated 01/08/25 indicated he was prescribed oxygen at 2 - 5 liters per minute by nasal canula for shortness of breath or if oxygen saturation (a measure of how well the lungs are working) was below 93%. During an observation on 01/06/25 at 10:20 a.m., Resident #76 was lying in bed with oxygen per nasal canula on at 2.5 liters/ minute to an oxygen concentrator. Resident #76 said he used his oxygen daily now. The humidifier bottle was empty, and the oxygen concentrator's filter was covered with a thick grey powdery, dusty substance. During an observation on 01/07/25 at 08:00 a.m., Resident #76 was lying in bed with oxygen per nasal canula on at 2.5 liters/ minute the humidifier bottle was empty, and the oxygen concentrator filter was covered with a thick grey powdery, dusty substance. During an observation and interview on 01/06/25 at 03:54 p.m., LVN C said she was providing care for Resident #76 today. She said he received oxygen as needed and was receiving oxygen currently. She said the humidifier bottle on the oxygen concentrator was empty and needed to be changed and she would change it. LVN C said the oxygen concentrator filter was dirty and should have been changed. She said she would get it cleaned. LVN C said she was responsible to ensure the oxygen concentrator filter was clean and the humidifier container be changed out and have water in it. She said the DON and ADON were the back up to double check oxygen concentrator filters were clean and oxygen humidifier bottles were changed when empty. She said it was overlooked. LVN C said it was not a resident risk for the humidifier bottle to be empty, the oxygen was just not humidified. She said a dirty oxygen concentrator filter was a resident risk of not allowing proper air exchange by the oxygen concentrator. During an interview on 01/07/25 at 3:59 p.m., the DON said the nurses were responsible to ensure the oxygen concentrators humidifier bottles were changed when needed. He said maintenance was responsible for cleaning the oxygen concentrator filters. He said the facility did not have a double check but would now have one. The DON said the empty humidifier bottle and dirty oxygen concentrator filter were overlooked. He said the staff were educated to change out the empty humidifier bottles and maintenance was educated to change or clean the dirty filter on the oxygen concentrators. He said the humidifier bottle being empty was not a risk, it was for comfort to humidify the oxygen. The DON said the resident risk of a dirty oxygen concentrator filter could decrease performance of the oxygen concentrator and not be as effective. He said his expectation was oxygen humidifier bottles be changed when necessary, tubing changed on 10/ 6 shift on Sundays and oxygen concentrator filters checked and if dirty notify the DON or ADON and they would have maintenance clean them until the nurses could be in-serviced on the proper way to clean the filters. During an interview on 01/08/25 at 8:30 a.m. the Maintenance Director, said the nurses were responsible to ensure the oxygen concentrator filters were cleaned if the filter was not covered by the machine as Resident #76's was. He said he cleaned the machines, serviced them and tagged them as clean. If he could not repair the machine, he would send it out for repair. The Maintenance Director said the nurses clean the filters after he sends out the machine and he was not sure what happened he said the nurse was responsible. He said he was educated on cleaning the concentrators and adding a clean filter. The Maintenance Director said the risk of a dirty filter on an oxygen concentrator was the concentrator may not work properly and could affect air going through it. During an interview on 01/08/25 at 11:48 a.m., the Administrator said the nurses were responsible for ensuring the oxygen concentrator humidifier bottles were filled or changed out and maintenance was responsible for cleaning the filters on the oxygen concentrator for now. He said the double check was administrative rounds. He said HR was Resident #76 administrative round person. The Administrator said the nurses were educated on changing out empty humidifier bottles and maintenance was educated on cleaning oxygen concentrators filters. He said they were overlooked. The Administrator said the resident risk of the dirty concentrator filter was decreased air flow and could affect the oxygen concentrator performance. He said the humidifier bottle not filled was not a resident risk the water was for comfort. The Administrator said his expectation was for all staff to follow policy and procedures. During an interview on 01/08/25 at 12:30 p.m., the HR said she made administrative rounds on Resident #76 normally and she was to double check on the oxygen concentrators filters and humidifier bottles. She said she would tell the nurse the humidifier bottle was empty and tell maintenance the oxygen concentrator filter was dirty. She said it was overlooked, she did not make rounds this week. The HR said the risk of a dirty oxygen concentrator filter was it could affect air flow to the oxygen concentrator, but she was unsure what effect an empty humidifier bottle could have on a resident. She said she was educated to check on the resident ask about pain, if clean and changed and care received and check if equipment was clean and working. Record Review of a facility policy revised 2009, titled, Maintenance Service indicated, . The Maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Record Review of a facility policy revised October 2010, titled, Oxygen Administration indicated, . 12. Check the mask, tank, humidifying jar, .to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. 14. Periodically re-check water level in humidifying jar. 15. Periodically check oxygen tubing and delivery device . to ensure cleanliness and change as necessary.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate administering of medications for 2 of 18 residents reviewed for pharmaceutical services. (Residents #2 and #19) The facility failed to ensure medication was not left at bedside for Resident #2. The facility failed to administer midodrine HCL prn as ordered on 01/02/25 and 01/06/25 when Resident #19's blood pressure was below prescribed parameters. These failures could place the residents at risk of not receiving the appropriate medications and services to maintain their highest practicable well-being. Findings included: 1. Record review of a face sheet dated 01/08/25 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included morbid (severe) obesity due to excess calories and age-related cognitive decline (subtle decline that affects thinking speed and attention). Record review of an annual MDS dated [DATE] indicated Resident #2 had a BIMS score of 15 indicating she was cognitively intact, was always understood and able to express ideas, and required partial/moderate assistance with most ADLs, Record review of physician orders dated January 2025 indicated Resident #2 was to receive Senna Oral Tablet 1 tablet by mouth two times daily for constipation. Record review of a care plan revised 01/06/25 indicated Resident #2 was at risk for constipation related to decreased mobility. During an observation and interview on 01/07/25 at 06:50 a.m., LVN D was administering a hydrocodone/APAP 5-325 mg 1 tablet every 6 hours as needed for pain for a complaint of right leg pain 10/10 on the pain scale. LVN D watched the resident swallow her medication. Resident #2 asked LVN D if she could take a Senna tablet in a dosage cup that MA B had left with her that morning along with her other medications to take. She said she noticed in the cup and did not want to take the pill because her bowels had been loose. LVN D took the Senna tablet and said she would dispose of it. LVN D said facility policy said for the nurse or the MA to ensure all medications were taken by the resident and never leave medications at bedside. During an interview on 01/07/25 at 06:59 a.m., MA B said she left Resident #2's morning medications with her to take that morning. She said she was trying to hurry and did not stay to watch the resident take the medications and did not know that she had not taken her Senna tablet. She said the facility policy was to stay with the resident until all medications were taken. She said because she did not stay, she did not know the Senna tablet was not taken. She said she should have stayed with Resident #2 and reported to LVN D that she did not take her Senna because she was having loose stools. During an interview on 01/07/25 at 10:30 a.m., the DON said it was the facility's policy for nurses and Mas to remain with a resident until all medications were administered and to not leave medications at the bedside. He said leaving medications at the bedside could result in the resident not getting their medications as ordered. During an interview on 01/08/25 at 8:25 a.m., Resident #2 said MA B usually waited while she took her medications, but she was one of the residents she could leave the medications with and she would remember to take them. During an interview on 01/08/25 at 1:38 p.m., the Administrator said he expected all nurses and MAs to stay with the residents until medications were taken and never leave medications at the bedside. Record review of a facility policy titled Administering Medications revised April 2019 indicated . Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care-planning team, has determined that they have the decision-making-capacity to do so safely. 2. Record review of Resident #19's Face sheet dated 01/06/25 indicated she was admitted on [DATE], was [AGE] years old with diagnoses which included hypertension (high blood pressure), and hypotension (low blood pressure) related to diabetes. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #19 had a BIMS score of 12 which indicated cognition was moderately impaired. She had a diagnosis of hypertension. Review of Resident #19's care plan dated 12/18/24 indicated the resident had diagnosis of hypotension related to diabetes. The interventions included give medications as ordered. Monitor for side effects and effectiveness and to monitor vital signs as ordered. Record review of physician orders dated January 2025 indicated Resident #19 was prescribed carvedilol 6.25 mg (used to lower blood pressure) twice daily for hypertension. The orders indicated to hold for blood pressure less than 110/60; and hold for heart rate below 60. Included was an order for midodrine HCL (used to treat low blood pressure) 5 mg every 12 hours as needed for hypotension (low blood pressure) - administer for systolic blood pressure below 100. Record review of Resident #19's MAR dated 01/01/25 through 01/06/25 indicated the following: 01/02/25 at 9:00 a.m., carvedilol 6.25 mg was held due to B/P 95/50; and 01/06/25 at 9:00 p.m., carvedilol 6.25 mg was held due to B/P 89/50. Record review of the MAR dated 01/01/25 through 01/06/25 gave no indication Resident #19 was administered midodrine 5 mg as prescribed by physician when the SBP was below 100 on 01/02/25 or 01/06/25. (SBP refers to the pressure in your arteries when your heart pumps blood throughout your body. It is the top number in a blood pressure reading). During an interview and record review on 01/08/25 at 9:45 a.m., LVN A acknowledged Resident #19's carvedilol had been held on 01/02/25 and 01/06/25 due to B/P outside prescribed parameters. She also said Resident #19 should have received midodrine 5 mg due to SBP below 100. LVN A said there was no documentation in Resident #19's electronic medical record to indicate it had been administered. She said MAs were responsible for taking vital signs of residents prior to administration of medications. She said anytime vital signs were outside of prescribed parameters, the MAs were to inform LVNs. Although LVN A was not on duty on these occasions, she said the nurses were responsible for administering PRN medications to residents. LVN A said potential negative outcome of not receiving prescribed medication included lethargy and blood pressure could continue to decrease. During an interview on 01/08/25 at 9:50 a.m., MA B said when a resident had blood pressure or heart rate outside of prescribed parameters, the charge nurses were notified and the nurse reassessed residents. During a joint interview and record review on 01/08/25 at 10:15 a.m., the DON and ADON said Resident #19's carvedilol had been held on 01/02/25 and 01/06/25 due to her B/P being outside the prescribed parameters. They said midodrine should have been given to Resident #19 as prescribed by the physician when her B/P fell outside the prescribed parameters. The DON said he expected nursing staff to check the resident's electronic record for PRN orders regarding decreased blood pressure readings. He said residents would not achieve therapeutic levels of medications if not adjusted. The ADON said possible negative outcomes included the B/P could continue to decrease. The DON said he expected the nursing staff to administer all medications as prescribed by the physician as intended. During an interview on 01/08/25 at 10:45 a.m., the Administrator said his expectations were for all residents to have medications administered as prescribed by the physician. Record review of the policy Administering Medications revised April 2019 indicated . Medications are administered in a safe and timely manner, and as prescribed.

Based on observation, interview and record review, the facility failed to ensure residents were provided the therapeutic diets as prescribed by the attending physician for 1 of 18 residents (Residents #21) reviewed for therapeutic diets food and nutrition services. The facility failed to ensure Resident #21 received a CC (control carbohydrate) diet (diet to help manage blood sugar) with the breakfast meals on 01/07/25 and 01/08/25 as ordered by physician. This failure could place residents with diet needs at risk for an increase in blood sugar level and potential decline in health. The findings included: Record review of Resident #21's admission record dated 01/07/25 indicated she was [AGE] years old and admitted on [DATE] with diabetes (disease that results in too much sugar in the blood). Record review of the physician's orders dated 01/07/25 indicated Resident #21's diet was NAS (no added salt), CC (controlled carbohydrate) diet with a start diet of 02/26/24. Record review of the MDS quarterly assessment dated [DATE], indicated Resident #21's BIMS score was 15 indicating no impairment with cognition. She required assist with set up or clean up; resident completed activity for eating. No weight loss or gain of 5% or more in the last month or loss of 10% or more in the last 6 months was noted. Therapeutic diet was noted. Resident #21 received hypoglycemic medication during the last seven days and had a diagnosis of diabetes. Record review of the care plan dated 10/21/24 indicated Resident #21 had diabetes and approaches included . Medication as ordered by doctor, Monitor/document for side effects and effectiveness, and Dietary consult for nutritional regimen and ongoing monitoring. Discuss mealtimes, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen. Monitor/document/report PRN compliance with diet and document any problems. During an interview on 01/06/25 at 10:40 a.m., Resident #21 said the kitchen always sent her regular condiments like syrup with sugar and regular jelly. She stated, I am a diabetic and I get insulin. She said she told someone, but she was unsure who or when. During an observation and interview on 01/07/25 at 8:00 a.m., Resident #21's breakfast tray had a package of regular grape jelly. She said they were still sending the wrong condiments. During an interview on 01/07/25 at 8:30 a.m., LVN D said she had checked Resident #21's breakfast tray and missed the jelly being regular. She said with the resident getting regular jelly, it could elevate her blood sugar. She said she was responsible for checking the tray and she had been trained. During an interview on 01/07/25 at 9:00 a.m., the DON said he would check with the dietician about the grape jelly to verify if the residents on the CC diet could have regular jelly. During an interview on 01/07/25 at 9:45 a.m., the DM said the residents on the CC diet should have received diet jelly and provided the dietary card with items listed for the CC diet for Resident #21. During an interview on 01/7/25 at 2:00 p.m., the DON said he had spoken to the dietician and thought it was ok. He stated you can speak to the DM and Dietician to clarify. During a telephone interview on 1/7/25 at 2:20 p.m., the Dietician said if the menu extension for CC indicated DT Jelly, the resident should receive the diet jelly. She said to check with the DM that she gave them the diet extension. She also said it always comes back to resident preference too. During an interview on 01/7/25 at 3:00 p.m., the Administrator said the meals should be served as ordered unless the resident requested something different. During an observation on 01/8/25 at 8:30 a.m., Resident #21 pointed at her breakfast tray and said the kitchen still sent regular syrup for her breakfast. She stated, I am a diabetic and need diet condiments. During an interview on 01/8/25 at 9:15 a.m., the DM said the dietary was responsible for sending the correct condiments. The DM said the residents on CC diet should have received diet syrup. She said Resident #21 was served regular syrup on her breakfast tray today and should have been served diet syrup. During an interview on 01/8/25 at 10:45 a.m., the dietician said the residents on the CC diet should have been served diet syrup for breakfast. Record review of the diet card dated 01/07/25 indicated Resident #21 was on a CC diet and should be served DT (diet) jelly for her toast. Record review of the diet card dated 01/08/25 indicated Resident #21 was on a CC diet and should be served DT (diet) syrup for her waffle.

Based on interviews, observations, and record reviews, the facility failed to ensure the residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, which includes but not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for 2 (Resident #1 and Resident #2) of 10 residents reviewed for involuntary seclusion. The facility failed to ensure CNA A did not place gloves in the Resident #1 and Resident #2 door to keep Resident #2 from wandering outside her room on 06/21/2024. The non-compliance was identified as past non-compliance. The noncompliance began on 06/21/2024 and ended on 06/21/2024. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk of feeling isolated, fearful, hopelessness uncomfortable, disrespected, decreased self-esteem, and diminished quality of life. Findings included: Record review of Resident #1's Admission Record dated 12/09/2024 indicated she was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which including diverticulitis (a gastrointestinal disease that occurs when pouches in the large intestine wall become inflamed or infected), muscle weakness, abnormal gait and mobility, protein malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), macular degeneration (a disease that causes central vision loss), and depression (mental illness that negatively affects how you feel, the way you think and how you act). Record review of Resident #1's admission MDS assessment, dated 05/13/2024, indicated a BIMS score of 15 which indicated she was cognitively intact and was able to make herself understood and understood others. She was continent of bowel and bladder. Functional Status reflected she required supervision or partial assistance with her ADLs except eating. Resident #1's Mobility Assessment reflected she required supervision or partial assistance with transfers and ambulation. Record review of Resident #1's care plan, dated 05/15/2024, indicated she required limited assistance by staff to move between surfaces and required a rollator walker when ambulating. She was an active participant in structed activities and to encourage resident to participate in activities of choice and respect resident's right to refuse activities that are not desired. Record review of Resident #2's Admission Record dated 12/09/2024 indicated she was a was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included fracture of left pubis (a break in the pelvic bone), muscle weakness, abnormalities of gait, dementia (loss of cognitive functioning) and depression (mental illness that negatively affects how you feel, the way you think and how you act). Record review of Resident #2's admission MDS, dated [DATE], indicated a BIMS score of 2 which indicated she was severely cognitively impaired and was able to make herself understood and understood others. She was always incontinent of bowel and bladder. Functional Status reflected she required moderate to maximum assistance with her ADLs except eating. Resident #1's Mobility Assessment reflected she required moderate to maximum assistance with transfers and did not ambulate used wheelchair for mobility. Record review of Resident #2's care plan, dated 07/06/2024, indicated she was an elopement risk/wanderer disoriented to place, had a history of attempts to leave facility unattended, had impaired safety awareness, and wandered aimlessly. She had interventions for staff to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. She had interventions for staff to identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Record review of the provider investigation report indicated incident category: neglect, and incident date 06/21/2024, description of allegation: CNA B reported that she went to answer a call light for Resident #1 and Resident #2 and noticed gloves had been shoved in the door frame keeping the door from opening. Provider Response: Administrator and DON immediately started to review cameras to see who placed gloves in the door frame. Local police department was notified. Head to toe assessments were done on resident's, families were notified, and Social Worker interviewed both residents to ensure they were ok, and both were fine and felt safe. Investigation Summary: After reviewing camera footage, it was found that CNA A had placed gloves in the door frame to keep it from opening. She was immediately suspended pending an investigation. DON spoke with CNA A later in the day, and she confirmed that she did put gloves in the door frame. Provider Action Taken Post-investigation: CNA A stated that she put gloves in the door frame to keep Resident #2 from wandering out of the room. CNA A was terminated. An in service was conducted on abuse and neglect. The Social Worker interviewed other residents, and everyone was ok and had no issues. Record Review of Resident #1 Skin assessment dated [DATE] indicated no skin abnormalities. Record Review of Resident #2 Skin assessment dated [DATE] indicated no skin abnormalities. Record review of the statement by Social Worker C (dated/undated) indicated she spoke with Resident #1 and Resident #2's responsible party following the incident and Resident #1 felt safe at the facility and was observed continuing her daily activities with no distress. Resident #2's responsible party was thankful for the information. In an interview on 12/09/2024 at 4:34 p.m. with CNA B, she said that when she arrived to work on 06/21/2024 at 6:00 a.m., shortly after report around 6:15 to 6:30 a.m., Resident #1's call light came on and she went to answer it. She stated when she arrived at the door entering Resident #1's room it would not open, and she noticed gloves shoved in the door frame above the door handle keeping the door from opening easily. She said she heard Resident #1 on the other side of the door saying she could not open the door that was why she pushed her call light; she was trying to get out of room to go have her morning coffee. She told Resident #1 to stand away for door and she pushed on the door with body/hip forcefully and the door came open. CNA B said she removed the gloves from the door frame and assisted Resident #1 out of the room to get her morning coffee and immediately went to the DON and reported the incident. CNA B said that Resident #1 was a little concerned when she could not get the door open, but once the door was opened and she got her morning coffee, she seemed fine, no signs of distress. CNA B said she returned to the room to check on Resident #2 and she remained in her bed unaware that the event had occurred. CNA B said she called CNA A and ask her about the gloves in the door and she said she had done that to keep Resident #2 from wandering. CNA B said she was told by CNA A that she had placed the gloves in the door frame around 5:30 a.m., while she was providing care to another resident to prevent Resident #1 from wandering out of her room while she was behind a closed door assisting another resident. CNA B said she removed the gloves and opened the door around 6:30 a.m. In an interview on 12/09/2024 at 4:51 p.m. with CNA A, she said on 06/21/2024 around 5:30 a.m. a call light came on for Hall 700, a resident requesting to be changed. While she was in the hallway getting supplies, she noticed Resident #2 was up wandering in the hallway, so she took Resident #2 back to her room and placed her in bed. When she exited the resident's room, she placed gloves in the door frame to keep the door closed so that Resident #2 could not be wandering in the hallway or possibly go outside while she was behind a closed door changing another resident. CNA A said at the time I thought I was protecting [Resident #2], since I was behind a closed door and could not monitor her. My coworker had left early that morning for clinicals, so I was trying to make sure she did not leave her room and wander away while I was occupied with another resident. I was going to go back and remove the gloves when I finished care on the other resident, but I forgot. CNA said when she finished providing care to the other resident she went and took the soiled trash outside to the dumpster and when she entered the facility, the oncoming staff were in the building. CNA A said, at the time I thought I was protecting the resident, but I now understand that was wrong and not to do that again. I was terminated because of the incident. CNA A denied using this technique in the past to keep residents in their room. In an interview on 12/10/2024 at 9:00 a.m. with the ADON, she said when management was notified of the incident regarding Resident #1 and Resident #2 door, she immediately provided a head-to-toe assessment of Resident #1 and Resident #2 with no injuries or distress observed. In an interview on 12/10/2024 at 9:45 a.m. with the DON, he said that he was notified of the incident with Resident #1 and Resident #2's door being hard to open because of gloves in the door frame on 06/21/2024 around 6:30 a.m. The DON said that they immediately started investigating the incident, ADON provided head to toe assessment of both residents, started watching cameras to identify who had placed the gloves in the door frame and interviewing involved staff. The DON said that CNA A admitted that she placed the gloves in the door frame of Resident #1 and Resident #2's door, to keep Resident #2 in her room while she provided care for another resident. The DON said CNA A said she thought she was protecting Resident #2 from wandering out of the room while she was behind a closed door changing another resident. The DON said CNA A was suspended during the investigation and later terminated. The DON said the [NAME] footage confirmed that CNA A was the staff that placed the gloves in the door frame of Resident #1 and Resident #2's room. In an interview on 12/10/2024 at 2:15 p.m. with the Administrator, he said he assisted in investigating the incident with Resident #1 and Resident #2's door being hard to open because of gloves in the door frame. The administrator said that he watched camera footage and interviewed involved staff and found that CNA A had placed the gloves in the door frame to keep Resident #2 from wandering out of her room while she was providing care to another resident. The Administrator said that the camera footage confirmed that CNA A placed the gloves in the door frame and that CNA A admitted , during an interview, that she placed the gloves in the door frame and thought she was protecting the resident. The Administrator said CNA A was suspended during the investigation and was later terminated due to the confirmation of abuse/neglect allegation. The administrator said the incident was also reported to the local police department. The Administrator said the residents involved were assessed with no injuries or distress noted, safe surveys provided by social worker with no negative outcomes, families and MD were notified of incident. The Administrator said staff were in-serviced regarding abuse and neglect. The Administrator said that the incident was reported to the State Agency as a neglect incident because he was unaware of what category the incident would fall under. The Administrator said his expectations were that the facility remains free of any resident abuse, neglect, and involuntary seclusion. .During observations on 12/09/2024 from 9:15 a.m. - 12/10/2024 4:00 p.m., on Hall 100, 200, 300, 500, 600, and 700 of sampled residents with wandering risk indicated staff closed doors only upon the request of the residents, for privacy during care and no resident seclusion observed. During interviews on 12/09/2024 from 9:15 a.m. - 12/10/2024 4:00 p.m., 1 RN had received training on resident rights, abuse, neglect including involuntary seclusion and was able to identify resident's rights, was knowledgeable that residents have the right to wander and that residents cannot be placed in a room with closed/obstructed door alone for prevention of wandering, was aware to notify the DON/ADON and the Administrator immediately of any resident involuntary seclusion. During interviews on 12/09/2024 from 09:15 a.m. - 12/10/2024 4:00 p.m., 4 LVNs had received training on resident rights, abuse, neglect including involuntary seclusion and were able to identify resident's rights, all were knowledgeable of the abuse, neglect, and involuntary seclusion policy, all were aware of that residents cannot be placed in a room with closed/obstructed door alone for prevention of wandering, and to notify the DON/ADON and the Administrator immediately of any resident involuntary seclusion. During interviews on 12/09/2024 from 09:15 a.m. - 12/10/2024 4:00 p.m., 4 CNAs (2 from each shift) and 3 MAs had received training on resident rights, abuse, neglect including involuntary seclusion and were able to identify resident's rights, were0 knowledgeable that residents have the right to wander and that residents cannot be placed in a room with closed/obstructed door alone for prevention of wandering, was aware to notify the DON/ADON and the Administrator immediately of any resident involuntary seclusion. Record review of an In-Service Attendance Record with subject of Abuse and Neglect, dated 06/21/2024, indicated that 38 staff members signed the in-service record. Record review of Incident logs from 12/09/2023 through 12/09/2024 indicated there were no other involuntary resident seclusion incidents at the facility. Record review of CNA A's employee file indicated she received training regarding abuse and neglect during initial orientation on 09/16/2023. CNA A was suspended on 06/21/2024 and terminated on 06/25/2024 for allegation of abuse and neglect. Record review of the facility's policy Abuse Prevention Program, date revised December 2016, indicated Policy Statement Our 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. Record review of the facility's policy Use of Restraints, date revised December 2023, indicated the facility does not use restraints. Policy Interpretation and Implementation: 7. Seclusion, which is defined as the placement of a resident alone in a room, shall not be employed.

Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse were reported, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or neglect resulting in serious bodily injury, to the State Survey Agency, for 2 of 10 residents (Resident #1, Resident #2) reviewed for reporting allegations of abuse. The facility failed to report an allegation of abuse (involuntary seclusion) to the State Agency within 2 hours when it was reported on 06/21/2024 that Resident #1 and Resident #2 was involuntary secluded in their room by CNA A. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of Resident #1's Admission Record dated 12/09/2024 indicated she was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which including diverticulitis (a gastrointestinal disease that occurs when pouches in the large intestine wall become inflamed or infected), muscle weakness, abnormal gait and mobility, protein malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), macular degeneration (a disease that causes central vision loss), and depression (mental illness that negatively affects how you feel, the way you think and how you act). Record review of Resident #1's admission MDS assessment, dated 05/13/2024, indicated a BIMS score of 15 which indicated she was cognitively intact and was able to make herself understood and understood others. She was continent of bowel and bladder. Functional Status reflected she required supervision or partial assistance with her ADLs except eating. Resident #1's Mobility Assessment reflected she required supervision or partial assistance with transfers and ambulation. Record review of Resident #1's care plan, dated 05/15/2024, indicated she required limited assistance by staff to move between surfaces and required a rollator walker when ambulating. She was an active participant in structed activities and to encourage resident to participate in activities of choice and respect resident's right to refuse activities that are not desired. Record review of Resident #2's Admission Record dated 12/09/2024 indicated she was a was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included fracture of left pubis (a break in the pelvic bone), muscle weakness, abnormalities of gait, dementia (loss of cognitive functioning) and depression (mental illness that negatively affects how you feel, the way you think and how you act). Record review of Resident #2's admission MDS, dated [DATE], indicated a BIMS score of 2 which indicated she was severely cognitively impaired and was able to make herself understood and understood others. She was always incontinent of bowel and bladder. Functional Status reflected she required moderate to maximum assistance with her ADLs except eating. Resident #1's Mobility Assessment reflected she required moderate to maximum assistance with transfers and did not ambulate used wheelchair for mobility. Record review of Resident #2's care plan, dated 07/06/2024, indicated she was an elopement risk/wanderer disoriented to place, had a history of attempts to leave facility unattended, had impaired safety awareness, and wandered aimlessly. She had interventions for staff to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. She had interventions for staff to identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Record review of the provider investigation report indicated incident category: neglect, and incident date 06/21/2024, description of allegation: CNA B reported that she went to answer a call light for Resident #1 and Resident #2 and noticed gloves had been shoved in the door frame keeping the door from opening. Provider Response: Administrator and DON immediately started to review cameras to see who placed gloves in the door frame. Local police department was notified. Head to toe assessments were done on resident's, families were notified, and Social Worker interviewed both residents to ensure they were ok, and both were fine and felt safe. Investigation Summary: After reviewing camera footage, it was found that CNA A had placed gloves in the door frame to keep it from opening. She was immediately suspended pending an investigation. DON spoke with CNA A later in the day, and she confirmed that she did put gloves in the door frame. Provider Action Taken Post-investigation: CNA A stated that she put gloves in the door frame to keep Resident #2 from wandering out of the room. CNA A was terminated. An in service was conducted on abuse and neglect. The Social Worker interviewed other residents, and everyone was ok and had no issues. Date and time reported to HHSC 06/21/2024 at 5:07 p.m. Unable to interview Resident #1 or Resident #2 they no longer reside at the facility. In an interview on 12/09/2024 at 4:34 p.m. with CNA B, she said that when she arrived to work on 06/21/2024 at 6:00 a.m., shortly after report around 6:15 to 6:30 a.m., Resident #1's call light came on and she went to answer it. She stated when she arrived at the door entering Resident #1's room it would not open, and she noticed gloves shoved in the door frame above the door handle keeping the door from opening easily. She said she heard Resident #1 on the other side of the door saying she could not open the door that was why she pushed her call light; she was trying to get out of room to go have her morning coffee. She told Resident #1 to stand away for door and she pushed on the door with body/hip forcefully and the door came open. CNA B said she removed the gloves from the door frame and assisted Resident #1 out of the room to get her morning coffee and immediately went to the DON and reported the incident. CNA B said that Resident #1 was a little concerned when she could not get the door open, but once the door was opened and she got her morning coffee, she seemed fine, no signs of distress. CNA B said she returned to the room to check on Resident #2 and she remained in her bed unaware that the event had occurred. CNA B said she called CNA A and ask her about the gloves in the door and she said she had done that to keep Resident #2 from wandering. CNA B said she was told by CNA A that she had placed the gloves in the door frame around 5:30 a.m., while she was providing care to another resident to prevent Resident #1 from wandering out of her room while she was behind a closed door assisting another resident. CNA B said she removed the gloves and opened the door around 6:30 a.m. In an interview on 12/09/2024 at 4:51 p.m. with CNA A, she said on 06/21/2024 around 5:30 a.m. a call light came on for Hall 700, a resident requesting to be changed. While she was in the hallway getting supplies, she noticed Resident #2 was up wandering in the hallway, so she took Resident #2 back to her room and placed her in bed. When she exited the resident's room, she placed gloves in the door frame to keep the door closed so that Resident #2 could not be wandering in the hallway or possibly go outside while she was behind a closed door changing another resident. CNA A said at the time I thought I was protecting [Resident #2], since I was behind a closed door and could not monitor her. My coworker had left early that morning for clinicals, so I was trying to make sure she did not leave her room and wander away while I was occupied with another resident. I was going to go back and remove the gloves when I finished care on the other resident, but I forgot. CNA said when she finished providing care to the other resident she went and took the soiled trash outside to the dumpster and when she entered the facility, the oncoming staff were in the building. CNA A said, at the time I thought I was protecting the resident, but I now understand that was wrong and not to do that again. I was terminated because of the incident. CNA A denied using this technique in the past to keep residents in their room. IIn an interview on 12/10/2024 at 9:45 a.m. with the DON, he said that he was notified of the incident with Resident #1 and Resident #2's door being hard to open because of gloves in the door frame on 06/21/2024 around 6:30 a.m. The DON said that they immediately started investigating the incident, ADON provided head to toe assessment of both residents, started watching cameras to identify who had placed the gloves in the door frame and interviewing involved staff. The DON said that CNA A admitted that she placed the gloves in the door frame of Resident #1 and Resident #2's door, to keep Resident #2 in her room while she provided care for another resident. The DON said CNA A said she thought she was protecting Resident #2 from wandering out of the room while she was behind a closed door changing another resident. The DON said CNA A was suspended during the investigation and later terminated. The DON said the [NAME] footage confirmed that CNA A was the staff that placed the gloves in the door frame of Resident #1 and Resident #2's room. In an interview on 12/10/2024 at 2:15 p.m. with the Administrator, he said he assisted in investigating the incident with Resident #1 and Resident #2's door being hard to open because of gloves in the door frame. The administrator said that he watched camera footage and interviewed involved staff and found that CNA A had placed the gloves in the door frame to keep Resident #2 from wandering out of her room while she was providing care to another resident. The Administrator said that the camera footage confirmed that CNA A placed the gloves in the door frame and that CNA A admitted , during an interview, that she placed the gloves in the door frame and thought she was protecting the resident. The Administrator said CNA A was suspended during the investigation and was later terminated due to the confirmation of abuse/neglect allegation. The administrator said the incident was also reported to the local police department. The Administrator said the residents involved were assessed with no injuries or distress noted, safe surveys provided by social worker with no negative outcomes, families and MD were notified of incident. The Administrator said staff were in-serviced regarding abuse and neglect. The Administrator said that the incident was reported to the State Agency as a neglect incident because he was unaware of what category the incident would fall under. The Administrator said his expectations were that the facility remains free of any resident abuse, neglect, and involuntary seclusion. Record review of the facility's policy Abuse Investigation and Reporting, date revised December July 2017, indicated Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Reporting 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury;

Based on interview and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 8 residents (Resident #1) reviewed for resident records. The facility failed to ensure LVN A documented Resident #1's change of condition, physician notification, and transport to hospital on 09/30/24. This failure could place residents at risk for delayed care and appropriate interventions. Findings included: Record review of Resident #1's face sheet dated 09/20/24 indicated he was a [AGE] year old male, admitted on [DATE] and his diagnoses included acute respiratory failure with hypoxia (impaired gas exchange between lungs and blood resulting in low oxygen levels in body tissues). Record review of Resident #1 physician orders dated 8/29/24 indicated Resident #1 was on enteral feed (feeding through G-tube) and he was administered medications via G-tube (feeding tube) for SOB, infection, dementia (gradual decline in cognitive abilities that interferes with daily life), and HTN (high blood pressure). Record review of Resident #1's discharge MDS dated [DATE] indicated Resident #1 was discharged with return anticipated. Record review of Resident #1's care plan dated 08/30/24 the facility would provide Resident #1 and his representative a summary of the base line care plan within 48 hours. Resident #1 had the following special treatments/needs: for treatment included IV medications, hospice care, tracheostomy (opening in the neck into the windpipe/trachea to allow air to flow into the lungs), suction, oxygen, CPAP (a machine that sues mild air pressure to keep breathing airways open while sleeping), isolation, wound vac (a treatment that uses a suction pump and dressing to help heal wounds), dialysis, diabetic care, and pressure ulcers. Record review of a progress note dated 08/30/24 at 8:39 a.m., completed by LVN A indicated Resident #1 was hospitalized . There was no documentation of Resident #1's change of condition, vital signs, physician notification, treatment or care provided, or that he was transported to hospital for evaluation and treatment. Record review of Resident #1's hospital records dated 08/30/24 indicated Resident #1 admitting diagnoses included hypertension, low O2 sats and his diagnoses included Parkinson's (brain disorder that affects movement and mental health) and Alzheimer's dementia (brain disorder that gradually destroys memory and thinking skills). Record review of a text message dated 08/30/24 sent to MD D by LVN A indicated Resident #1 was sent to (named hospital) for hypoxia and tachycardia. O2 was 70 and hr was 118. O2 15 L applied. O2 84. Record review of a text message dated 08/30/24 indicated MD D responded OK to LVN A's text message. During an interview on 09/20/24 at 12:31 p.m., CNA B said she checked on Resident #1 between 6:00 a.m. and 7:30 a.m. on 08/30/24. She said Resident #1 was on his right side facing the doorway of his room. She said she continued on her rounds and started passing breakfast trays. CNA B said she heard Resident #1's daughter calling for help at approximately 7:30 a.m. She said Resident #1's daughter said he had vomited and was spitting out of his mouth. She said she went into Resident #1's room and observed Resident #1 had vomited. She said she reported Resident #1 had vomited to LVN A. She said LVN A checked for Resident #1's code and then called code and all the nurses arrived at Resident #1's room with the crash carts. She said she left the room to continue care of the other residents. During an interview on 09/20/24 at 12:59 p.m., CMA C said she administered Resident #1's eye drops at 7:00 a.m. on 08/30/24 and then went into another resident's room. She said she heard Resident #1's daughter was calling for help because Resident #1 had vomited. During an interview on 09/20/24 at 11:50 a.m., the DON said he became aware on 09/20/24 that LVN A had not documented Resident #1's change of condition or transport to hospital in the EMR on 08/30/24. He said it was his expectation all staff completed documentation prior to end of shift. He said residents were at risk for delayed care if the proper documentation was not completed. During an interview on 09/20/24 at 1:19 p.m., LVN A said it was hectic on 08/30/24 when Resident #1 had vomited and required transport to the hospital due to change of condition. He said the physician was notified by secure message he (LVN A) was sending Resident #1 to the hospital and the doctor responded ok via the secure message system. He said he said he forgot about documenting Resident #1's change of condition in Resident #1's chart. He said he was aware he should have documented Resident #1's change of condition, physician communication, and transport to hospital in Resident #1's EMR. Record review of the facility's policy Charting and Documentation policy dated 2001 (revised July 2017) indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. 2. The following information is to be documented in the resident medical record: a. Objective observations; 2. Medications administered, Treatments or services performed: d. Changed in the resident's condition; Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives.7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided care; c. the assessment data and .or any unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; notification of family, physician or other staff, if indicated; and g. the signature and title of the individual documenting.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 14 residents (Resident #1) reviewed for infection control. CNA A did not wash or sanitize her hands or change gloves while performing incontinent care for Resident #1. CNA B entered Resident #1's room wearing gloves she had previously handled trash with and did not wash or sanitize her hands or change gloves. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of Resident #1's face sheet dated 02/07/24 indicated he was [AGE] years old, admitted on [DATE], and his diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) affecting left dominant side, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), depression (common mental disorder), and anxiety (feeling of fear, dread, and uneasiness). Record review of Resident #1's MDS dated [DATE] indicated he was usually understood and understood others, had moderate cognitive impairment (BIMS score 8), and was incontinent of bowel and bladder. Record review of Resident #1's care plan dated 05/18/23 indicated he had an ADL self-care performance deficit. Interventions included the assistance of one staff for toileting and to ensure the resident's dignity was maintained and privacy was provided. During an observation and interview on 02/06/24 at 11:20 p.m., Resident #1 told CNA A that he was soiled and needed to be changed. Outside the doorway to Resident #1's bed area there was a glove box holder and a hand sanitizer dispenser on the wall. CNA A said Resident #1 had to be changed often because he had frequent BMs and Resident #1 agreed. Resident #1 was lying in bed with a hospital gown and thin sheet. He complained he was cold and CNA A said she would get him a blanket. CNA A returned to the room and did not enter the bathroom to wash her hands and did not reach for the hand sanitizer dispenser. CNA A laid a brief and blanket on the small dresser across from the foot of the bed. CNA A stepped out of the room again. CNA B was outside Resident #1's room and placed trash in the container and entered Resident #1's room wearing the same gloves. CNA B said she heard someone talking with the resident and came in to see who was talking with him. CNA B did not remove her gloves or sanitize her hands until after the surveyor asked her what she was doing prior to entering the resident's room which she said she was putting trash into the container outside the door. When the surveyor asked CNA B what she was supposed to do prior to entering the resident's room and after she entered the resident room. CNA B said she should have removed the gloves and washed/sanitized her hands. CNA B then exited the resident's room and did not return. CNA A returned to the resident's room. She did not enter the bathroom to wash her hands, did not reach for the hand sanitizer dispenser, and donned gloves. CNA A proceeded to provide Resident #1 incontinent care. CNA A pulled Resident #1's sheet off, pull the hospital gown up, and started opening the brief. CNA A did not cover Resident #1 with gown or sheet, removed her gloves, and exited the room. She returned to the resident's room again did not enter the bathroom to wash her hands, and did not reach for the hand sanitizer dispenser, and donned gloves. CNA A pulled wipes from the package and placed them on the bed. CNA A said she pulled some wipes out to clean Resident #1. CNA A finished opening the brief and tucked the front down between his legs. CNA A then told Resident #1 the wipes were going to be cold and proceeded to clean him from the tip of the penis down. CNA A then applied barrier cream to the front part of the genitals. CNA A rolled Resident #1 on to his right side. CNA A cleaned the resident of feces, removed the dirty brief, and removed the gloves. CNA A did not turn him to the left side to clean the left buttock or hip. CNA A looked for the brief and realized she left it on the small dresser. CNA A did not wash or sanitize her hands, grabbed the brief and placed it on the bed. CNA A left Resident #1 uncovered and exited the room. CNA A returned to the room and did not enter the bathroom to wash her hands, did not reach for the hand sanitizer dispenser, and donned gloves. Resident #1 had urinated on the pad under his lower torso. CNA A removed the pad, placed a new pad and brief under him, then closed the brief. CNA A then covered Resident #1 with his gown, the sheet, and a blanket. During an interview on 02/06/24 at 11:45 p.m., CNA A said she was trained in incontinent care and infection control. She said she was supposed to wash her hands and put on gloves prior to performing incontinent care. She said she was supposed to change her gloves from dirty to clean before putting on clean undergarments and clothes on Resident #1. CNA A said she would not have done anything different with the incontinent care. CNA A said they could use hand sanitizer 3 times before they need to wash their hands. During an interview on 02/06/24 at 11:50 p.m., LVN C said CNA A should not have touched dirty and clean briefs with the same gloves. She said CNA A should have changed gloves and performed hand hygiene after performing incontinent care. She said residents could be at risk of an infection if they did not wash or sanitize their hands when changing their gloves. During an interview on 02/06/24 at 11:50 p.m., LVN D said CNA A should not have touched dirty and clean briefs with the same gloves. She said CNA A should have changed gloves and performed hand hygiene after performing incontinent care. She said residents could be at risk of an infection if they did not wash or sanitize their hands when changing their gloves. During an interview on 02/07/24 at 4:44 p.m., the DON said CNA A should have washed or sanitized their hands between glove changes and before performing tasks with the resident to prevent infections. She stated she expected infection control measures were followed. She stated she expected all staff to follow infection control and hand hygiene measures with every task to prevent the spread of infections. Record review of the facility's Perineal Care policy dated 2001 (revised February 2018) indicated The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skins irritation, and to observe the resident's skin condition. 2. Assemble the equipment and supplies as needed.The following equipment and supplies will be necessary when performing this procedure: 1. Wash basin; 2. Towels; 3. Washcloth, Soap (or other authorized cleaning agent: and 5. Personal protective equipment (e.g., gowns, gloves, masks, etc., as needed). Steps in the Procedure 1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 5. Fold the sheet down to the lower part of the body. Cover the upper torso with a sheet. 6. Raise the gown or lower the pajamas. Avoid unnecessary exposure of the resident's body. 7. Put on gloves. 9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry hands thoroughly. 12. Reposition the bed covers. Make the resident comfortable. 13. Place the call light within easy reach of the resident. 14. Clan the wash basin and return to the designated storage area. 15. Clean the bedside stand. 16. Wash and dry your hands thoroughly.

Based on observations, interviews, and record reviews, the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 1 of 14 residents (Resident #1) reviewed for resident rights. CNA A failed to provide privacy to Resident #1 when providing incontinent care on 02/06/24. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety. Findings: Record review of Resident #1's face sheet dated 02/07/24 indicated he was [AGE] years old, admitted on [DATE], and his diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) affecting left dominant side, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), depression (common mental disorder), and anxiety (feeling of fear, dread, and uneasiness). Record review of Resident #1's MDS dated [DATE] indicated he was usually understood and understood others, had moderate cognitive impairment (BIMS score 8), and was incontinent of bowel and bladder. Record review of Resident #1's care plan revised 05/18/23 indicated his initial treatment goal was to remain in LTC. Interventions included having all needs anticipated and met to ensure the highest practicable level of well-being and dignity preservation. Record review of Resident #1's care plan dated 05/18/23 indicated he had an ADL self-care performance deficit. Interventions included the assistance of one staff for toileting and to ensure the resident's dignity was maintained and privacy was provided. During an observation and interview on 02/06/24 at 11:20 p.m., Resident #1 received incontinent care from CNA A. The privacy curtain was not pulled and the door was not closed. He complained he was cold. CNA A said she would get him a blanket. CNA A laid the brief and blanket on the small dresser across from the foot of the bed. CNA A pulled Resident #1's sheet off, pull the hospital gown up, and started opening the brief without closing the resident room door or the privacy curtain. The surveyor asked CNA A if anyone walking by the resident room could have full view of the resident. CNA A said yes and closed the privacy curtain. CNA A did not cover Resident #1 with a gown or sheet, removed her gloves, and exited the room. She returned to the room, pulled wipes from the package and placed them on the bed. Resident #1 said he was cold for the second time. CNA A finished opening the brief and tucked the front down between his legs. CNA A then told Resident #1 the wipes were going to be cold and proceeded to clean him. CNA A left Resident #1 uncovered and exited the room again. Resident #1 said he was cold for the third time. CNA A returned to the room. Resident #1 had urinated on the pad under him. CNA A removed the pad, placed a new pad and brief under him, then closed the brief. CNA A then covered Resident #1 with his gown, the sheet, and a blanket. During an interview on 02/06/24 at 11:45 p.m., CNA A said she should make sure the door or privacy curtain was closed to provide privacy prior to completing incontinent care. She said not providing residents privacy during care cause anxiety and embarrassment. During an interview on 02/07/24 at 10:00 a.m., Resident #1 said staff do not usually cover his upper body during care and he is always cold. He said he would like the staff to cover him during care so he was not cold. He said staff did not always close the privacy curtain during care. He said he would prefer the privacy curtain was closed during care. During an interview on 02/07/24 at 4:44 p.m., the DON said all staff were expected to pull the privacy curtains and shut the doors to resident room while providing care. She said residents could be exposed during care and exposure could cause anxiety and embarrassment. Record review of the facility's Resident Rights policy dated 2001 (revised December 2016) indicated . Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; . Record review of the facility's Quality of Life-Dignity policy dated 2001 (revised February 202) indicated Each resident shall be care for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem.1. Resident are treated with dignity and respect at all times.10. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Record review of the facility's Perineal Care (also known as peri-care-involves cleaning the private areas of a patient) policy dated 2001 (revised February 2018) indicated The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skins irritation, and to observe the resident's skin condition. 2. Assemble the equipment and supplies as needed. 5. Fold the sheet down to the lower part of the body. Cover the upper torso with a sheet. 6. Raise the gown or lower the pajamas. Avoid unnecessary exposure of the resident's body.12. Reposition the bed covers. Make the resident comfortable.

Based on observation, interview, and record review, the facility failed to ensure residents' right to be free from abuse and neglect for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. The facility failed to provide incontinent care to Resident #1 for more than 8 hours on 09/24/23. Resident #1 sustained excoriation (injury to the skin), swollen labia, and a blister to her peri-area (delicate portion of skin between your genitals and anus). An Immediate Jeopardy (IJ) situation was identified on 09/28/23 at 1:43 p.m. While the IJ was removed on 09/29/23, the facility remained out of compliance at a severity level of 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 of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated 09/27/23 indicated Resident #1 was a [AGE] year old female, admitted on [DATE], and her diagnoses included Alzheimer's (most common cause of dementia) - a gradual decline in memory, thinking, behavior and social skills, muscle wasting and atrophy-multiple sites (muscles appear smaller than usual due to a lack of muscle tissue), other abnormalities of gait and mobility, difficulty in walking, depression (serious mood disorder), altered mental status (change in mental function), cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, understanding jokes or metaphors, or following directions), need for assistance with personal care, muscle weakness, ataxic gait (failure of muscle coordination and is characterized by an irregular foot placement), diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) with diabetic polyneuropathy (type of nerve damage), kidney disease (disorder characterized by gradual and usually permanent loss of kidney function resulting in renal failure), affective mood disorder (marked disruptions in emotions -severe lows called depression or highs called hypomania or mania), and anxiety (feeling of fear, dread, and uneasiness). Record review of an MDS assessment dated [DATE] indicated Resident #1 had clear speech, was usually able to make herself understood and understand others, had severe cognitive impairment (BIMS score of 6), required extensive assist of one staff for toilet use (includes incontinent care), was always incontinent of bladder and frequently incontinent of bowel. Resident #1 was at risk of developing pressure ulcers. Record review of a care plan dated 09/06/22 indicated Resident #1 had an ADL self-care deficit and limitations in physical mobility related to Alzheimer's, dementia, cognitive deficits, confusion, forgetfulness, impaired balance, limited mobility, ROM, and musculoskeletal impairment. Goals included: Resident will remain free of complications related to limitations in mobility, including skin-breakdown. Interventions included: toilet use- resident requires extensive assist of one staff for toileting and skin inspection-during resident general care and incontinent care inspect resident's skin and observe for redness, open areas, scratches, bruises and report changes to nurse. Record review of a care plan dated 09/06/22 indicated Resident #1 had the potential for alteration in skin integrity related to pressure ulcer/pressure injury secondary to impaired mobility and incontinency. Interventions included to keep skin clean and dry, provide incontinent care as quickly as possible following episodes of voiding or bowel movement. Record review of a care plan dated 07/20/23 indicated Resident #1 was on diuretic (reduce fluid buildup in the body; increase urinary frequency and may cause urinary urgency and incontinence) therapy Spironolactone (a potassium-sparing diuretic) and Lasix (diuretic that prevents your body from absorbing too much salt) related to edema. Interventions included administer medications as ordered and monitor for effectiveness every shift. Record review of a care plan dated 07/20/23 indicated Resident #1 had bowel and bladder incontinence related to Alzheimer's/dementia, impaired mobility, physical limitations, and inability to communicate needs. Interventions included clean peri-area with each incontinence episode. Record review of a care plan revised 07/20/23 indicated Resident #1 would remain in LTC. Interventions included Resident #1 was at risk for skin breakdown and required assistance with pressure relieving position changes and toileting. Record review of a care plan revised 08/14/23 indicated Resident #1 had the potential for impairment to skin integrity related to fragile skin and incontinency of bladder and bowel. Interventions included avoid scratching and keep hands and body parts from excessive moisture. Record review of video dated 09/24/23 at 4:13 a.m. indicated CNA C provided incontinent care for Resident #1. Family member arrived at 12:13 p.m. At 12:49 p.m. family member finds Resident #1 is incontinent and her peri-area is red. At 12:50 p.m. the family member walks out of Resident #1's room and returns to the room at 12:51 p.m. At 12:55 p.m. family member places a white wash cloth on Resident #1's peri-area. Resident #1 is crying in pain. At 12:58 p.m., the family member walks out of the room. At 12:59 p.m., the family member walks back into the room and staff followed into the room. At 1:03 p.m., staff brought in towels and Resident #1 was crying and upset. Record review of a progress note dated 09/25/23 on 10:49 a.m., completed by LVN B indicated Resident #1's family member wanted Resident #1 to go to the ER due to rash in peri-area. LVN B spoke to family member about treatment already in place with zinc oxide and would contact the physician to get new orders. Family member agreed. Physician notified and ordered nystatin cream(antifungal) and zinc (medicated cream, ointment or paste that treats or prevents skin irritation) to peri-area TID. Physician would see Resident #1 in the facility. Record review of a skin assessment dated [DATE] indicated Resident #1 had redness and a blister on her right labia and redness and excoriation of her peri-area. During observation and interview on 09/26/23 at 1:30 p.m., CNA G provided Resident #1's incontinent care. Resident #1 was able to assist with repositioning and turning. CNA G said Resident #1 developed some redness over the weekend in her peri-area. Resident #1 grimaced and appeared in pain and discomfort during incontinent care. Resident #1 said ouch while being wiped by CNA G. Resident #1's right and left labia were red and inflamed and swollen, the right labia had a blister on the outer area, the left abdominal fold/crease has red and macerated (skin is in contact with moisture for too long), and the left inner thigh was reddened. After she completed incontinent care she called for LVN B to apply Nystatin (antifungal)/Zinc (medicated cream, ointment or paste that treats or prevents skin irritation) compound to Resident #1's peri-area. LVN B indicated Resident #1's physician assessed Resident #1 on 09/26/23 and ordered the Nystatin/Zinc compound TID. During an interview on 09/27/23 at 12:45 p.m., a family member indicated Resident #1 was upset and crying when she arrived on 09/24/23. She said she arrived after 12:00 p.m. She said she found Resident #1's undergarment soaking wet and very heavy with urine. She said Resident #1's labia was swollen and had a blister. She said Resident #1's entire peri-area was very red and excoriated. She said she had applied a cold cloth and attempted to find staff two times before a CNA E and an MA P came in to provide incontinent care. She said Resident #1 was very upset and crying and saying ouch when she was wiped. She said LVN A came in later (after incontinent care was completed) to assess Resident #1. She said she reviewed video and found the last time Resident #1 received incontinent care was 4:13 a.m. on 09/24/23. She said Resident #1 was neglected. During an interview on 09/28/23 at 10:15 a.m., The DON said she began investigating a grievance from Resident #1's family member on 09/25/23. She said Resident #1's family member was upset with staffing because Resident #1 did not have an assigned CNA on 09/24/23. She said her investigation of the grievance revealed LVN A did not assign an aide to Resident #1 until after 11 a.m. on 09/24/23. She said she directed LVN A on 09/24/23 at 6:45 a.m. via text to assign CNAs and MAs to provide resident care. She said she directed LVN A to pass medications. She said LVN A refused to pass medications to the residents on her assigned hall (Hall 400). She said Resident #1 was not provided incontinent care until after 12:30 p.m., after Resident #1's family member notified LVN A of Resident #1 being in pain and incontinent. She said LVN A was suspended and subsequently terminated for insubordination on 09/26/23. She said she inserviced staff on following orders, providing incontinent care, reporting skin issues, and documentation. She said the nurses were supposed to monitor the aides to ensure residents received care as required. She said staff were supposed to check and change residents every 2 hours and as needed. She said residents were at risk of neglect if care was not provided as required. She said not providing care as required was neglect. She said skin assessments of all residents on hall 400 were completed as of 09/28/23. During an interview on 09/28/23 at 11:39 a.m. LVN A said she did not assign aides to provide resident care. She said she expected they would assign themselves. She said she finished passing medications on Hall 100 and noticed Resident #1 was in the same position. She said she asked who was assigned to Resident #1 and no one knew. She said she did not follow the DON's orders. She said after Resident #1's family member came to the nurse station, she said MA P and CNA E provided care to Resident #1. She said she talked to Resident #1's physician about Resident #1's red skin and received new orders for Nystatin. She said Resident #1 was neglected because she did not receive care as required and she developed a rash. She said staff were to check and change residents every 2 hours and PRN. During an interview on 09/28/23 at 12:45 p.m., LVN I said she assessed Resident #1 on 09/25/23. She said Resident #1 had a tendency to be red but she did not have a rash or a blister previously. She said the blister could be caused by lying in urine and feces for an extended period. She said residents should be checked and changed every 2 hours and as needed. During an interview on 09/28/23 at 1:11 p.m., LVN F said LVN A refused to do her own medication pass and did not assign aides. She said Resident #1 did not have an assigned CNA on 09/24/23 for the morning shift (6:00 am) and did not receive care as required. She said Resident #1 was neglected. She said residents were to be checked and changed every 2 hours and as needed. During an interview on 09/28/23 at 2:37 p.m., CNA G said she was not assigned to provide care for Resident #1 09/24/23. She said she was not directed to care for Resident #1. She said there was usually a book at the nurse station with assignments. She said residents were supposed to be checked and changed every 2 hours and as needed. She said a resident was neglected if the resident did not receive care as required. She said she provided care for Resident #1 on 09/24/23 later in the day. Resident #1 was crying and saying she hurt (peri-area). She said Resident #1's labia was swollen, the peri area was red and inflamed, and there was a blister on her right labia. She said there was a little bleeding when she wiped feces from Resident #1's peri-area. She said Resident #1's peri-area was not swollen, inflamed, or bleeding the previous day. During an interview on 09/28/23 at 3:04 p.m., CNA E said she was originally scheduled to work as a medication aide on 09/24/23. She said LVN A re-assigned her (CNA E) to work as an aide on hall 300. She said she stopped by MA P after 12:00 p.m. on 09/24/23 and asked to assist with Resident #1's incontinent care. She said Resident #1's family member had removed the incontinent brief and applied a cold cloth to Resident #1's peri-area. She said Resident #1's abdominal creases and inner thighs were red and inflamed. She said Resident #1 was crying and upset. She said residents should be checked and changed every 2 hours and as necessary. She said failure to provide timely incontinent care could result in skin breakdown. CNA E said it was neglect if care was not provided as required. During an interview on 09/28/23 at 3:14 p.m., MA P said she was at the nurse station and Resident #1's family member came to the nurse station. She said Resident #1's family member was in tears and informed LVN A of Resident #1 needing care and she (Resident #1) had not been tended to. LVN A said she would find someone. She said CNA E came by the nurse station and (MA P) told CNA E to assist with providing care to Resident #1. She said Resident #1 cried and whimpered and said it hurt when she was being wiped. She said residents should be checked and changed every 2 hours and as necessary. She said failure to provide timely incontinent care could result in skin breakdown. CNA C said it was neglect if care was not provided as required. Record review of LVN A's personnel file indicated she was terminated on 09/26/23 for insubordination. Record review of the facility's Abuse Prevention Program dated 2001 (revised December 2016) provided by the facility and included the Long-Term Care Regulatory Provider Letter (PL 19-17) indicated Our residents have the right to be free of abuse, neglect, misappropriation of resident property and exploitation.Abuse also includes the deprivation by an individual, including caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being.Neglect . failure to provide goods and services that are necessary to avoid physical or emotional harm, pain, . The Administrator and the DON were notified of the Immediate Jeopardy on 09/28/23 at 1:43 p.m. and the Administrator was provided the Immediate Jeopardy template. The Administrator was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 09/29/23 at 5:42 p.m. and reflected the following: Immediate action: Resident # 1 was assessed by the charge nurse on duty on September 25, 2023 @10:15 a.m. The attending physician was contacted by Charge Nurse, new order to add Nystatin Cream to the existing Zinc Oxide order to be applied three times per day, was received and initiated on 09/25/2023. Upon receipt of the grievance from Resident #1's representative on 09/25/2023, the Assistant Director of Nursing and Director of Nursing began investigating the cause of the grievance on 09/25/2023. Upon investigation it was noted that the division of duties was not carried out by the charge nurse as directed by the Director of Nursing on 09/24/2023 @ 6:45 a.m. The charge nurse that was instructed to divide the resident care duties was interviewed and terminated from employment for refusal to obey orders of a supervisor on 09/26/2023 @ 5:07 p.m. via telephone by the Director of Nursing. On 09/26/2023 The Director of Nursing provided the information regarding the practice of the terminated nurse to the Director of Clinical Operations from the corporate office for further review regarding potential referral to the Texas Board of Nursing. The decision to make the referral was referred to legal counsel on 09/28/2023 when the investigation of the nurse was completed. On 09/26/2023 @ 5:30 p.m., The Director of Nursing initiated an in-service with nursing staff: both direct and licensed regarding following directives given by the supervisor during their shift and the consequences that might arise from failure to adhere to direction given. The in-service education will continue until all nursing staff: direct care and licensed, have been provided with this education and staff will not be able to begin their next scheduled shift without acknowledgment of understanding. The in-service education will be completed no later than 09/29/2023. On 09/26/2023, upon identification of the directive from the supervisor not being carried out, further investigation by the Director of Nursing revealed CNAs were not assigned to provide care on the 400 hall on 09/24/2023 from approximately 6:00 a.m. until 12:30 p.m. On 09/26/2023 at 5:45 p.m., The Director of Nursing and Designees completed full body skin assessments on all residents on the 400 hall. No adverse findings were noted on completion for residents' residing on 400 Hall on 09/26/23 at 7:50 p.m. On 09/26/2023 @ 5:30 p.m., the Director of Nursing initiated an in-service with nursing staff: regarding direct and licensed regarding resident care rounds. This in-service directed nursing staff: direct care and licensed, that residents should be rounded on/checked on at least every two hours to ensure their needs are being met timely and appropriately, with emphasis on residents with higher acuity and dependent on care. The in-service education will continue until all nursing staff: both licensed and direct care, have been provided with this education and staff will not be able to begin their next scheduled shift without acknowledgment of understanding. The in-service education will be completed no later than 09/29/2023. On 09/26/2023 @ 5:30 p.m., the Director of Nursing initiated an in-service with the nursing staff: both direct and licensed and therapy staff regarding the importance of incontinent care and general ADL care. The in-service education will continue until all nursing staff: direct care and licensed, and therapy staff have been provided with this education and staff will not be able to begin their next scheduled shift without acknowledgment of understanding. The in-service education will be completed no later than 09/29/2023. On 09/26/2023, the Director of Nursing and Designees conducted resident life satisfaction surveys on residents residing who are able to be interviewed on the 400 hallway; no concerns regarding care were noted upon completion on 09/28/2023. Facilities Plan to Ensure Compliance Quickly Impromptu QAPI was held September 28, 2023 @ 6:18 p.m. with the facility Medical Director and informed him of the two immediate jeopardies that the Facility obtained for F600-Neglect and F677-ADL Care for Dependent Residents. The Medical Director was informed of the facility efforts to correct the alleged violations including assessments, interviews, disciplinary action, education, and initiation of procedural changes. On September 28, 2023, the facility will implement a new procedure for assigning staff to residents based on the number of staff present. This procedure will provide instruction on how to divide the resident care duties efficiently and equally to ensure adequate care of residents. The division of duties will be specific to different staffing numbers and instances. Each day on the daily assignment sheet one charge nurse will be assigned to be the person responsible for ensuring the correct division of duties is confirmed with all staff at the beginning of the shift. The Director of Nursing shall provide an in-service to all staff regarding the process of staff assignments. The in-service education will continue until all nursing staff, direct care and licensed, have been provided with this education and staff will not be able to begin their next scheduled shift without acknowledgment of understanding. The in-service education will be completed no later than 09/29/2023. The Director of Nursing and/or Designee shall review the daily assignment sheets for adequate division of duties Monday through Friday and the weekend supervisor shall review on Saturday and Sunday. On 09/29/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on 09/29/23 from 4:30 p.m. through 6:55 p.m. and included 3 alert residents, nurses including 5 LVNs, 6 CNAs, 2 MA, (who work all shifts), the ADON, and the DON. Staff indicated residents were checked every 2 hours for incontinence, lines (moisture indicators) were checked for wetness, water and ADL care provided PRN. Residents were monitored during rounds. Residents were asked about their needs. The lead nurse assigns aides as necessary and if aides were not available, aides would split halls based on guide in book at nurse station. They indicated if staff refused direct orders from their supervisor they would report to the DON and the administrator. Staff were required to check their assigned residents at the start of their shift and end of their shift. Staff would be suspended and possibly terminated for refusing direct orders. During an interview on 09/29/23 at 4:42 p.m. the DON said lead nurse assignments were in place to ensure all residents had assigned CNA's. She said all in-services were completed. She said skin assessments were completed for Hall 400 and the entire facility. She said there was no additional negative findings. During observation and interview on 09/29/23 at 5:52 p.m., Resident #1 said staff were keeping her changed and dry. Resident #1's undergarment was dry and the Nystatin/Zinc compound was applied to her per-area. Redness was observed on Resident #1's peri-area and she was clean and dry. Record review of the facility implemented a monitoring system effective 09/29/23. The facility Administrator and/or Director of Nursing indicated they were responsible for the monitoring and would conduct observation rounds and conduct interviews related to resident care, duties and assignments, and lead nurse responsibilities. Record review of Resident #1's skin assessment dated [DATE], physician orders, and TAR indicated Resident #1 received care as required. Record review of 100% of hall 400 skin assessments indicated the facility reviewed all residents to ensure no adverse findings. Record review of grievances for previous three months through 09/29/23 indicated the facility addressed grievances as required. The grievance from Resident #1's family member on 09/25/23, the ADON and DON determined LVN A had not assigned duties as directed by the DON on 09/24/23. CNAs were not assigned to provide care on the 400 hall on 09/24/23 from approximately 6:00 a.m. until 12:30 p.m. Record review of staff in-service dated 09/29/23 indicated all licensed and direct care staff were trained on following directives from their supervisors. Record review of staff in-service dated 09/26/23 indicated direct care and licensed staff were trained that residents should be rounded on/checked on at least every two hours to ensure their needs are being met timely and appropriately, with emphasis on residents with higher acuity and dependent on care. Record review of staff in-service dated 09/26/23 indicated direct and licensed and therapy staff were trained regarding the importance of incontinent care and general ADL care. Record review of resident life satisfaction surveys on residents residing who are able to be interviewed on the 400 hallway indicated no concerns regarding care were noted upon completion on 09/28/2023. Record review of the facility's new procedure dated 09/28/23 for assigning staff to residents based on the number of staff present indicated the following: on the daily assignment sheet one charge nurse would be assigned responsible for ensuring the correct division of duties was confirmed with all staff at the beginning of the shift. The DON inserviced all staff regarding the process of staff assignments. The DON and/or Designee would review the daily assignment sheets for adequate division of duties Monday through Friday and the weekend supervisor would review on Saturday and Sunday. Record of staff post tests were reviewed for accuracy and knowledge. No concerns noted. On 09/29/23 at 6:55 p.m., the Administrator was informed the IJ was removed; however, 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.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 of 10 residents (Resident #1) reviewed for ADL care. The facility failed to provide incontinent care to Resident #1 for more than 8 hours on 09/24/23. Resident #1 sustained excoriation (injury to the skin), swollen labia, and a blister to her peri-area (delicate portion of skin between your genitals and anus). An Immediate Jeopardy (IJ) situation was identified on 09/28/23 at 1:43 p.m. While the IJ was removed on 09/29/23, the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failures could place residents at risk of embarrassment, discomfort, and skin breakdown. Findings included: Record review of a face sheet dated 09/27/23 indicated Resident #1 was a [AGE] year old female, admitted on [DATE], and her diagnoses included Alzheimer's (most common cause of dementia) - a gradual decline in memory, thinking, behavior and social skills, muscle wasting and atrophy-multiple sites (muscles appear smaller than usual due to a lack of muscle tissue), other abnormalities of gait and mobility, difficulty in walking, depression (serious mood disorder), altered mental status (change in mental function), cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, understanding jokes or metaphors, or following directions), need for assistance with personal care, muscle weakness, ataxic gait (failure of muscle coordination and is characterized by an irregular foot placement), diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) with diabetic polyneuropathy (type of nerve damage), kidney disease (disorder characterized by gradual and usually permanent loss of kidney function resulting in renal failure), affective mood disorder (marked disruptions in emotions -severe lows called depression or highs called hypomania or mania), and anxiety (feeling of fear, dread, and uneasiness). Record review of an MDS assessment dated [DATE] indicated Resident #1 had clear speech, was usually able to make herself understood and understand others, had severe cognitive impairment (BIMS score of 6), required extensive assist of one staff for toilet use (includes incontinent care), was always incontinent of bladder and frequently incontinent of bowel. Resident #1 was at risk of developing pressure ulcers. Record review of a care plan dated 09/06/22 indicated Resident #1 had an ADL self-care deficit and limitations in physical mobility related to Alzheimer's, dementia, cognitive deficits, confusion, forgetfulness, impaired balance, limited mobility, ROM, and musculoskeletal impairment. Goals included: Resident will remain free of complications related to limitations in mobility, including skin-breakdown. Interventions included: toilet use- resident requires extensive assist of one staff for toileting and skin inspection-during resident general care and incontinent care inspect resident's skin and observe for redness, open areas, scratches, bruises and report changes to nurse. Record review of a care plan dated 09/06/22 indicated Resident #1 had the potential for alteration in skin integrity related to pressure ulcer/pressure injury secondary to impaired mobility and incontinency. Interventions included to keep skin clean and dry, provide incontinent care as quickly as possible following episodes pf voiding or bowel movement. Record review of a care plan dated 07/20/23 indicated Resident #1 was on diuretic (reduce fluid buildup in the body; increase urinary frequency and may cause urinary urgency and incontinence) therapy Spironolactone (a potassium-sparing diuretic) and Lasix (diuretic that prevents your body from absorbing too much salt) related to edema. Interventions included administer medications as ordered and monitor for effectiveness every shift. Record review of a care plan dated 07/20/23 indicated Resident #1 had bowel and bladder incontinence related to Alzheimer's/dementia, impaired mobility, physical limitations, and inability to communicate needs. Interventions included clean peri-area with each incontinence episode. Record review of a care plan revised 07/20/23 indicated Resident #1 would remain in LTC. Interventions included Resident #1 was at risk for skin breakdown and required assistance with pressure relieving position changes and toileting. Record review of a care plan revised 08/14/23 indicated Resident #1 had the potential for impairment to skin integrity related to fragile skin and incontinency of bladder and bowel. Interventions included avoid scratching and keep hands and body parts from excessive moisture. Record review of video dated 09/24/23 at 4:13 a.m. indicated CNA C provided incontinent care for Resident #1. Family member arrived at 12:13 p.m. At 12:49 p.m. family member finds Resident #1 is incontinent and her peri-area is red. At 12:50 p.m. the family member walks out of Resident #1's room and returns to the room at 12:51 p.m. At 12:55 p.m. family member places a white wash cloth on Resident #1's peri-area. Resident #1 is crying in pain. At 12:58 p.m., the family member walks out of the room. At 12:59 p.m., the family member walks back into the room and staff followed into the room. At 1:03 p.m., staff brought in towels and Resident #1 was crying and upset. Record review of a progress note dated 09/25/23 on 10:49 a.m., completed by LVN B indicated Resident #1's family member wanted Resident #1 to go to the ER due to rash in peri-area. LVN B spoke to family member about treatment already in place with zinc oxide and would contact the physician to get new orders. Family member agreed. Physician notified and ordered nystatin cream(antifungal) and zinc (medicated cream, ointment or paste that treats or prevents skin irritation) to peri-area TID. Physician would see Resident #1 in the facility. Record review of a skin assessment dated [DATE] indicated Resident #1 had redness and a blister on her right labia and redness and excoriation of her peri-area. During observation and interview on 09/26/23 at 1:30 p.m., CNA G provided Resident #1's incontinent care. Resident #1 was able to assist with repositioning and turning. CNA G said Resident #1 developed some redness over the weekend in her peri-area. Resident #1 grimaced and appeared in pain and discomfort during incontinent care. Resident #1 said ouch while being wiped by CNA G. Resident #1's right and left labia were red and inflamed and swollen, the right labia had a blister on the outer area, the left abdominal fold/crease has red and macerated (skin is in contact with moisture for too long), and the left inner thigh was reddened. After she completed incontinent care she called for LVN B to apply Nystatin (antifungal)/Zinc (medicated cream, ointment or paste that treats or prevents skin irritation) compound to Resident #1's peri-area. LVN B indicated Resident #1's physician assessed Resident #1 on 09/26/23 and ordered the Nystatin/Zinc compound TID. During an interview on 09/27/23 at 12:45 p.m., a family member indicated Resident #1 was upset and crying when she arrived on 09/24/23. She said she arrived after 12:00 p.m. She said she found Resident #1's undergarment soaking wet and very heavy with urine. She said Resident #1's labia was swollen and had a blister. She said Resident #1's entire peri-area was very red and excoriated. She said she had applied a cold cloth and attempted to find staff two times before a CNA E and an MA P came in to provide incontinent care. She said Resident #1 was very upset and crying and saying ouch when she was wiped. She said LVN A came in later (after incontinent care was completed) to assess Resident #1. She said she reviewed video and found the last time Resident #1 received incontinent care was 4:13 a.m. on 09/24/23. She said Resident #1 was neglected. During an interview on 09/28/23 at 10:15 a.m., The DON said she began investigating a grievance from Resident #1's family member on 09/25/23. She said Resident #1's family member was upset with staffing because Resident #1 did not have an assigned CNA on 09/24/23. She said her investigation of the grievance revealed LVN A did not assign an aide to Resident #1 until after 11 a.m. on 09/24/23. She said she directed LVN A on 09/24/23 at 6:45 a.m. via text to assign CNAs and CMAs to provide resident care. She said she directed LVN A to pass medications. She said LVN A refused to pass medications to the residents on her assigned hall (Hall 400). She said Resident #1 was not provided incontinent care until after 12:30 p.m., after Resident #1's family member notified LVN A of Resident #1 being in pain and incontinent. She said LVN A was suspended and subsequently terminated for insubordination on 09/26/23. She said she inserviced staff on following orders, providing incontinent care, reporting skin issues, and documentation. She said the nurses were supposed to monitor the aides to ensure residents received care as required. She said staff were supposed to check and change residents every 2 hours and as needed. She said residents were at risk of neglect if care was not provided as required. She said not providing care as required was neglect. She said skin assessments of all residents on hall 400 were completed as of 09/28/23. During an interview on 09/28/23 at 11:39 a.m. LVN A said she did not assign aides to provide resident care. She said she expected they would assign themselves. She said she finished passing medications on Hall 100 and noticed Resident #1 was in the same position. She said she asked who was assigned to Resident #1 and no one knew. She said she did not follow the DON's orders. She said after Resident #1's family member came to the nurse station, she said MA P and CNA E provided care to Resident #1. She said she talked to Resident #1's physician about Resident #1's red skin and received new orders for Nystatin. She said Resident #1 was neglected because she did not receive care as required and she developed a rash. She said staff were to check and change residents every 2 hours and PRN. During an interview on 09/28/23 at 12:45 p.m., LVN I said she assessed Resident #1 on 09/25/23. She said Resident #1 had a tendency to be red but she did not have a rash or a blister previously. She said the blister could be caused by lying in urine and feces for an extended period. She said residents should be checked and changed every 2 hours and as needed. During an interview on 09/28/23 at 1:11 p.m., LVN F said LVN A refused to do her own medication pass and did not assign aides. She said Resident #1 did not have an assigned CNA on 09/24/23 for the morning shift (6:00 am) and did not receive care as required. She said Resident #1 was neglected. She said residents were to be checked and changed every 2 hours and as needed. During an interview on 09/28/23 at 2:37 p.m., CNA G said she was not assigned to provide care for Resident #1 09/24/23. She said she was not directed to care for Resident #1. She said there was usually a book at the nurse station with assignments. She said residents were supposed to be checked and changed every 2 hours and as needed. She said a resident was neglected if the resident did not receive care as required. She said she provided care for Resident #1 on 09/24/23 later in the day. Resident #1 was crying and saying she hurt (peri-area). She said Resident #1's labia was swollen, the peri area was red and inflamed, and there was a blister on her right labia. She said there was a little bleeding when she wiped feces from Resident #1's peri-area. She said Resident #1's peri-area was not swollen, inflamed, or bleeding the previous day. During an interview on 09/28/23 at 3:04 p.m., CNA E said she was originally scheduled to work as a medication aide on 09/24/23. She said LVN A re-assigned her (CNA E) to work as an aide on hall 300. She said she stopped by MA P after 12:00 p.m. on 09/24/23 and asked to assist with Resident #1's incontinent care. She said Resident #1's family member had removed the incontinent brief and applied a cold cloth to Resident #1's peri-area. She said Resident #1's abdominal creases and inner thighs were red and inflamed. She said Resident #1 was crying and upset. She said residents should be checked and changed every 2 hours and as necessary. She said failure to provide timely incontinent care could result in skin breakdown. CNA E said it was neglect if care was not provided as required. During an interview on 09/28/23 at 3:14 p.m., MA P said she was at the nurse station and Resident #1's family member came to the nurse station. She said Resident #1's family member was in tears and informed LVN A of Resident #1 needing care and she (Resident #1) had not been tended to. LVN A said she would find someone. She said CNA E came by the nurse station and (MA P) told CNA E to assist with providing care to Resident #1. She said Resident #1 cried and whimpered and said it hurt when she was being wiped. She said residents should be checked and changed every 2 hours and as necessary. She said failure to provide timely incontinent care could result in skin breakdown. CNA E said it was neglect if care was not provided as required. Record review of LVN A's personnel file indicated she was terminated on 09/26/23 for insubordination. Record review of the facility's Abuse Prevention Program dated 2001 (revised December 2016) provided by the facility and included the Long-Term Care Regulatory Provider Letter (PL 19-17) indicated Our residents have the right to be free of abuse, neglect, misappropriation of resident property and exploitation.Abuse also includes the deprivation by an individual, including caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being.Neglect . failure to provide goods and services that are necessary to avoid physical or emotional harm, pain, . The Administrator and the DON were notified of the Immediate Jeopardy on 09/28/23 at 1:43 p.m. and the Administrator was provided the Immediate Jeopardy template. The Administrator was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 09/29/23 at 5:42 p.m. and reflected the following: Immediate action: Resident # 1 was assessed by the charge nurse on duty on September 25, 2023 @10:15 a.m. The attending physician was contacted by Charge Nurse, new order to add Nystatin Cream to the existing Zinc Oxide order to be applied three times per day, was received and initiated on 09/25/2023. Upon receipt of the grievance from Resident #1's representative on 09/25/2023, the Assistant Director of Nursing and Director of Nursing began investigating the cause of the grievance on 09/25/2023. Upon investigation it was noted that the division of duties was not carried out by the charge nurse as directed by the Director of Nursing on 09/24/2023 @ 6:45 a.m. The charge nurse that was instructed to divide the resident care duties was interviewed and terminated from employment for refusal to obey orders of a supervisor on 09/26/2023 @ 5:07 p.m. via telephone by the Director of Nursing. On 09/26/2023 The Director of Nursing provided the information regarding the practice of the terminated nurse to the Director of Clinical Operations from the corporate office for further review regarding potential referral to the Texas Board of Nursing. The decision to make the referral was referred to legal counsel on 09/28/2023 when the investigation of the nurse was completed. On 09/26/2023 @ 5:30 p.m., The Director of Nursing initiated an in-service with nursing staff: both direct and licensed regarding following directives given by the supervisor during their shift and the consequences that might arise from failure to adhere to direction given. The in-service education will continue until all nursing staff: direct care and licensed, have been provided with this education and staff will not be able to begin their next scheduled shift without acknowledgment of understanding. The in-service education will be completed no later than 09/29/2023. On 09/26/2023, upon identification of the directive from the supervisor not being carried out, further investigation by the Director of Nursing revealed CNAs were not assigned to provide care on the 400 hall on 09/24/2023 from approximately 6:00 a.m. until 12:30 p.m. On 09/26/2023 at 5:45 p.m., The Director of Nursing and Designees completed full body skin assessments on all residents on the 400 hall. No adverse findings were noted on completion for residents' residing on 400 Hall on 09/26/23 at 7:50 p.m. On 09/26/2023 @ 5:30 p.m., the Director of Nursing initiated an in-service with nursing staff: regarding direct and licensed regarding resident care rounds. This in-service directed nursing staff: direct care and licensed, that residents should be rounded on/checked on at least every two hours to ensure their needs are being met timely and appropriately, with emphasis on residents with higher acuity and dependent on care. The in-service education will continue until all nursing staff: both licensed and direct care, have been provided with this education and staff will not be able to begin their next scheduled shift without acknowledgment of understanding. The in-service education will be completed no later than 09/29/2023. On 09/26/2023 @ 5:30 p.m., the Director of Nursing initiated an in-service with the nursing staff: both direct and licensed and therapy staff regarding the importance of incontinent care and general ADL care. The in-service education will continue until all nursing staff: direct care and licensed, and therapy staff have been provided with this education and staff will not be able to begin their next scheduled shift without acknowledgment of understanding. The in-service education will be completed no later than 09/29/2023. On 09/26/2023, the Director of Nursing and Designees conducted resident life satisfaction surveys on residents residing who are able to be interviewed on the 400 hallway; no concerns regarding care were noted upon completion on 09/28/2023. Facilities Plan to Ensure Compliance Quickly Impromptu QAPI was held September 28, 2023 @ 6:18 p.m. with the facility Medical Director and informed him of the two immediate jeopardies that the Facility obtained for F600-Neglect and F677-ADL Care for Dependent Residents. The Medical Director was informed of the facility efforts to correct the alleged violations including assessments, interviews, disciplinary action, education, and initiation of procedural changes. On September 28, 2023, the facility will implement a new procedure for assigning staff to residents based on the number of staff present. This procedure will provide instruction on how to divide the resident care duties efficiently and equally to ensure adequate care of residents. The division of duties will be specific to different staffing numbers and instances. Each day on the daily assignment sheet one charge nurse will be assigned to be the person responsible for ensuring the correct division of duties is confirmed with all staff at the beginning of the shift. The Director of Nursing shall provide an in-service to all staff regarding the process of staff assignments. The in-service education will continue until all nursing staff, direct care and licensed, have been provided with this education and staff will not be able to begin their next scheduled shift without acknowledgment of understanding. The in-service education will be completed no later than 09/29/2023. The Director of Nursing and/or Designee shall review the daily assignment sheets for adequate division of duties Monday through Friday and the weekend supervisor shall review on Saturday and Sunday. On 09/29/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on 09/29/23 from 4:30 p.m. through 6:55 p.m. and included 3 alert residents, nurses including 5 LVNs, 6 CNAs, 2 MA, (who work all shifts), the ADON, and the DON. Staff indicated residents were checked every 2 hours for incontinence, lines were checked for wetness, water and ADL care provided PRN. Residents were monitored during rounds. Residents were asked about their needs. The lead nurse assigns aides as necessary and if aides were not available, aides would split halls based on guide in book at nurse station. They indicated if staff refused direct orders from their supervisor they would report to the DON and the administrator. Staff were required to check their assigned residents at the start of their shift and end of their shift. Staff would be suspended and possibly terminated for refusing direct orders. During an interview on 09/29/23 at 4:42 p.m. the DON said lead nurse assignments were in place to ensure all residents had assigned CNA's. She said all in-services were completed. She said skin assessments were completed for Hall 400 and the entire facility. She said there was no additional negative findings. During observation and interview on 09/29/23 at 5:52 p.m., Resident #1 said staff were keeping her changed and dry. Resident #1's undergarment was dry and the Nystatin/Zinc compound was applied to her per-area. Redness was observed on Resident #1 and she was clean and dry. The facility implemented a monitoring system effective 09/29/23. The facility Administrator and/or Director of Nursing indicated they were responsible for the monitoring and would conduct observation rounds and conduct interviews related to resident care, duties and assignments, and lead nurse responsibilities. Record review of Resident #1's skin assessment dated [DATE], physician orders, and TAR indicated Resident #1 received care as required. Record review of 100% of hall 400 skin assessments indicated the facility reviewed all residents to ensure no adverse findings. Record review of grievances for previous three months from through 09/29/23 indicated the facility addressed grievances as required. The grievance from Resident #1's family member on 09/25/23, the ADON and DON determined LVN A had not assigned duties as directed by the DON on 09/24/25. CNAs were not assigned to provide care on the 400 hall on 09/24/23 from approximately 6:00 a.m. until 12:30 p.m. Record review of LVN A's personnel file LVN A was terminated for insubordination on 09/26/23. Record review of staff in-service dated 09/29/23 indicated all licensed and direct care staff were trained on following directives from their supervisors. Record review of staff in-service dated 09/26/23 indicated direct care and licensed staff were trained that residents should be rounded on/checked on at least every two hours to ensure their needs are being met timely and appropriately, with emphasis on residents with higher acuity and dependent on care. Record review of staff in-service dated 09/26/23 indicated direct and licensed and therapy staff were trained regarding the importance of incontinent care and general ADL care. Record review of resident life satisfaction surveys on residents residing who are able to be interviewed on the 400 hallway indicated no concerns regarding care were noted upon completion on 09/28/2023. Record review of the facility's new procedure dated 09/28/23 for assigning staff to residents based on the number of staff present indicated the following: on the daily assignment sheet one charge nurse would be assigned responsible for ensuring the correct division of duties was confirmed with all staff at the beginning of the shift. The DON inserviced all staff regarding the process of staff assignments. The DON and/or Designee would review the daily assignment sheets for adequate division of duties Monday through Friday and the weekend supervisor would review on Saturday and Sunday. Record of staff post tests were reviewed for accuracy and knowledge. No concerns noted. On 09/29/23 at 6:55 p.m., the Administrator was informed the IJ was removed; however, 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.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents. On [DATE] CNA B left Resident #1 in the bathroom unsupervised. She was found on the floor deceased with a right temporal hematoma and 3 cm laceration to her head. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:42 p.m. While the IJ was removed on [DATE] at 2:27 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 falls resulting in injury, pain, and hospitalization . Findings included: Record review of a face sheet dated [DATE] indicated Resident #1 was an [AGE] year-old female, admitted on [DATE], and her diagnoses included heart failure, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), abnormalities of gait and mobility, diabetes, ataxic gait (difficulty walking in a straight line, lateral veering, poor balance, a widened base of support, inconsistent arm motion, and lack of repeatability), muscle weakness, lack of coordination (uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), pseudobulbar affect (a condition characterized by episodes of sudden uncontrollable and inappropriate laughing or crying), Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), COPD (a group of diseases that cause airflow blockage and breathing-related problems), and difficulty walking. Record review of an MDS assessment dated [DATE] indicated Resident #1 was usually able to make herself understood, was usually able to understand others, had short term and long-term memory problems, was not able to recall current season, location of her own room, staff names and faces, or that she was in a nursing facility. She required extensive physical assist of one person for bed mobility and transfers. She required full staff assistance for toilet use. She was not steady and only able to stabilize with staff assistance when moving from moving from seated to standing position and surface to surface transfer. She utilized a wheelchair for mobility. She always incontinent of bowel and bladder. Record review of a care plan revised on [DATE] indicated Resident #1 had ADL self-care performance deficit and limitations in physical mobility related to impaired balance and limited mobility/ROM, and musculoskeletal impairment. Interventions included limited assistance of one staff to transfer and total assistance of one staff for toileting (revised [DATE]). Record review of a care plan revised on [DATE] indicated Resident #1 was at risk for falls related to confusion and gait/balance problems. Interventions included follow fall precautions protocol (revised [DATE]). Record review of a care plan revised on [DATE] indicated Resident #1 had falls on [DATE], [DATE], [DATE], [DATE], and [DATE]. Interventions included investigate to determine and address causative factors of the fall and obtain statements for witnessed falls (revised [DATE]). There were no statements available for review. Record review of a care plan revised [DATE] indicated Resident #1 was on anticoagulant therapy related to heart disease. Interventions included to take precautions to avoid falls (revised [DATE]). Record review of a progress note dated [DATE] at 6:37 p.m., completed by LVN A indicated Resident #1 had an unwitnessed fall in her bathroom. LVN A was passing medication on another hall when she was called by the CNAs on the hall stating Resident #1 had fallen. Hurry up she is bleeding and there is a lot of blood on her face. LVN A witnessed two CNAs turned Resident #1 from a prone position to a supine position, facing the ceiling. Resident #1's head was close to the wall of the shower and her legs were stretched out toward the toilet seat. She had a large hematoma to the right temple and a 3 cm laceration. There was a large amount of blood on the face and neck. There was no rise or drop of her chest wall, no audible heart rate, no pulse. Resident #1's pants were midway to her waits and her diaper was pulled up completely. Resident #1's shoes were on her feet. The call light was not activated and was in reach. Resident #1 was moved from the shower area to the entrance way between her room and the bathroom. LVN A noted the wheelchair was under the sink with the brakes not locked. Four paramedics arrived and pronounced Resident #1 deceased as of 3:30 p.m. MD and family made aware of Resident #1's expiring. Record review of an incident report dated [DATE] at 3:00 p.m., Completed by LVN A, indicated Resident #1 had an unwitnessed fall in her bathroom. LVN A was passing medication on another hall when she was called by the CNAs on the hall stating Resident #1 had fallen. Hurry up she is bleeding and there is a lot of blood on her face. LVN A witnessed two CNAs turned Resident #1 from a prone position to a supine position, facing the ceiling. Resident #1's head was close to the wall of the shower and her legs were stretched out toward the toilet seat. She had a large hematoma to the right temple and a 3 cm laceration. There was a large amount of blood on the face and neck. There was no rise or drop of her chest wall, no audible heart rate, no pulse. Resident #1's pants were midway to her waits and her diaper was pulled up completely. Resident #1's shoes were on her feet. The call light was not activated and was in reach. Resident #1 was moved from the shower area to the entrance way between her room and the bathroom. LVN A noted the wheelchair was under the sink with the brakes not locked. Four paramedics arrived and pronounced Resident #1 deceased as of 3:30 p.m. MD and family made aware of Resident #1's expiring. DON and ADON were made aware. During an interview on [DATE] at 1:12 p.m., the DON said Resident #1 had a wheelchair and was mobile and would go to the bathroom on her own. She said Resident #1 was found with no life signs at approximately 3:00 p.m. on [DATE]. She said Resident #1 was administered medication at 2:43 p.m. She said Resident #1 was not supposed to transfer without assistance. She said Resident #1 did have a history of falls. She said fall interventions included a low bed, call light in reach, and signs hung up in Resident #1's room to remind her (Resident #1) to call for assistance to transfer. An observation on [DATE] at 2:50 p.m. of Resident #1's bathroom area indicated there was not observed fall hazards. The toilet was situated across from a walk-in shower. The floor was tiled. There was a working call light adjacent to the toilet. There was a grab bar adjacent to the toilet. During an interview on [DATE] at 3:49 p.m., CNA B said on [DATE] Resident #1 was in the hall and had vomited. She said she brought Resident #1 to the bathroom and then went to tell LVN A of Resident #1 vomiting and gather a basin and supplies to clean her up. She said she could not recall what the time was when Resident #1 vomited or when she took her to the bathroom. She said she returned to the bathroom a few minutes later and found Resident #1 on the floor. She said Resident #1's head was on the floor of the shower and she was lying on her side. She said Resident #1's feet were in front of the toilet. She said Resident #1 did not respond to her name and she called for LVN A. She said she could not recall where the wheelchair was or if it was locked. She said the wheelchair was between the toilet and the hand sink. She said she left out of the bathroom to call for the nurse. She said there was blood on her head and her neck. She said her pants were down around her knees but her diaper was not down. During an interview on [DATE] at 8:05 a.m. CNA C said on [DATE] Resident #1 said she was sick and asked us (CNA B and CNA C) to bring her to the bathroom. She said she could not recall the exact time Resident #1 vomited or was taken to the bathroom. Resident #1 was still in her wheelchair and it was locked. She said the wheelchair was between the sink and the toilet. She said she told Resident #1 to pull the call light when she was done (vomiting.) She said she and CNA C left the bathroom to get a basin and towels. She said she realized after a few minutes Resident #1 had not pulled the call light and went to check on her and found her on the floor. She said Resident #1's head was on the floor of the shower and she was lying on her side. She said Resident #1's feet were in front of the toilet. She said her pants were down around her knees but her diaper was not down. She said Resident #1 did not respond to her name and she called for LVN A. She said Resident #1 was left in the bathroom for approximately two or three minutes. She said they (CNA B and CNA C) notified LVN A of Resident #1 vomiting and LVN A said she would check the resident after she completed BP check. She said by the time LVN A was coming to check on Resident #1, they (CNA B and CNA C) had already found Resident #1 on the floor of the bathroom. She said Resident #1 was a one-person assist for transfers. She said Resident #1 required supervision to use the toilet. She said Resident #1 could stand and was limited assist to use the toilet. She said if she had taken her to the bathroom to use the toilet, she would not have left her alone and would have helped her in the bathroom until she was able to get another staff to get a nurse. During an interview on [DATE] at 9:00 a.m., LVN A said she was at the nurse station on [DATE] when she was approached by CNA B. She said she could not recall the exact time but it was before 3:00 p.m. She said CNA B said Resident #1 had vomited. LVN A said she told CNA B she (LVN A) was going to check another resident's BP on a different hall and would be right back to check on Resident #1. She said she was on her way back to check on Resident #1 a few minutes later, when she heard CNA B calling out her name. She said CNA B said Resident #1 was on the floor. She said she immediately went to Resident #1's bathroom. She said Resident #1 was lying on her right side on the floor. She said her head was laying towards the shower and her feet were by the toilet. She said the wheelchair was locked and between the toilet and the sink. She said she unblocked the wheelchair and moved it under the sink. She said two aides turned Resident #1 to lay flat on her back. She said she checked for pulse and breathing. She said there was no signs of life. She said there was a 3 cm laceration on her forehead and blood was coming out of her mouth. There was blood on the floor. She was a DNR so no CPR was performed. Another nurse called the police and we were instructed not to touch her but we had already moved her from the bathroom floor to the floor between the bathroom and the bedroom in case we had to do CPR. EMS arrived and they checked and she had no signs of life. LVN A said from the time CNA B informed her Resident #1 had vomited to the time she was called and informed Resident #1 was on the floor was approximately ,d+[DATE] minutes. She said Resident #1 would go to the bathroom on her own but would require staff assist to use the toilet. She said Resident #1 was not steady on her legs. She said Resident #1 had a history of falls. She said Resident #1's bedroom had signs to remind her to use the call light for help. She said Resident #1 would scream for help but when asked, she did not know what she needed. She said Resident #1 was totally dependent on staff to use the toilet. She said Resident #1 required supervision in the bathroom. She said Resident #1 should not have been left alone in the bathroom. During an interview on [DATE] at 10:29 a.m., the DON said she was made aware of Resident #1's fall and death immediately on [DATE]. She said she did not investigate the incident. She said she talked to LVN A, CNA B and CNA C. She said residents were at risk of injuries if they were left alone and required supervision. During an interview on [DATE] at 11:00 a.m., the ADON said staff were not supposed to leave Resident #1 unsupervised in the bathroom. She said Resident #1 required staff assist for transfers and toileting. She said residents were at risk of injuries if they were left alone and required supervision. During an interview on [DATE] at 12:59 p.m., MDS LVN J said supervision of residents meant they were not left alone if the resident required assist for transfers in the bathroom or was totally dependent on staff for toileting. She said residents were at risk of injuries if they were left alone and required supervision. During an interview on [DATE] at 4:03 p.m. CNA C said Resident #1 would normally go around the facility in her wheelchair and do her own thing. She said if we could not see Resident #1 and we would look for her we would find her in the bathroom. She said we would have to remind her to ask for assistance. She said she did not know if she should have left Resident #1 alone in the bathroom to wait for CNA B. She said if she had known Resident #1 should not be left alone she would have stayed with her in the bathroom until CNA B brought LVN A to the bathroom. During an interview on [DATE] at 3:45 p.m., LVN K said Resident #1 require supervision in the bathroom. She said Resident #1 was totally dependent on staff for toileting and required assist to transfer. She said supervision meant eyes on the resident. She said Resident #1 should not have been left alone in the bathroom. During an interview on [DATE] at 11:30 a.m., CNA E said Resident #1 was not able to stand without assist to use the toilet. She said Resident #1 required supervision in the bathroom. She said she require assist and prompts to use the support bars. She said Resident #1 was not supposed to go to the bathroom alone because she would attempt to use the toilet without assist. She said Resident #1 required supervision in the bathroom. During an interview on [DATE] at 11:43 a.m., CNA F said Resident #1 was not supposed to be left alone in the bathroom. She said staff had to watch Resident #1 because if she went towards her room she would try to use the bathroom without calling for staff or try to transfer to her bed without calling for staff. She said staff would offer different activities or snacks and coffee to keep Resident #1 away from her room and in view of staff. She said staff would offer to take her to the bathroom if she was headed to her room or she would try to do it by herself. CNA F said Resident #1 always required supervision in the bathroom. During an interview on [DATE] at 12:32 p.m., CNA G said Resident #1 needed assistance to transfer. He said Resident #1 required supervision in the bathroom. He said with supervision meant she was not supposed to be left alone. During an interview on [DATE] at 12:45 p.m. CNA H said Resident #1 was not supposed to be left alone in the rest room because she would try to transfer on her own. She said staff kept Resident #1 in their sight because she would try to go to the bathroom and use the toilet without supervision . During an interview on [DATE] at 1:09 p.m., CNA I said Resident #1 required assist for transfers and supervision in the bathroom. She said Resident #1 would head towards the bathroom and staff would have to watch her and offer to help or she would go in there by herself and attempt to transfer without assistance. She said Resident #1 would hold on to the support bars and staff would pull her pants and undergarments down before Resident #1 would turn to sit on the toilet. CNA I said staff were supposed to gather all supplies necessary before going to the bathroom. She said staff should not have left Resident #1 in the bathroom alone. During an interview on [DATE] at 1:41 p.m., LVN K said supervision of residents meant they were not left alone if the resident required assist for transfers in the bathroom or was totally dependent on staff for toileting. She said residents were at risk of injuries if they were left alone and required supervision. Record review of the facility's Safety and Supervision of Residents policy dated 2001 (Revised [DATE]) indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. Record review of Managing Falls and Fall Risk policy dated 2001 (revised [DATE]) indicated: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 2. Resident conditions that may contribute to the risk of falls include: . c. delirium and other cognitive impairment; . e. lower extremity weakness; f. poor grip strength; g. medication side effects, h. orthostatic hypotension, i. functional impairments; j. visual deficits; and k. incontinence. 3. Medical factors that contribute to the risk of falls include: arthritis; b. heart failure; c. anemia; d. neurological disorders; and e. balance and gait disorders; etc. Resident-Centered Approaches to Managing Falls and Fall Risk-1. The staff, with the input of the attending physician, will implement a resident-centered prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:42 p.m. While the IJ was removed on [DATE] at 2:27 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. The Facility's Plan of Removal for Immediate Jeopardy was accepted on [DATE] and indicated the following: Immediate action: Immediately upon notification of the alleged deficient practice on [DATE] @ (2:42 p.m.), the Director of Clinical Operations from the Corporate Office provided an in-service to the Facility Administrator, Director of Nursing, Assistant Director of Nursing, and MDS coordinator with an in-service regarding F689 including: the definition of supervision, how to determine each residents level of supervision, accident prevention/reduction interventions, identification of changes in resident condition that may change their level of supervision needed with examples provided, current professional standards of practice, how to audit resident records to ensure the correct level of supervision is indicated, and what to do if an accident occur as a result of the incorrect level of supervision being practiced. Following the in-service education and knowledge check provided to the Facility Administrator, Director of Nursing, Assistant Director of Nursing, and MDS Coordinator, the Director of Nursing and designees provided an in-service to all nursing staff present regarding supervision of residents during toileting and other ADL's, being aware of where to locate the level of assistance needed for care (electronic Kardex), when and how to notify the supervising nurse of changes in resident condition including changes in residents physical ability to perform ADL task(s). This in-service will begin with the day shift (,d+[DATE]) on [DATE] and all nursing staff will be required to attend this in-service before the start of their next scheduled shift. The process of in-servicing will continue until all active nursing employees are educated or before [DATE], at 1900. In addition to current staff, the in-service conducted on [DATE], regarding supervision will be provided to newly hired employees prior to being assigned residents. Beginning on [DATE], the Director of Nursing and/or designee will provide an updated in-service to all nursing staff on shift, prior to beginning their next shift and at the time of hire. This updated in-service will include the definition of supervision, why it is important to know each resident's individual need/level of supervision, how we determine the residents need for supervision, and how supervision plays an integral role in the mitigation/reduction of accidents. Staff will be provided with scenarios of negative outcomes when adequate supervision was not provided and consequences of not following the resident plan of care as indicated in the Kardex. Following the completion of both in-services, each nursing staff member will be provided with a quiz which will consist of ten questions related to the in-service education provided over both days. A grade of 80 or above will be considered passing. Any staff member that scores below 80 will be re-educated and observed to ensure knowledge is retained. The updated in-service will be completed no later than [DATE], at 1900. A log of test scores shall be presented to the QAPI committee for review during the next scheduled QAPI meeting on [DATE]. The Director of Nursing contacted the C.N.A. that was providing care to Resident #1 on [DATE] @ (4:12 p.m.) to inform her that she was suspended pending the outcome of the investigation and provided with education regarding resident supervision. The Director of Nursing, the MDS Coordinator, and the Assistant Director of Nursing, began an audit of all resident plans of care to ensure the correct level of care and supervision consistent with each individual resident's needs. This audit will ensure the resident Kardex is updated with the correct information. The audit was initiated on [DATE], and will be completed no later than [DATE] @ (7:00 p.m.). Any noted changes made to existing resident's plans of care will be noted on the audit log and presented to the QAPI committee on [DATE], to determine if there is a system failure or a limited resident failure and make recommendations as necessary. The Director of Nursing and the Assistant Director of Nursing conducted interviews with staff to ensure residents with a recent change of condition were identified and evaluated to ensure there has not been a change in their level of assistance or necessary supervision. At the time of the interviews on [DATE], and [DATE], there were no identified changes in condition reported. Facilities Plan to Ensure Compliance Quickly Impromptu QAPI was held [DATE] @ (5:30 p.m.) with the Medical Director and informed him of the three immediate jeopardies that the Facility obtained for F607-Implementing Abuse and Neglect Policies and Procedures, F689-Accidents/Supervision, F610-Alleged Violations-Investigate/Prevent/Correct. The Medical Director was informed of the facility efforts to correct the alleged violations including audits of all resident records to ensure correct ADL coding is passed to the C.N.A.'s through to the Kardex, supervision of residents for safety, ensuring the abuse and neglect policy is implemented and incidents are reported and investigated. The Medical Director enforced supervision with toileting and room location for frequent fallers when possible. Beginning [DATE], The Director of Nursing and/or designee will walk the halls in real time and ask questions to random nursing staff regarding their role in resident supervision and where to find a resident's level of assistance required prior to rendering care to ensure knowledge from education provided was retained. On [DATE], the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: The administrator, DON, ADON, and MDS coordinator were able to define supervision, how to determine each resident's level of supervision, list accident prevention/reduction interventions, identify of changes in resident condition that may change their level of supervision needed with examples provided, were aware of current professional standards of practice, audited resident records to ensure the correct level of supervision was indicated, and were aware of what to do if an accident occurred due to the incorrect level of supervision. Record review of the in-services dated [DATE] and [DATE] included the definition of supervision, why it was important to know each resident's individual need/level of supervision, how to determine the resident's need for supervision, and how supervision played an integral role in the mitigation/reduction of accidents. Staff were provided with scenarios of negative outcomes when adequate supervision was not provided and consequences of not following the resident plan of care as indicated in the Kardex. During interviews conducted on [DATE] from 9:00 a.m. through 2:00 p.m. with 5 LVNs, 9 CNAs, 3 MA, (who work all shifts), the MDS coordinator, the ADON, the DON and the Administrator. Staff were aware of where to locate the level of assistance needed for care (electronic Kardex), when and how to notify the supervising nurse of changes in resident condition including changes in residents physical ability to perform ADL task(s). Staff were able to define supervision, why it was important to know each resident's individual need/level of supervision, how to determine the resident's need for supervision, and how supervision played an integral role in the mitigation/reduction of accidents. Staff were provided with scenarios of negative outcomes when adequate supervision was not provided and consequences of not following the resident plan of care as indicated in the Kardex. Record review of quiz results indicated all staff passed the quiz related to resident level of supervision and prevention of accidents. Record review of the facility's audit of all resident care plans indicated all residents' level of supervision corresponded with their need. Record review of 6 resident electronic records indicated all care plans included level of supervision based on resident needs. Staff interviews indicated there were no identified changes in condition reported. Observations conducted on [DATE] from 9:00 a.m. through 2:00 p.m. indicated no observed concerns related to supervision or assistance. On [DATE] at 2:27 p.m., the Administrator and DON were informed the IJ was removed; however, 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.

Based on observation, interview and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure the abuse coordinator and/or designee reported immediately to HHSC after Resident #1 was found deceased on the floor of her bathroom with injuries of unknown origin. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:42 p.m. While the IJ was removed on [DATE] at 2:27 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 of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated [DATE] indicated Resident #1 was an [AGE] year-old female, admitted on [DATE], and her diagnoses included heart failure, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), abnormalities of gait and mobility, diabetes, ataxic gait (difficulty walking in a straight line, lateral veering, poor balance, a widened base of support, inconsistent arm motion, and lack of repeatability), muscle weakness, lack of coordination (uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), pseudobulbar affect (a condition characterized by episodes of sudden uncontrollable and inappropriate laughing or crying), Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), COPD (a group of diseases that cause airflow blockage and breathing-related problems), and difficulty walking. Record review of an MDS assessment dated [DATE] indicated Resident #1 was usually able to make herself understood, was usually able to understand others, had short term and long-term memory problems, was not able to recall current season, location of her own room, staff names and faces, or that she was in a nursing facility. She required extensive physical assist of one person for bed mobility and transfers. She was totally dependent on staff assistance for toilet use. She was not steady and only able to stabilize with staff assistance when moving from moving from seated to standing position and surface to surface transfer. She utilized a wheelchair for mobility. She always incontinent of bowel and bladder. Record review of a care plan revised on [DATE] indicated Resident #1 had ADL self-care performance deficit and limitations in physical mobility related to impaired balance and limited mobility/ROM, and musculoskeletal impairment (injuries or disorders of the muscles, nerves, tendons, joints, cartilage, and spinal discs). Interventions included limited assistance of one staff to transfer and total assistance of one staff for toileting (revised [DATE]). Record review of a care plan revised on [DATE] indicated Resident #1 was at risk for falls related to confusion and gait/balance problems. Interventions included follow fall precautions protocol (revised [DATE]). Record review of a care plan revised on [DATE] indicated Resident #1 had falls on [DATE], [DATE], [DATE], [DATE], and [DATE]. Interventions included investigate to determine and address causative factors of the fall and obtain statements for witnessed falls (revised [DATE]). There were no statements available for review. Record review of a care plan revised [DATE] indicated Resident #1 was on anticoagulant therapy related to heart disease. Interventions included to take precautions to avoid falls (revised [DATE]). Record review of a progress note dated [DATE] at 6:37 p.m., completed by LVN A indicated Resident #1 had an unwitnessed fall in her bathroom. LVN A was passing medication on another hall when she was called by the CNAs on the hall stating Resident #1 had fallen. Hurry up she is bleeding and there is a lot of blood on her face. LVN A witnessed two CNAs turned Resident #1 from a prone position to a supine position, facing the ceiling. Resident #1's head was close to the wall of the shower and her legs were stretched out toward the toilet seat. She had a large hematoma to the right temple and a 3 cm laceration. There was a large amount of blood on the face and neck. There was no rise or drop of her chest wall, no audible heart rate, no pulse. Resident #1's pants were midway to her waits and her diaper was pulled up completely. Resident #1's shoes were on her feet. The call light was not activated and was in reach. Resident #1 was moved from the shower area to the entrance way between her room and the bathroom. LVN A noted the wheelchair was under the sink with the brakes not locked. Four paramedics arrived and pronounced Resident #1 deceased as of 3:30 p.m. MD and family made aware of Resident #1's expiring. Record review of an incident report dated [DATE] at 3:00 p.m., Completed by LVN A, indicated Resident #1 had an unwitnessed fall in her bathroom. LVN A was passing medication on another hall when she was called by the CNAs on the hall stating Resident #1 had fallen. Hurry up she is bleeding and there is a lot of blood on her face. LVN A witnessed two CNAs turned Resident #1 from a prone position to a supine position, facing the ceiling. Resident #1's head was close to the wall of the shower and her legs were stretched out toward the toilet seat. She had a large hematoma to the right temple and a 3 cm laceration. There was a large amount of blood on the face and neck. There was no rise or drop of her chest wall, no audible heart rate, no pulse. Resident #1's pants were midway to her waits and her diaper was pulled up completely. Resident #1's shoes were on her feet. The call light was not activated and was in reach. Resident #1 was moved from the shower area to the entrance way between her room and the bathroom. LVN A noted the wheelchair was under the sink with the brakes not locked. Four paramedics arrived and pronounced Resident #1 deceased as of 3:30 p.m. MD and family made aware of Resident #1's expiring. DON and ADON were made aware. There was no facility investigation available for review as of [DATE]. During an interview on [DATE] at 1:12 p.m., the DON said Resident #1 had a wheelchair and was mobile and would go to the bathroom on her own. She said Resident #1 was found with no life signs at approximately 3:00 p.m. on [DATE]. She said Resident #1 was administered medication at 2:43 p.m. She said Resident #1 was not supposed to transfer without assistance. She said Resident #1 did have a history of falls. She said fall interventions included a low bed, call light in reach, and signs hung up in Resident #1's room to remind her (Resident #1) to call for assistance to transfer. An observation on [DATE] at 2:50 p.m. of Resident #1's bathroom area reflected there was not observed fall hazards. The toilet was situated across from a walk-in shower. The floor was tiled. There was a working call light adjacent to the toilet. There was a grab bar adjacent to the toilet. During an interview on [DATE] at 3:30 p.m., the DON said she did not report Resident #1's fall and injury or death to the state because she did not know if Resident #1 fell and sustained the injury and then expired or if something caused Resident #1 to expire and then fall. She said she spoke to the LVN A, CNA B, and CNA C but did not obtain any statements. During an interview on [DATE] at 3:49 p.m., CNA B said on [DATE] Resident #1 was in the hall and had vomited. She said she brought Resident #1 to the bathroom and then went to tell LVN A of Resident #1 vomiting and gather a basin and supplies to clean her up. She said she could not recall what the time was when Resident #1 vomited or when she took her to the bathroom. She said she returned to the bathroom a few minutes later and found Resident #1 on the floor. She said Resident #1's head was on the floor of the shower, and she was lying on her side. She said Resident #1's feet were in front of the toilet. She said Resident #1 did not respond to her name and she called for LVN A. She said she could not recall where the wheelchair was or if it was locked. She said the wheelchair was between the toilet and the hand sink. She said she left out of the bathroom to call for the nurse. She said there was blood on her head and her neck. She said her pants were down around her knees, but her diaper was not down. During an interview on [DATE] at 8:05 a.m. CNA C said on [DATE] Resident #1 said she was sick and asked us (CNA B and CNA C) to bring her to the bathroom. She said she could not recall the exact time Resident #1 vomited or was taken to the bathroom. Resident #1 was still in her wheelchair, and it was locked. She said the wheelchair was between the sink and the toilet. She said she told Resident #1 to pull the call light when she was done (vomiting.) She said she and CNA C left the bathroom to get a basin and towels. She said she realized after a few minutes Resident #1 had not pulled the call light and went to check on her and found her on the floor. She said Resident #1's head was on the floor of the shower, and she was lying on her side. She said Resident #1's feet were in front of the toilet. She said her pants were down around her knees, but her diaper was not down. She said Resident #1 did not respond to her name and she called for LVN A. She said Resident #1 was left in the bathroom for approximately two or three minutes. She said they (CNA B and CNA C) notified LVN A of Resident #1 vomiting and LVN A said she would check the resident after she completed BP check. She said by the time LVN A was coming to check on Resident #1, they (CNA B and CNA C) had already found Resident #1 on the floor of the bathroom. She said Resident #1 was a one-person assist for transfers. She said Resident #1 required supervision to use the toilet. She said Resident #1 could stand and was limited assist to use the toilet. She said if she had taken her to the bathroom to use the toilet, she would not have left her alone and would have helped her in the bathroom until she was able to get another staff to get a nurse. During an interview on [DATE] at 9:00 a.m., LVN A said she was the nurse station when she was approached by CNA B, She said CNA B said Resident #1 had vomited. LVN A said she told CNA B she (LVN A) was going to check another resident's BP on a different hall and would be right back to check on Resident #1. She said she was on her way back to check on Resident #1 when she heard CNA B calling out her name. She said CNA B said Resident #1 was on the floor. She said she immediately went to Resident #1's bathroom. She said Resident #1 was lying on her right side on the floor. She said her head was laying towards the shower and her feet were by the toilet. She said the wheelchair was locked and between the toilet and the sink. She said she unblocked the wheelchair and moved it under the sink. She said two aides turned Resident #1 to lay flat on her back. She said she checked for pulse and breathing. She said there was no signs of life. She said there was a 3 cm laceration on her forehead and blood was coming out of her mouth. There was blood on the floor. She was a DNR, so no CPR was performed. Another nurse called the police, and we were instructed not to touch her, but we had already moved her from the bathroom floor to the floor between the bathroom and the bedroom in case we had to do CPR. EMS arrived and they checked, and she had no signs of life. LVN A said from the time CNA B informed her Resident #1 had vomited to the time she was called, and informed Resident #1 was on the floor was approximately ,d+[DATE] minutes. She said Resident #1 would go to the bathroom on her own but would require staff assist to use the toilet. She said Resident #1 was not steady on her legs. She said Resident #1 had a history of falls. She said Resident #1's bedroom had signs to remind her to use the call light for help. She said Resident #1 would scream for help but when asked, she did not know what she needed. She said Resident #1 was totally dependent on staff to use the toilet. She said Resident #1 required supervision in the bathroom. She said Resident #1 should not have been left alone in the bathroom. During an interview on [DATE] at 10:29 a.m., the DON said she was made aware of Resident #1's fall and death immediately on [DATE]. She said she did not report the incident because she was not sure if Resident #1 fell and expired or what caused Resident #1 to fall. She said she did not investigate the incident. She said she was aware injuries of unknown origin were supposed to be reported to the state if there was possible neglect. She said not reporting and investigating could place other residents at risk of abuse and neglect. During an interview on [DATE] at 10:29 a.m., the administrator said all allegations of abuse or neglect, or injuries of unknown sources should be reported to the state within 2 hours. He said he was the abuse coordinator. He said he was made aware of the incident immediately on the [DATE] but could not give a reason Resident #1's fall and death were not reported or investigated. He said not reporting and investigating could place other residents at risk of abuse and neglect. During an interview on [DATE] at 11:00 a.m., the ADON said staff were not supposed to leave Resident #1 unsupervised in the bathroom. She said Resident #1 required staff assist for transfers and toileting. She said residents were at risk of injuries if they were left alone and required supervision. During an interview on [DATE] at 12:59 p.m., MDS LVN J said supervision of residents meant they were not left alone if the resident required assist for transfers in the bathroom or was totally dependent on staff for toileting. She said residents were at risk of injuries if they were left alone and required supervision. During an interview on [DATE] at 4:03 p.m. CNA C said Resident #1 would normally go around the facility in her wheelchair and do her own thing. She said if we could not see Resident #1 and we would look for her we would find her in the bathroom. She said we would have to remind her to ask for assistance. She said she did not know if she should have left Resident #1 alone in the bathroom to wait for CNA B. She said if she had known Resident #1 should not be left alone, she would have stayed with her in the bathroom until CNA B brought LVN A to the bathroom. During an interview on [DATE] at 11:30 a.m., CNA E said Resident #1 was not able to stand without assist to use the toilet. She said Resident #1 required supervision in the bathroom. She said she required assist and prompts to use the support bars. She said Resident #1 was not supposed to go to the bathroom alone because she would attempt to use the toilet without assist. She said Resident #1 required supervision in the bathroom. During an interview on [DATE] at 11:43 a.m., CNA F said Resident #1 was not supposed to be left alone in the bathroom. She said staff had to watch Resident #1 because if she went towards her room, she would try to use the bathroom without calling for staff or try to transfer to her bed without calling for staff. She said staff would offer different activities or snacks and coffee to keep Resident #1 away from her room and in view of staff. She said staff would offer to take her to the bathroom if she was headed to her room or she would try to do it by herself. CNA F said Resident #1 always required supervision in the bathroom. During an interview on [DATE] at 12:32 p.m., CNA G said Resident #1 needed assistance to transfer. He said Resident #1 required supervision in the bathroom. He said with supervision meant she was not supposed to be left alone. During an interview on [DATE] at 12:45 p.m. CNA H said Resident #1 was not supposed to be left alone in the rest room because she would try to transfer on her own. She said staff kept Resident #1 in their sight because she would try to go to the bathroom and use the toilet without supervision. During an interview on [DATE] at 1:09 p.m., CNA I said Resident #1 required assist for transfers and supervision in the bathroom. She said Resident #1 would head to the bathroom and staff would have to watch her and offer to help or she would go in there by herself and attempt to transfer without assistance. She said Resident #1 would hold on to the support bars and staff would pull her pants and undergarments down before Resident #1 would turn to sit on the toilet. CNA I said staff were supposed to gather all supplies necessary before going to the bathroom. She said staff should not have left Resident #1 in the bathroom alone. Record review of the facility's Abuse Prevention Program dated 2001 (revised [DATE]) indicated Our 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 resident's symptoms. 3. Develop and impellent policies and procedures to aide out facility in preventing abuse, neglect, or mistreatment of our residents. 6. Identify and assess all possible incidents of abuse. 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Record review of the facility's Abuse Investigation and Reporting Policy dated 2002 (revised [DATE]) indicated: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. 1. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the administrator will assign the investigation to an appropriate individual. 4. The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation.Reporting - 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor of Record); . e. Law enforcement officials; f, The resident's attending physician; and g. The facility's medical director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source) and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; . An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:42 p.m. While the IJ was removed on [DATE] at 2:27 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. The Facility's Plan of Removal for Immediate Jeopardy was accepted on [DATE] and indicated the following: Immediate action: Immediately upon notification of the alleged deficient practice on [DATE] @ (2:02 p.m.) the Facility Administrator, Director of Nursing, and Assistant Director of Nursing were provided an in-service by the Director of Clinical Operations from the Corporate Office. The in-service consisted of the facility abuse and neglect policy, conducting thorough investigations of any fall with injury/death to determine cause of injury/death, reporting incidents according to regulatory compliance, and reporting incidents of abuse or neglect that result in serious bodily injury/death. During this in-service each F tag was taken from Appendix-PP and presented, along with Texas HHSC provider letter number ,d+[DATE] dated [DATE], and Texas HHSC provider letter ,d+[DATE] dated [DATE]. The Facility Administrator and/or Director of Nursing are to contact the Director of Clinical Operations from the Corporate office with any incident that results in serious bodily injury/death. On [DATE] @ (4:00 p.m.) the Facility Administrator and the Director of Nursing began auditing all incidents from the previous 90 days to ensure any incidents that resulted in serious bodily injury were investigated and reported if necessary. No incidents of injury of unknown source resulting in injury/death were identified. Beginning on [DATE] @ (5:30 p.m.) all staff (nursing and non-nursing) present were provided with an in-service by the Director of Nursing regarding the facility abuse and neglect policy, the procedure for reporting incidents of unknown source with serious harm and/or death, suspected abuse/neglect and staff was offered the opportunity to report any known allegation at that time. No known allegations or suspected events were reported. This in-service will be repeated to every staff member prior to the start of their next scheduled shift and with each new hire. Following the in-service, a quiz will be administered to each employee which consists of 6 questions and a score of 80 will be considered passing. Any staff member who does not pass this quiz will be re-educated prior to working. In-servicing will continue until all staff have completed them but no later than [DATE] @ (7:00 p.m.). A log of test scores shall be presented to the QAPI committee for review during the next scheduled QAPI meeting on [DATE]. Facilities Plan to Ensure Compliance Quickly Impromptu QAPI was held [DATE] @ (5:30 p.m.) with the facility Medical Director and informed him of the three immediate jeopardies that the facility obtained for F607-Implementing Abuse and Neglect Policies and Procedures, F689-Accidents/Supervision, F610-Alleged Violations-Investigate/Prevent/Correct. The Medical Director was informed of the facility efforts to correct the alleged violations including audits of all resident records to ensure correct ADL coding was passed to the C.N.A.'s through to the Kardex, supervision of residents for safety, ensuring the abuse and neglect policy is implemented and incidents are reported and investigated. The Medical Director enforced supervision with toileting and room location for frequent fallers when possible. The facility will implement a new incident investigation tool to be followed for each incident to ensure potential reportable incidents are identified, falls are investigated to determine cause and the addition of any necessary interventions, and to allow for an interdisciplinary approach to resident care planning. On [DATE], the Facility Administrator and Director of Nursing were provided with an in-service by the Director of Clinical Operations regarding the use of this tool. The nursing staff will be provided the same in-service and the system will be implemented [DATE]. The Facility Administrator and Director of Nursing will ensure staff knowledge is retained through reviewing the tool following each individual incident. The QAPI committee will review the results of each investigation tool to ensure any patterns of predisposing factors identified through root cause analysis are addressed and any sign of abuse/neglect discovered is reported according to State and Federal regulations. On [DATE], the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on [DATE] from 9:00 a.m. through 2:00 p.m. with 5 LVNs, 9 CNAs, 3 MA, (who work all shifts), the ADON, the DON and the Administrator indicated staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report all falls and fall with injuries and allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse, and immediate intervention procedures. During interviews conducted on [DATE] from 9:00 a.m. through 2:00 p.m., the Administrator, DON and ADON said they were monitoring all incident and accidents daily during morning meeting. They would contact the Director of Clinical Operations from the Corporate office with any incident that results in serious bodily injury/death. During an interview on [DATE] at 1:30 p.m. the Administrator said he was in-serviced on [DATE] by the Director of Clinical Operations from the Corporate Office. He was able to verbalize the facility abuse, and neglect policy and they would conduct a thorough investigation of any fall with injury/death to determine cause of injury/death. He understood he was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that result in serious bodily injury/death. During an interview on [DATE] at 2:02 p.m. the DON said she was in-serviced on [DATE] by the Director of Clinical Operations from the Corporate Office. She was able to verbalize the facility abuse, and neglect policy and would conduct a thorough investigation of any fall with injury/death to determine cause of injury/death. The DON understood she was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that result in serious bodily injury/death. Record review of all incidents from the previous 90 days indicated there were no additional incidents of injury of unknown source or falls and death identified. Record review of all staff (nursing and non-nursing) in-serviced by the Director of Nursing regarding the facility abuse and neglect policy, the procedure for reporting incidents of unknown source with serious harm and/or death, and suspected abuse/neglect. Record review of quiz results indicated all staff passed the quiz regarding abuse, neglect, and reporting. Record review of the facility's new incident and investigation tool (date pending utilization) to be followed for each incident indicated it would ensure potential reportable incidents were identified, falls were investigated to determine cause and the addition of any necessary interventions and would allow for an interdisciplinary approach to resident care planning. Record review of an in-service dated [DATE] regarding the new incident and investigation tool indicated the administrator, DON, and nursing staff were provided with an in-service by the Director of Clinical Operations regarding the use of this tool. The administrator, DON and nursing staff were able to verbalize how to use the new incident and investigation tool to ensure any patterns of predisposing factors identified through root cause analysis were addressed and any sign of abuse/neglect discovered was reported according to State and Federal regulations. During interviews on [DATE] from 9:00 a.m. through 2:00 p.m., the Administrator and DON said the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegation or instances of abuse and/or neglect. During interviews on [DATE] from 9:00 a.m. through 2:00 p.m., the Administrator and DON stated the RN Supervisor and/or the Manager on duty would act as designees for the Administrator and Director of Nursing on the weekend. This was effective [DATE] and on-going. On [DATE] at 2:27 p.m., the Administrator and DON were informed the IJ was removed; however, 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.

Based on interview and record review the facility failed to thoroughly investigate and take measures to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation was in process, and failed to ensure corrective action was taken for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. The facility failed to investigate allegations of abuse and neglect and ensure corrective actions were in place after Resident #1 was found deceased on the floor of her bathroom, with injuries of unknown origin. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:42 p.m. While the IJ was removed on [DATE] at 2:27 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 of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated [DATE] indicated Resident #1 was an [AGE] year-old female, admitted on [DATE], and her diagnoses included heart failure, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), abnormalities of gait and mobility, diabetes, ataxic gait (difficulty walking in a straight line, lateral veering, poor balance, a widened base of support, inconsistent arm motion, and lack of repeatability), muscle weakness, lack of coordination (uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), pseudobulbar affect (a condition characterized by episodes of sudden uncontrollable and inappropriate laughing or crying), Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), COPD (a group of diseases that cause airflow blockage and breathing-related problems), and difficulty walking. Record review of an MDS assessment dated [DATE] indicated Resident #1 was usually able to make herself understood, was usually able to understand others, had short term and long-term memory problems, was not able to recall current season, location of her own room, staff names and faces, or that she was in a nursing facility. She required extensive physical assist of one person for bed mobility and transfers. She required full staff assistance for toilet use. She was not steady and only able to stabilize with staff assistance when moving from moving from seated to standing position and surface to surface transfer. She utilized a wheelchair for mobility. She always incontinent of bowel and bladder. Record review of a care plan revised on [DATE] indicated Resident #1 had ADL self-care performance deficit and limitations in physical mobility related to impaired balance and limited mobility/ROM, and musculoskeletal impairment. Interventions included limited assistance of one staff to transfer and total assistance of one staff for toileting (revised [DATE]). Record review of a care plan revised on [DATE] indicated Resident #1 was at risk for falls related to confusion and gait/balance problems. Interventions included follow fall precautions protocol (revised [DATE]). Record review of a care plan revised on [DATE] indicated Resident #1 had falls on [DATE], [DATE], [DATE], [DATE], and [DATE]. Interventions included investigate to determine and address causative factors of the fall and obtain statements for witnessed falls (revised [DATE]). There were no statements available for review. Record review of a care plan revised [DATE] indicated Resident #1 was on anticoagulant therapy related to heart disease. Interventions included to take precautions to avoid falls (revised [DATE]). Record review of a progress note dated [DATE] at 6:37 p.m., completed by LVN A indicated Resident #1 had an unwitnessed fall in her bathroom. LVN A was passing medication on another hall when she was called by the CNAs on the hall stating Resident #1 had fallen. Hurry up she is bleeding and there is a lot of blood on her face. LVN A witnessed two CNAs turned Resident #1 from a prone position to a supine position, facing the ceiling. Resident #1's head was close to the wall of the shower and her legs were stretched out toward the toilet seat. She had a large hematoma to the right temple and a 3 cm laceration. There was a large amount of blood on the face and neck. There was no rise or drop of her chest wall, no audible heart rate, no pulse. Resident #1's pants were midway to her waits and her diaper was pulled up completely. Resident #1's shoes were on her feet. The call light was not activated and was in reach. Resident #1 was moved from the shower area to the entrance way between her room and the bathroom. LVN A noted the wheelchair was under the sink with the brakes not locked. Four paramedics arrived and pronounced Resident #1 deceased as of 3:30 p.m. MD and family made aware of Resident #1's expiring. Record review of an incident report dated [DATE] at 3:00 p.m., Completed by LVN A, indicated Resident #1 had an unwitnessed fall in her bathroom. LVN A was passing medication on another hall when she was called by the CNAs on the hall stating Resident #1 had fallen. Hurry up she is bleeding and there is a lot of blood on her face. LVN A witnessed two CNAs turned Resident #1 from a prone position to a supine position, facing the ceiling. Resident #1's head was close to the wall of the shower and her legs were stretched out toward the toilet seat. She had a large hematoma to the right temple and a 3 cm laceration. There was a large amount of blood on the face and neck. There was no rise or drop of her chest wall, no audible heart rate, no pulse. Resident #1's pants were midway to her waits and her diaper was pulled up completely. Resident #1's shoes were on her feet. The call light was not activated and was in reach. Resident #1 was moved from the shower area to the entrance way between her room and the bathroom. LVN A noted the wheelchair was under the sink with the brakes not locked. Four paramedics arrived and pronounced Resident #1 deceased as of 3:30 p.m. MD and family made aware of Resident #1's expiring. DON and ADON were made aware. There was no facility investigation available for review as of [DATE]. An observation on [DATE] at 2:50 p.m. of Resident #1's bathroom area indicated there was not observed fall hazards. The toilet was situated across from a walk-in shower. The floor was tiled. There was a working call light adjacent to the toilet. There was a grab bar adjacent to the toilet. During an interview on [DATE] at 3:30 p.m., the DON said she did not report Resident #1's fall and injury or death to the state because she did not know if Resident #1 fell and sustained the injury and then expired or if something caused Resident #1 to expire and then fall. She said she spoke to the LVN A, CNA B, and CNA C but did not obtain any statements. She said she did not complete a full investigation of Resident #1's fall, injury of unknown origin or death. During an interview on [DATE] at 3:49 p.m., CNA B said on [DATE] Resident #1 was in the hall and had vomited. She said she brought Resident #1 to the bathroom and then went to tell LVN A of Resident #1 vomiting and gather a basin and supplies to clean her up. She said she could not recall what the time was when Resident #1 vomited or when she took her to the bathroom. She said she returned to the bathroom a few minutes later and found Resident #1 on the floor. She said Resident #1's head was on the floor of the shower and she was lying on her side. She said Resident #1's feet were in front of the toilet. She said Resident #1 did not respond to her name and she called for LVN A. She said she could not recall where the wheelchair was or if it was locked. She said the wheelchair was between the toilet and the hand sink. She said she left out of the bathroom to call for the nurse. She said there was blood on her head and her neck. She said her pants were down around her knees but her diaper was not down. During an interview on [DATE] at 8:05 a.m. CNA C said on [DATE] Resident #1 said she was sick and asked me and CNA C to bring her to the bathroom. She said she could not recall the exact time Resident #1 vomited or was taken to the bathroom. Resident #1 was still in her wheelchair and it was locked. She said the wheelchair was between the sink and the toilet. She said she told Resident #1 to pull the call light when she was done (vomiting.) She said she and CNA C left the bathroom to get a basin and towels. She said she realized after a few minutes Resident #1 had not pulled the call light and went to check on her and found her on the floor. She said Resident #1's head was on the floor of the shower and she was lying on her side. She said Resident #1's feet were in front of the toilet. She said her pants were down around her knees but her diaper was not down. CNA C said Resident #1 did not respond to her name and she called for LVN A. She said Resident #1 was left in the bathroom for approximately two or three minutes. She said they (CNA B and CNA C) notified LVN A of Resident #1 vomiting and LVN A said she would check the resident after she completed BP check. She said by the time LVN A was coming to check on Resident #1, they (CNA B and CNA C) had already found Resident #1 on the floor of the bathroom. She said Resident #1 was a one-person assist for transfers. CNA C said Resident #1 required supervision to use the toilet. She said Resident #1 could stand and was limited assist to use the toilet. She said if she had taken her to the bathroom to use the toilet, she would not have left her alone and would have helped her in the bathroom until she was able to get another staff to get a nurse. During an interview on [DATE] at 9:00 a.m., LVN A said she was the nurse station when she was approached by CNA B, She said CNA B said Resident #1 had vomited. LVN A said she told CNA B she (LVN A) was going to check another resident's BP on a different hall and would be right back to check on Resident #1. She said she was on her way back to check on Resident #1 when she heard CNA B calling out her name. She said CNA B said Resident #1 was on the floor. She said she immediately went to Resident #1's bathroom. She said Resident #1 was lying on her right side on the floor. She said her head was laying towards the shower and her feet were by the toilet. She said the wheelchair was locked and between the toilet and the sink. She said she unblocked the wheelchair and moved it under the sink. She said two aides turned Resident #1 to lay flat on her back. She said she checked for pulse and breathing. She said there was no signs of life. She said there was a 3 cm laceration on her forehead and blood was coming out of her mouth. There was blood on the floor. She was a DNR so no CPR was performed. Another nurse called the police and we were instructed not to touch her but we had already moved her from the bathroom floor to the floor between the bathroom and the bedroom in case we had to do CPR. EMS arrived and they checked and she had no signs of life. LVN A said from the time CNA B informed her Resident #1 had vomited to the time she was called and informed Resident #1 was on the floor was approximately ,d+[DATE] minutes. She said Resident #1 would go to the bathroom on her own but would require staff assist to use the toilet. She said Resident #1 was not steady on her legs. She said Resident #1 had a history of falls. She said Resident #1's bedroom had signs to remind her to use the call light for help. She said Resident #1 would scream for help but when asked, she did not know what she needed. She said Resident #1 was totally dependent on staff to use the toilet. She said Resident #1 required supervision in the bathroom. She said Resident #1 should not have been left alone in the bathroom. During an interview on [DATE] at 10:29 a.m., the DON said she was made aware of Resident #1's fall and death immediately . She said she did not report the incident because she was not sure if Resident #1 fell or did not fall. She said she did not investigate the incident. She said she was aware injuries of unknown origin were supposed to be reported to the state if there was possible neglect. She said not reporting and investigating could place other residents at risk of abuse and neglect. During an interview on [DATE] at 10:29 a.m., the administrator said all allegations of abuse or neglect or injuries of unknown sources should be reported to the state within 2 hours. He said he was the abuse coordinator. He said he was made aware of the incident immediately on the [DATE] but could not give a reason Resident #1's fall and death were not reported or investigated. He said not reporting and investigating could place other residents at risk of abuse and neglect. During an interview on [DATE] at 4:03 p.m. CNA C said Resident #1 would normally go around the facility in her wheelchair and do her own thing. She said if we could not see Resident #1 and we would look for her we would find her in the bathroom. She said we would have to remind her to ask for assistance. She said she did not know if she should have left Resident #1 alone in the bathroom. She said if she had known Resident #1 should not be left alone she would have stayed with her in the bathroom until CNA B brought LVN A to the bathroom. Record review of the facility's Abuse Prevention Program dated 2001 (revised [DATE]) indicated Our 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 resident's symptoms. 3. Develop and impellent policies and procedures to aide out facility in preventing abuse, neglect, or mistreatment of our residents. 6. Identify and assess all possible incidents of abuse. 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Record review of the facility's Abuse Investigation and Reporting Policy dated 2002 (revised [DATE]) indicated: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. 1. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the administrator will assign the investigation to an appropriate individual. 4. The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation.Reporting - 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor of Record); . e. Law enforcement officials; f, The resident's attending physician; and g. The facility's medical director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source) and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; . An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:42 p.m. While the IJ was removed on [DATE] at 2:27 p.m., the facility remained out of compliance at ----- with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. The Facility's Plan of Removal for Immediate Jeopardy was accepted on [DATE] and indicated the following: Immediate action: Immediately upon notification of the alleged deficient practice on [DATE] @ (2:02 p.m.) the Facility Administrator, Director of Nursing, and Assistant Director of Nursing were provided an in-service by the Director of Clinical Operations from the Corporate Office. The in-service consisted of the facility abuse and neglect policy, conducting thorough investigations of any fall with injury/death to determine cause of injury/death, reporting incidents according to regulatory compliance, and reporting incidents of abuse or neglect that result in serious bodily injury/death. During this in-service each F tag was taken from Appendix-PP and presented, along with Texas HHSC provider letter number ,d+[DATE] dated [DATE], and Texas HHSC provider letter ,d+[DATE] dated [DATE]. The Facility Administrator and/or Director of Nursing are to contact the Director of Clinical Operations from the Corporate office with any incident that results in serious bodily injury/death. On [DATE] @ (4:00 p.m.) the Facility Administrator and the Director of Nursing began auditing all incidents from the previous 90 days to ensure any incidents that resulted in serious bodily injury were investigated and reported if necessary. No incidents of injury of unknown source resulting in injury/death were identified. Beginning on [DATE] @ (5:30 p.m.) all staff (nursing and non-nursing) present were provided with an in-service by the Director of Nursing regarding the facility abuse and neglect policy, the procedure for reporting incidents of unknown source with serious harm and/or death, suspected abuse/neglect and staff was offered the opportunity to report any known allegation at that time. No known allegations or suspected events were reported. This in-service will be repeated to every staff member prior to the start of their next scheduled shift and with each new hire. Following the in-service, a quiz will be administered to each employee which consists of 6 questions and a score of 80 will be considered passing. Any staff member who does not pass this quiz will be re-educated prior to working. In-servicing will continue until all staff have completed them but no later than [DATE] @ (7:00 p.m.). A log of test scores shall be presented to the QAPI committee for review during the next scheduled QAPI meeting on [DATE]. Facilities Plan to Ensure Compliance Quickly Impromptu QAPI was held [DATE] @ (5:30 p.m.) with the facility Medical Director and informed him of the three immediate jeopardies that the facility obtained for F607-Implementing Abuse and Neglect Policies and Procedures, F689-Accidents/Supervision, F610-Alleged Violations-Investigate/Prevent/Correct. The Medical Director was informed of the facility efforts to correct the alleged violations including audits of all resident records to ensure correct ADL coding was passed to the C.N.A.'s through to the Kardex, supervision of residents for safety, ensuring the abuse and neglect policy is implemented and incidents are reported and investigated. The Medical Director enforced supervision with toileting and room location for frequent fallers when possible. The facility will implement a new incident investigation tool to be followed for each incident to ensure potential reportable incidents are identified, falls are investigated to determine cause and the addition of any necessary interventions, and to allow for an interdisciplinary approach to resident care planning. On [DATE], the Facility Administrator and Director of Nursing were provided with an in-service by the Director of Clinical Operations regarding the use of this tool. The nursing staff will be provided the same in-service and the system will be implemented [DATE]. The Facility Administrator and Director of Nursing will ensure staff knowledge is retained through reviewing the tool following each individual incident. The QAPI committee will review the results of each investigation tool to ensure any patterns of predisposing factors identified through root cause analysis are addressed and any sign of abuse/neglect discovered is reported according to State and Federal regulations. On [DATE], the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on [DATE] from 9:00 a.m. through 2:00 p.m. with 5 LVNs, 9 CNAs, 3 MA, (who work all shifts), the ADON, the DON and the Administrator indicated staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report all falls and fall with injuries and allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse, and immediate intervention procedures. During interviews on [DATE] from 9:00 a.m. through 2:00 p.m., the Administrator, DON and ADON said they were monitoring all incident and accidents daily during morning meeting. They would contact the Director of Clinical Operations from the Corporate office with any incident that results in serious bodily injury/death. During an interview on [DATE] at 1:30 p.m. the Administrator said he was in-serviced on [DATE] by the Director of Clinical Operations from the Corporate Office. He was able to verbalize the facility abuse, and neglect policy and they would conduct a thorough investigation of any fall with injury/death to determine cause of injury/death. He understood he was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that result in serious bodily injury/death. During an interview on [DATE] at 2:02 p.m. the DON said she was in-serviced on [DATE] by the Director of Clinical Operations from the Corporate Office. She was able to verbalize the facility abuse, and neglect policy and would conduct a thorough investigation of any fall with injury/death to determine cause of injury/death. The DON understood she was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that result in serious bodily injury/death. Record review of all incidents from the previous 90 days indicated there were no additional incidents of injury of unknown source or falls and death identified. Record review of all staff (nursing and non-nursing) in-serviced by the Director of Nursing regarding the facility abuse and neglect policy, the procedure for reporting incidents of unknown source with serious harm and/or death, and suspected abuse/neglect. Record review of quiz results indicated all staff passed the quiz regarding abuse, neglect, and reporting. Record review of the facility's new incident and investigation tool (date pending utilization) to be followed for each incident indicated it would ensure potential reportable incidents were identified, falls were investigated to determine cause and the addition of any necessary interventions and would allow for an interdisciplinary approach to resident care planning. Record review of an in-service dated [DATE] regarding the new incident and investigation tool indicated the administrator, DON, and nursing staff were provided with an in-service by the Director of Clinical Operations regarding the use of this tool. The administrator, DON and nursing staff were able to verbalize how to use the new incident and investigation tool to ensure any patterns of predisposing factors identified through root cause analysis were addressed and any sign of abuse/neglect discovered was reported according to State and Federal regulations. During interviews on [DATE] from 9:00 a.m. through 2:00 p.m., the Administrator and DON said the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegation or instances of abuse and/or neglect. During interviews on [DATE] from 9:00 a.m. through 2:00 p.m., the Administrator and DON stated the RN Supervisor and/or the Manager on duty would act as designees for the Administrator and Director of Nursing on the weekend. This was effective [DATE] and on-going. On [DATE] at 2:27 p.m., the Administrator and DON were informed the IJ was removed; however, 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.

Based on observation, interview, and record review the facility failed to complete and accurate admission orders for the resident's immediate care for 2 of 19 residents reviewed (CR #138, and Resident #241). *The facility failed to ensure Resident CR#138, a new admission with a diagnosis of diabetes was provided with a physician's order for insulin or blood sugar checks. The facility did not receive any intervention until resident family intervened on 09/15/22 (6 days after admission). Resident CR#138's blood sugar on 09/15/22 was 528 mg/dl. * The facility failed to ensure Resident #241's hospital discharge medication order for Betapace (anti-arrhythmic med used to treat a-fib) was transcribed and followed. Resident CR#241's Betapace medication was omitted 6 days after admission. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/11/22 at 3:10 p.m. and was removed on 10/13/22, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. These failures could place residents at risk for not receiving appropriate care, treatment, and services to prevent serious harm or serious impairment. Findings included: CR #138 Record review of CR# 138's face sheet indicated he was [AGE] years old and was admitted on [DATE] with diagnoses which included type 2 diabetes (an impairment in the way the body regulates and uses sugar (glucose) as a fuel) CR #138 was discharged to the hospital on 09/17/22. Record review of CR #138's previous facility discharge packet dated 09/09/22 indicated his primary diagnosis was type 2 diabetes and included orders for finger stick blood sugar checks before meals and at bedtime and Insulin Glargine Solution (Lantus) 100 Unit/ml, inject 10 unit subcutaneously one time a day for diabetes (hold if blood sugar <80). Record review of CR #138's Nursing Admission Evaluation and History dated 09/09/22 at 9:09 p.m. and signed by LVN F indicated Resident was transferred from another long-term facility accompanied by transport, had relevant history of diabetes, and orders were received /clarified from admitting physician. Record review of CR #138's nurse's progress note dated 09/15/22 at 8:24 p.m. and signed by LVN C indicated LVN C received a call at 11:00 a.m. from Resident's family who asked if Resident had been getting his blood sugar checked regularly. LVN C wrote she told the family she would check Resident's blood sugar and call her back. LVN C arrived in resident room, and he was on a video call with the family member. Blood sugar was 528 mg/dl. Family called the DON and Administrator who then went to CR #138's room. LVN C reviewed orders from previous facility and notified physician of order for Lantus and Resident's blood sugar of 528 mg/dl. Physician gave order for FSBS before meals and at bedtime. Physician ordered Humalog 15 units now, start sliding scale insulin, and Lantus 10 units at bedtime. LVN administered 15 units Humalog to Resident CR #138 and rechecked blood sugar after 15 minutes. Blood sugar had decreased to 474 mg/dl. LVN informed Resident's family she would review medications further to make sure medications were not missed upon admission. Record review of Admission MDS dated [DATE] CR #138 had severely impaired cognition, required extensive assistance with most activities of daily living, had an active diagnosis of diabetes, and had received insulin 2 days out of 7 during the 7-day look back period. Record review of #CR 138's cumulative physician orders, dated 10/11/22, indicated the following medications were added in the electronic medical record on 09/15/22: *09/15/22 Lantus Solution 100 Unit/ml (Insulin Glargine) Inject 10 unit subcutaneously at bedtime for diabetes *09/15/22 Humalog Solution 100 Unit/ml (Insulin Lispro) Inject per sliding scale - FSBS 0-70 - 0 units and initiate hypoglycemia protocol FSBS 71-130 = 0 units FSBS 131-180 = 2 units FSBS 181-240 = 4 units FSBS 241-300 = 6 units FSBS 301-350 = 8 units FSBS 351-400 = 10 units FSBS 401+ = 12 units and call doctor Subcutaneously before meals and at bedtime for diabetes. Record review of facility incident report dated 9/16/22 at 3:06 p.m., written by the Administrator indicated Resident CR #138 was admitted to the facility on [DATE] and had a diagnosis of type 2 diabetes. Resident had orders to receive Lantus at bedtime. Nurse that put in orders omitted this order resulting in Resident not receiving ordered medication. Family was inquiring how resident doing and it was discovered that Resident had not been receiving medication. The attending nurse took Resident's blood sugar, and it was determined that the blood sugar was above normal limits. The doctor was notified. Nurses were in-serviced on the admissions process. It was implemented the DON/ADON will check all admissions within 24 hours of admitting. An admission check off was issued. The admitting nurse was in-serviced and re-educated. Orders for insulin and blood sugar orders were put in. Record review of the Provider Investigation Report dated 9/21/22 and signed by the Administrator, indicated in investigation summary that DON/ADON went through the admission packet/orders for CR #138 and found that the admitting nurse forgot to put in the order for the Resident's insulin Lantus. Record review of Resident CR#138's undated baseline care plan, indicated Resident #CR138 was a diabetic, his interventions included: Diabetes medication as ordered by doctor and fasting serum blood sugar as ordered by doctor. Record review of Resident CR#138's Medication Administration Record (MAR) indicated Resident's blood sugar levels were as follows: *09/15/22 5:00 p.m. 303 mg/dl, *09/15/22 9:00 p.m. 196 mg/dl, *09/16/22 7:00 a.m. 149 mg/dl *09/16/22 11:00 a.m. 272 mg/dl *09/16/22 5:00 p.m. 357 mg/dl *09/16/22 9:00 p.m. 241 mg/dl *09/17/22 7:00 a.m. 267 mg/dl *09/17/22 11:00 a.m. 276 mg/dl *09/17/22 5:00 p.m. 321 mg/dl Centers for Disease Control (CDC) guidelines for diabetics indicate recommended blood sugar before meals be less than 130 mg/dl and less then 180 mg/dl two hours after eating. During an interview on 10/10/22 at 2:15 p.m., the DON said he first learned of the incident when CR #138's family called on 9/15/22 stating the facility had not been checking resident's blood sugar and now his sugar was over 500 mg/dl. The DON said he and the Administrator went to check on the Resident. The DON said LVN C had called the physician and administered insulin to CR#138. The DON said he then reviewed transfer orders and noted orders for Lantus and FSBS checks had been left off of the admission orders, so blood sugar checks and insulin administration was not done until family intervention on 09/15/22. He said an in-service had been completed with LVN F and other nurses to review each residents admitting diagnosis and ensure medication orders reflect the diagnosis. To have a second nurse review the admission orders if admitting nurse is unsure, and if resident is capable, assess Resident's history to ensure diagnosis of diabetes is not overlooked. He said an action plan had been set in place that he or the ADON would review all admission orders within 24 hours of resident admission. During an interview on 10/10/22 at 3:55 p.m., CR #138's family said the resident called her several times on 09/15/22 complaining of stomach pain and stating the facility had not been checking his blood sugar. The family said she got upset and called LVN C insisting she check his blood sugar. The family member said LVN C told her she didn't know CR #138 was diabetic. The family member said she was shocked when she learned his blood sugar was more than 500 mg/dl. The family member said the nurse told her she had called the doctor, given him insulin, and his blood sugar would be checked regularly. The family member said Resident was sent to the hospital 2 days later and admitted with diagnosis of nephritis (kidney inflammation) and UTI (urinary tract infection). The family member said CR #138 was discharged from the hospital after a 7 day stay and admitted to another facility because she did not want the resident going back to the facility. Record review of CR #138's nurse's progress note dated 9/18/22 at 12:40 a.m. indicated Resident was sent to hospital for further evaluation due to intractable pain (pain whose cause cannot be removed, and according to generally accepted medical practice, the full range of pain management modalities appropriate for this patient has been used without adequate result). During an interview on 10/10/22 at 5:07 p.m., LVN F said she had worked at the facility for 2 weeks before the incident and had received training/orientation from the ADON which included resident admission. She said on the evening of 09/09/22 she had 3 admissions and was very busy. LVN F said the transferring facility sent transfer orders and medications for CR #138. She said she compared medications received with the transfer orders, but the transferring facility had not sent Lantus insulin, so she missed the orders for FSBS and Lantus. She said she was unaware CR #138 had a diagnosis of diabetes. She said possible negative outcome for the resident not receiving blood sugar checks and insulin could be elevated blood sugar and resident decline. During an interview on 10/10/22 at 5:22 p.m., the ADON said she completed orientation training with LVN F. She said LVN F demonstrated understanding of admission process during the orientation. She stated she and the DON were responsible to reviewing all new admissions and re-admissions within 24 hours of admit, but she could not recall if CR#138's admission records had been reviewed. She said possible negative outcome of a resident not receiving blood sugar checks and insulin could be elevated blood sugar. During an interview on 10/11/22 at 2:30 p.m., MD D said he was the physician for CR#138. He said he had reviewed the transfer orders from the previous facility and approved them. He said those orders included FSBS check four times daily before meals and at bedtime and Lantus 10 units daily. He said he was unaware the resident was not receiving ordered blood sugar checks and insulin until he received a call from the facility on 09/15/22 to report blood sugar of 528 mg/dl and the resident not receiving insulin or blood sugar checks since admission. He said he gave orders to the facility for Humalog 15 units now, Humalog per sliding scale with blood sugar checks before meals and at bedtime, and Lantus 10 units daily. He said he believed the resident's elevated blood sugar was related to the resident not receiving blood sugar checks and insulin, but it was also related to the resident's Nephritis(inflammation of the kidneys) and UTI that he was hospitalized for 2 days later. During an interview on 10/12/22 at 11:02 a.m., CR#138's family said she had never known the Resident to have a blood sugar over 500 mg/dl until the nurse at the facility checked it on 09/15/22. She said the Resident's blood sugar usually stayed in the 100 mg/dl to 200 mg/dl range. During an interview on 10/12/22 at 11:10 a.m., LVN C said on 09/15/22 she received a call from CR #138's family who asked if his blood sugar was being checked. She said she checked CR#138's blood sugar and it was 528 mg/dl. She said she called MD D who gave orders for Humalog now, Humalog per sliding scale with blood sugar checks before meals and at bedtime, and Lantus daily. She said she administered 15 units Humalog subcutaneously and re-checked his blood sugar 15 minutes after the dosage was given. Blood sugar was then 474 mg/dl. She said she was unaware the Resident was diabetic until family called the facility asking if his blood sugar was being checked. During an interview on 10/13/22 at 1:14 p.m., the DON said the admission orders for CR #138 were missed by LVN F on admission and not caught by staff during morning meeting/review. He said he did not recall if CR#138's admission orders were ever reviewed in the morning meeting or by himself or the ADON. He said, we just missed those orders and dropped the ball. 22183 Resident #241 Record review of Resident #241's face sheet, dated 10/11/22, revealed an [AGE] year-old female, admitted to the facility on [DATE], had diagnoses which included paroxysmal atrial fibrillation and chronic diastolic (congestive) heart failure. Record review of Resident #241's admission MDS dated [DATE] revealed it was in progress and was not completed. Record review of Resident #241's undated care plan revealed Focus: Provide the resident and their representative with a summary of the baseline care plan within 48 hours of admission that includes(at minimum): .c) services and treatments to be administered by the facility . Interventions: .The resident medication orders and dietary instructions were reconciled upon admission . Record review of Resident #241's Nursing Admission Evaluation and History dated 10/05/22 completed by RN H revealed Resident #241 was alert, oriented (person, place, time and situation) and her cognition was intact. Section O. Medications documented 1b. orders received/clarified from admitting physician. Record review of Resident #241's Hospital Medication List printed on 10/04/22 at 9:50 a.m. revealed, the resident was supposed to continue taking Betapace (sotalol) order stated dose 40mg, route oral, frequency daily. Record review of Resident #241's Order Summary Report, dated 10/11/22, revealed no order for Betapace(sotalol) until 10/11/22 sotalol 80 mg give 0.5 tablet by mouth one time a day for arrhythmia hold medication if heart rate is below 60 or sbp less than 110 dbp less than 60, on hold from 10/11/22 to 10/14/22. Record review of Residents #241's MAR dated, October 2022, revealed no documented administrations and no physician order transcribed for Betapace(sotalol) indicating Resident #241 received Betapace(sotalol) dose 40mg, route oral, frequency daily. Further review of the MAR indicated no vital signs/heart rate were obtained. In an interview on 10/11/22 at 3:37 p.m. MD D stated he was not aware of Resident #241 not receiving betapace. MD D stated the resident not having the medication poses no risk for anything because reality of things was she does not need the medication. MD D stated the medication was for heart rate control in atrial fibrillation and hers (Resident #241) looked ok. He said he reviewed the vital signs and the residents heart rate was not abnormal(while not taking) and resident didn't need it. Surveyor told him the facility had no vitals recorded for the resident, he said he had vitals/HR and they were fine. MD D said if Resident #241's heart rate was out of control it could have done her no harm. MD D said, I don't think it's harmful that she did not recieve the betapace. In an interview on 10/12/22 at 1:00 p.m. Resident #241 stated she was not aware she was not getting her heart medication, betapace. Resident #241 said she took the medication while she was in the hospital and just assumed the facility was giving her the same medications. Resident #241 said she took the medication for a fast heart, and she has not had any problems with her heart . In an attempted telephone interview with RN H on 10/11/22 at 3:00p.m., was unsuccessful and a voice message could not be recorded due to the mailbox being full. In an attempted telephone interview with RN H on 10/12/22 at 11:45a.m., was unsuccessful and a voice message could not be recorded due to the mailbox being full. In an interview on 10/13/22 at 1:30 p.m. the DON said we dropped it, we failed the process of checks and balances and the nurse(RN H) just did not do it. The DON said he was responsible for reviewing all new admissions and re-admissions within 24 hours of admit but couldn't remember if they had checked Resident #241 admission orders. He said nurses are training in admission process which included transcribing orders during orientation and annual or as the need arise. The DON also said not giving Resident #241 the medication betapace put her at risk of potential harm because that was an important medication to control her A-fib. The DON said no vital signs/heart rate were taken and heart rate was to be taken daily before administering the betapace. Record review of the facility's Admissions Policies revised December 2006 indicated The primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility. Record review of the facility's policy revised dated April 2014, titled Adverse Consequences and Medication Errors .#6. Examples of medication errors include : a. omission of drug is ordered but not administered . Record review of the facility's policy revised dated February 2014, titled Verbal Orders 1. Only authorized licensed practitioners or individuals authorized to make verbal orders from practitioners shall be allowed to write orders in the medical record. 2. Verbal orders are those written by an authorized practitioner directly to a person authorized to receive and transcribe orders on his or her behalf a telephone order is a verbal order given over the phone . 4. The individual receiving the verbal order must write it on a telephone on a physicians order sheet as V.O. (verbal order) or T.O. (telephone order) . Record review of the facility's policy revised dated November 2014, titled Medication Orders Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders . 3. Orders must be written and maintained in chronological order . The Administrator was notified on 10/11/22 at 2:04 p.m. an Immediate Jeopardy (IJ) situation was identified due to the above failures and an IJ template was provided. The facility's Plan of Removal was accepted on 10/12/22 at 1:09 p.m. and included: On October 11, 2022, the Corporate Director of Clinical Operations. Corporate MDS Specialist, and Corporate Health Information Manager provided in-service training regarding daily review of admission records, admission order reconciliation, review of 24/72 hour report, and communication with non-nursing disciplines to the DON, ADON, Wound Care Nurse, and MDS Coordinator. By 2:00 p.m. on 10/12/22 all nursing staff were provided in-service training regarding admission/re-admission process, the admission/re-admission medication reconciliation process, transcribing and carrying out physician orders, and following up on recommendations from other disciplines. All newly hired nurses will be educated before beginning their first shift. A complete chart audit was conducted on all resident medical records by the DON, ADON, and Wound Care Nurse on 10/11/22 for medication orders, treatment orders, recommendations from other disciplines, and admission/re-admission. The facility has re-educated all nursing staff on admission/re-admission process, the admission/re-admission medication reconciliation process, transcribing and carrying out physician orders, and following up on recommendations from other disciplines. On 10/13/22 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 10/13/22 at 1:14 p.m., the DON said all staff have received in-service training on admission process and all new hires will be trained during orientation. He said he the corporate nurse will be providing mock admissions during training to ensure staff is following the new process. DON said the new process included: 1) Admitting nurse will verify/confirm admission orders with physician and put all orders into electronic medical record. 2) After inputting orders in electronic medical record, a hard copy of chart would be reviewed in morning meeting. If on the weekend will be reviewed by the DON or ADON. 3) If doctor did not want to continue an order that will be charted in nurse's notes. 4) There is a new tracking tool in place to make sure all steps are followed. 5) Also included in new process is to check all admitting diagnosis are addressed. During an interview on 10/13/22 at 1:55 p.m., the Administrator said all admission orders will be reviewed by DON or ADON within 24 hours of resident admission to ensure all diagnosis have been addressed and all medications have been accurately transcribed, and residents are receiving all ordered care and medications. He said this will be done during morning meetings, clinical meetings, and weekend admissions will be reviewed by either DON or the ADON remotely. The Administrator said he, the DON, ADON, wound care nurse, and MDS nurse will talk daily and will follow the new process of reviewing all admission orders within 24 hours. He said staff is trained through in-service, venders, corporate nurses, Relias (computer training) and one on one. The Administrator said the IJ happened because of oversight, orders were just missed, and the new process put in place will ensure oversights don't happen. He said possible negative outcome to a resident from not receiving ordered FSBS and insulin was hyperglycemia (high blood sugar). The Administrator said the new process will be monitored by himself and DON making rounds together every morning. Talking to residents and asking them questions. Assessing non-verbal residents. Talking to staff, asking about any problems, and having an open-door policy. Interviews on 10/12/22 at 3:10 p.m. to 4:30 p.m. with 6 LVNs (LVN C, L, M, N, O and P) indicated they were able to correctly state the protocol for admission/re-admission process, the admission/re-admission medication reconciliation process, transcribing and carrying out physician orders, and following up on recommendations from other disciplines. During interviews on 10/13/22 at 8:25a.m. to 8:36 a.m. of the Respiratory Therapy staff (RT J and RT K) the retraining related to procedure for ensuring recommendations are adequately communicated to nursing staff and followed up accordingly was confirmed. Record Review of Respiratory Policy and set guidelines of communication between contracted Respiratory Therapists and facility staff was confirmed. Record review of the facility's in-service dated 10/12/22 training indicated all nursing staff had received in-service training on admission/re-admission process, the admission/re-admission medication reconciliation process, transcribing and carrying out physician orders, and following up on recommendations from other disciplines. Record review of facility audit for medication order reviews for all residents identified and all residents admitted and readmitted for reconciliation of hospital discharge orders/admitting orders and diagnosis/health conditions of residents was addressed/noted in the electronic health record including any diagnostic testing necessary for monitoring the health condition was confirmed. On 10/13/22 at 9:40 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.